Care Utilization, Costs Significantly Differ Between First-line Metastatic Melanoma Treatments

As the treatment landscape for cancer expands, so does the need to evaluate therapy regimens for real-world effectiveness, safety, and cost of care. A retrospective cohort study published in JCO Oncology Practice aims to provide economic perspective on several first-line metastatic melanoma treatment options, comparing health care resource utilization and costs across regimens.

There were significant differences across therapies, with ipilimumab-containing regimens leading to the highest cost and resource utilization and pembrolizumab or nivolumab monotherapy leading to the lowest utilization and cost. Patients diagnosed with melanoma and secondary malignant neoplasm were included in the analysis, and the drug-based cohorts included patients treated with 7 systemic therapies:

• Pembrolizumab
• Nivolumab
• Ipilimumab
• Ipilimumab plus nivolumab
• BRAF-inhibitor (BRAF-i) plus MEK inhibitor (MEK-i)
• BRAF-i or MEK-i monotherapy
• Chemotherapy

The study compared health care utilization—including hospitalizations, emergency room visits, and outpatient visits—and costs per patient per month (PPPM) using 2-part and generalized linear models. Data were pulled from IBM MarketScan Commercial and Medicare Supplemental Research Databases commercial claims from July 2011 to December 2017, and the final overall study cohort included patients who had initiated one of the therapies between 2012 and 2017. The results are only generalizable to patients covered by commercial or Medicare supplemental insurance due to the nature of the data, the authors noted.

A total of 1870 patients were included in the analysis. There were 185 patients treated with pembrolizumab, 103 nivolumab, 689 ipilimumab, 185 on combination nivolumab plus ipilimumab, 214 treated with combination BRAF-i plus MEK-i, 240 given BRAF-i or MEK-i monotherapy, and 254 on chemotherapy. All patients were 18 years of age or older and treatment-naïve.

The ipilimumab monotherapy and combination ipilimumab plus nivolumab cohorts had the highest average PPPM health care utilization. This included hospitalizations, length of stays, outpatient visits, outpatient visits excluding treatment visits, and in the case of combination ipilimumab plus nivolumab patients specifically, more emergency department visits.

Pembrolizumab or nivolumab monotherapy patients saw the lowest PPPM health care utilization and costs, and there were no significant differences between the regimens, both of which are anti–PD-L1 monoclonal antibodies.

The study authors note that data from clinical trials and meta-analyses has shown ipilimumab-containing therapies to carry higher rates of moderate to severe immune-related adverse drug events (ADEs). Anti–PD-L1 antibodies have also shown improved responses and survival benefits compared with ipilimubab. Therefore, closer patient monitoring and more frequent treatment for acute ADEs might be a cause of higher utilization rates during the course of the ipilimumab-containing therapies. “Consequently, pembrolizumab and nivolumab have been established as the preferred first-line treatment choice over ipilimumab, which our findings support,” the authors wrote.

The mean total PPPM costs for each regimen (in USD) were as follows:

1. Nivolumab: $18,725
2. Pembrolizumab: $21,102 USD
3. BRAF-i or MEK-i monotherapy: $21,853
4. Chemotherapy: $22,254
5. Combination BRAF-i plus MEK-i : $31,184
6. Combination ipilimumab plus nivolumab: $71,689
7. Ipilimumab: $80,139

Monthly drug-related costs were a main driver in overall cost of care, making up $15,718 in the pembrolizumab cohort (74.5% of total health care costs), $70,051 for ipilimumab monotherapy treatment (87.4%), and $19,648 for the combination BRAF-inhibitor plus MEK inhibitor (63.0%).

The authors also highlighted the ongoing issue of oncology drug pricing on the whole. As oncologists gain more real-world experience with available drugs, treatment costs may be positively affected, they added. “However, structural reforms (e.g. incentivizing physicians to use more cost-effective treatments, allowing Medicare to negotiate drug prices, and disincentivizing pharmacy benefit managers from accepting high list prices of brand-name drugs) are needed to address the rising prices of cancer drugs in the United States.”

While the study provides insight on costs from the payer perspective, the authors noted that patients face direct and indirect costs of first-line metastatic melanoma therapy that can lead to serious financial hardship and discontinuation of treatment. Therefore, more studies are needed to assess the issue of cost from a patient perspective.

Reference

Boemmel-Wegmann S, Brown J, Diaby V, Huo J, Silver N, Park H. Health care utilization and costs associated with systemic first-line metastatic melanoma therapies in the United States. JCO Oncol Pract. Published online July 06, 2021. doi:10.1200/OP.21.00140