The high cost of cancer treatments and ongoing drug shortages may prompt cancer patients to buy drugs from illegitimate online pharmacies, research suggests.

These online pharmacies sell “unapproved, counterfeit, or otherwise unsafe medicines outside the safeguards followed by licensed pharmacies,” according to the US Food and Drug Administration (FDA).1 

“With the COVID-19 pandemic, more people have gotten comfortable shopping for medicines online but are not aware that 96% of the sites selling prescription medications are not legitimate,” said Sachiko Ozawa, PhD, a health economist and professor at the Eshelman School of Pharmacy of the University of North Carolina in Chapel Hill.2 

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Online drug purchases increased during the early days of the pandemic as some patients were unable to obtain treatments in person.3 As the pandemic wears on, patients may continue to buy drugs online because supply chain issues have created new shortages of cancer treatments and exacerbated existing shortages.4 

A survey of organizations belonging to the Hematology/Oncology Pharmacy Association revealed frequent shortages of oncology drugs in 2020.5 Of 68 organizations surveyed between December 2019 and July 2020, 64% said they had experienced at least 1 oncology drug shortage per month.

Even before the pandemic, shortages of cancer drugs motivated patients to buy treatments online. In a study published in 2018, researchers investigated the ease of online access to out-of-stock cancer drugs (bleomycin, carboplatin, carmustine, cisplatin, fluorouracil, gemcitabine, irinotecan, methotrexate, mitomycin, and etoposide) in 2014 and 2016.6 

Internet searches revealed that 100% of these medications could be purchased online without a prescription. The number of online sellers offering out-of-stock cancer drugs increased by roughly 15% between 2014 and 2016, and none of the identified vendors were deemed legitimate.

More recently, Dr Ozawa and colleagues studied online pharmacies selling imatinib.7 The researchers noted that the high cost of long-term imatinib use may cause patients to seek lower prices online. 

Of the 44 online pharmacies the researchers studied, 7% were certified, 30% sold imatinib without a prescription, and 48% did not limit the quantity consumers could purchase.

“It was also concerning that over 75% of online pharmacies identified did not have access for patients to speak with a pharmacist,” Dr Ozawa said.

Risks of Buying Drugs Online

Buying cancer drugs online may present numerous risks, explained Tim K. Mackey, PhD, a professor in the Global Health Program at the University of California, San Diego, and director of the Global Health Policy and Data Institute. 

He noted that drugs purchased from illegitimate pharmacies “may contain only partial or no active pharmaceutical ingredients, rendering them ineffective or worsening prognosis.” In addition, drugs from illegitimate pharmacies may be adulterated or cause adverse events.

Toxicity related to the use of counterfeit drugs may be challenging to tease apart from the side effects of any legitimate treatments patients may be receiving, Dr Mackey said. Even if counterfeit drugs are detected, attributing poor outcomes to these agents may be difficult. 

These issues can “make manufacturing and selling counterfeit cancer drugs a ‘perfect crime,’ as the practice may not be easily detectable and can be highly profitable given the high cost of many cancer drugs and the ability to charge high prices for counterfeit versions,” Dr Mackey said.

He added that the purchase of counterfeit drugs can also cause financial hardship when patients pay out of pocket for medications that are ineffective or cause harm. 

“Vulnerable populations who either don’t have access [to] or can’t afford cancer therapy may disproportionately suffer from the impacts of these counterfeit drugs,” Dr Mackey said. 

Data are limited regarding specific counterfeit cancer drugs available online. However, Dr Mackey said one of the most widely reported cases may be counterfeit bevacizumab (Avastin). 

Dr Mackey noted that the “counterfeit versions of Avastin entered the US drug supply chain in 2012 through a network of gray market distributors,” as he and his colleagues discussed in a 2015 paper.8 

“To this day, we really don’t have an exact number of how many patients were impacted,” Dr Mackey said. “But, based on the number of warning letters sent out by the FDA, it is likely in the thousands.”

Another breast cancer drug the FDA has warned about is letrozole.9 In 2018, the agency discovered an online company selling an unapproved version of the drug (Fempro). 

In 2019, the World Health Organization issued a warning that counterfeit batches of the leukemia drug ponatinib (Iclusig) were being sold online.10 These fakes contained paracetamol instead of the active ingredient. 

Even if patients who order from illegitimate pharmacies receive a legitimate version of the drug they need, ordering these medications without a prescription poses numerous additional risks, according to Dr Ozawa.

“Patients bypassing interactions with providers are likely to face much greater risks of nonadherence, discontinuation, treatment failures, and adverse events” due to less stringent monitoring, Dr Ozawa said.