Drug dose optimization and substitutions to improve access for patients with gastrointestinal and neuroendocrine cancers

The cost of cancer care has significantly increased, with a major cause being the high cost of new drugs, limiting their access worldwide. Drug dose optimization (DDO) and substitutions may help improve treatment access for patients residing in financially resource-limited countries. We propose and discuss these strategies for patients with gastrointestinal (GI) cancers and neuroendocrine tumors (NET) who are treated in low- and middle-income countries, considering the available scientific evidence. Overall recommendations include dose-reductions of palliative chemotherapy, avoiding colony-stimulation growth factors when unnecessary, lower doses of immune checkpoint inhibitors and paclitaxel as a substitute for nab-paclitaxel. Specific proposals by tumor type are discussed and recommended according to resource availability.