Ontario Court Overturns OHIP Denial for Cancer Treatment Patient

An Ontario court has quashed a decision denying provincial health coverage for out-of-country cancer treatment to a 37-year-old man with Stage 4 melanoma, ruling that the government offered no basis for its main reasoning. Shved asked the Divisional Court for a judicial review, and the court ordered OHIP to issue a new decision by the end of next week.

Judges Challenge OHIP Reasoning on Drug Pricing Negotiations

The majority judges wrote that the core reason for OHIP’s denial appeared to be that approving Shved’s request would undermine potential future price negotiations with drug manufacturers for public funding in Ontario. Routine out-of-country funding in advance of evidence-based reviews, he argued, would undermine the incentive structure for manufacturers to participate in Canada’s drug review processes. The judges found this conclusion counter-intuitive and lacking reasoning or data.

Evaluating Tumour-Infiltrating Lymphocyte Therapy Costs and Benefits

Shved discovered a growing mole in 2020 and has since tried various treatments as his disease progressed. His doctors state he is a good candidate for tumour-infiltrating lymphocyte (TIL) therapy, a complex procedure where doctors remove tumours, extract immune cells infiltrating those tumours, multiply them in the billions, infuse chemotherapy, and inject the multiplied cells back into the patient to attack the cancer. A version of TIL therapy known as lifileucel was approved for sale last year by Health Canada and is undergoing provincial drug plan reviews, a process that can take years. The treatment carries an estimated cost of about $600,000 US.

Dissenting Opinion and Next Steps for OHIP Review

Meanwhile, Shved is participating in a clinical drug trial in Toronto and remains stable, relatively speaking, while his disease continues to progress.