ROS1-positive lung cancer treatment access gap across Canada - A call for equitable, patient-centered care

Title : ROS1-Positive Lung Cancer Treatment Access Gap Across Canada - A Call for Equitable, Patient-Centred CareBackground: ROS1-positive non-small cell lung cancer (NSCLC) represents 1-2% of NSCLC cases, yet patients face significant treatment access barriers despite availability of effective targeted tyrosine kinase inhibitors (TKIs). This analysis evaluates provincial coverage disparities for ROS1 TKIs across Canada to inform patient advocacy and policy reform efforts. Methods : We conducted a comprehensive pan-Canadian analysis of public drug coverage policies for ROS1-targeted therapies as of March 2026, examining first-line through third-line treatment access across all Canadian provinces and territories. Coverage policies, exceptional access programs, and clinical trial availability were systematically reviewed. Results : While first-line agents (crizotinib, entrectinib) demonstrate universal coverage, profound inequities emerge in advanced-line therapy access in Canada. Second-line coverage requires case-by-case review with documented intolerance rather than progression, creating clinical and ethical challenges. Any advanced-line therapies remain virtually inaccessible through public funding across all provinces, forcing patients toward clinical trials or treatment discontinuation. Next-generation TKIs addressing resistance mutations (repotrectinib, taletrectinib, zidesamtinib) and CNS disease remain accessible only through clinical trials. Critically, coverage termination after exhaustion of first TKI line creates a "therapeutic cliff" for patients who develop resistance, despite availability of potentially effective subsequent therapies. Conclusions : Canadian patients with ROS1-positive NSCLC face unjustifiable barriers to life-extending therapies beyond first-line treatment. The disconnect between therapeutic availability and public funding perpetuates health inequities and undermines precision oncology principles. Urgent policy reform is needed to: (1) establish consistent pan-Canadian coverage frameworks, (2) enable progression-based (not just intolerance-based) second-line access, (3) create pathways for third-line and resistance-directed therapy funding, and (4) accelerate approval timelines for next-generation TKIs. Patient-centered knowledge dissemination regarding clinical trial opportunities and exceptional access pathways remains critical until systemic coverage improvements are achieved. This analysis provides an evidence-based framework to support patient advocacy, inform healthcare provider counselling, and guide policy reform toward equitable access to ROS1-targeted therapies.