Cancer care

Female oncology patients’ fertility testing rejected by Medicare

Medicare has knocked back a bid to give female oncology patients access to a test of ovarian reserve that would help decision making on fertility preservation when undergoing gonadotoxic chemotherapy.

An application by clinicians for an MBS item for Anti-Mullerian hormone (AMH) testing in premenopausal female cancer patients was rejected by the Medicare Services Advisory Committee on the grounds of uncertain clinical evidence and cost effectiveness.

The request for MBS listing was made by clinicians from the Kids Cancer Centre at the Sydney Children’s Hospital, who noted that the AMH test is already used in about of 50% of young female patients undergoing gonadotoxic cancer treatment. By giving an indication of ovarian reserve before and after treatment the AMH test can enable better prediction of the return of reproductive function and help inform decision making around interventions such as oocyte cryopreservation, they said.

But MSAC reviewers said they had not provided enough evidence to show that AMH test offered any benefit over and above current ovarian function assessment methods such as FSH tests or obtaining an “antral follicle count”  (AFC) by vaginal ultrasound.

The committee said there was a high degree of variability between AMH assays and a lack of evidence that AMH testing would change patient management, since cryopreservation would be most likely conducted regardless of test result.

It said the proposed $100 fee for AMH testing was too high and there was a risk of ‘leakage’ beyond the estimated $570,000 cost of testing to the MBS annually.

The applicants responded that they were “very unhappy” with the MSAC decision, which they said was based on data for AMH testing that was outdated and unsubstantiated

They said FSH and AFC were not valid comparators of ovarian reserve and the claims of variability between assays made by MSAC were incorrect as there was little variability with second generation tests. They also rejected the MSAC assertion that AMH testing was not clinically useful.

“AMH testing provides invaluable information to inform fertility preservation for young cancer patients,” they said. “We were … reassured by the overwhelmingly positive comments regarding the usefulness of AMH in the fertility preservation setting especially from patients who find the information helpful in decision making,” they added.

MSAC advised that a resubmission of application for an MBS listing should include additional evidence to address the points raised.

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