Exploring Oncology Financial Toxicity, Cost of Care

Two posters presented at the 2019 American Society of Clinical Oncology Annual Meeting, held May 31 to June 4, 2019, in Chicago, Illinois, discussed the growing issue of financial toxicity and the costs of care in cancer treatment.

In the first poster, researchers selected 4 phase 3 trials of immuno-oncology (IO) treatments for non-small cell lung cancer (NSCLC) in a first-line setting and found that while median progression-free survival doubled, so did costs. The researchers said the expense has to be quantified in relation to per capita gross national product in the United States ($53,128 in 2017). Costs appear economically unsustainable even when accepting a higher threshold of $100,000 for 1 quality adjusted life year gained, they wrote. But given the significant PFS gains, there is a need to use IOs through innovative cost sharing platforms, they said.¹

In the second poster, researchers hypothesized that weight-based dosing of pembrolizumab and nivolumab in order to allow vial sharing among patients would result in substantial cost savings.² The 2 drugs were originally investigated and FDA-approved with weight-based dosing strategies, but later the approval label was amended to a fixed-dose administration.

Researchers retrospectively examined all outpatient doses of pembrolizumab and nivolumab given at 3 Stanford Medicine infusion centers between July 1, 2018, and October 31, 2018, using the Stanford Medicine Research Data Repository (STARR) database. Cost-minimization analysis was conducted to model the impact of dosing strategies based upon patient weight versus fixed dosing (2 mg/kg vs 200 mg every 3 weeks for pembrolizumab; 3 mg/kg vs 240 mg every 2 weeks or 6 mg/kg vs 480 every 4 weeks for nivolumab).

“Dose-minimization” (DM) was defined as whichever dose was lower (weight-based or fixed dose). The impact of allowing vial sharing (considering commercially available vial sizes) between patients treated at the same site and on the same date was assessed. Average sales price (ASP) from CMS for Part B drugs was used for cost estimates.

A total of 1029 doses of pembrolizumab or nivolumab were administered across a variety of cancer types. For most doses (n = 789, 77%), the calculated weight-based dose was less than the fixed dose. DM resulted in decreased usage and expenditures of both pembrolizumab and nivolumab, and a further decrease was observed with vial sharing.

Total savings estimated with DM and vial sharing strategy were greater than $1.4 million. This amounted to savings of >22,000 mg of P (112 fixed doses) and > 11,000 mg of N (47 fixed doses). Savings were greatest at the highest volume infusion center.

Alternative dosing strategies of pembrolizumab and nivolumab would result in significantly less drug utilization and pharmaceutical spending, without anticipated impact on efficacy, but there are barriers to this approach, such as existing policies regarding vial sharing and drug vial sizes.

References

1. Ashraf SMM, Pandita S, Alimpertis E, et al. Progression free survival (PFS) benefits of immuno-oncology agents (IOs) and implications for market cost-sharing inefficiencies. Presented at: American Society of Clinical Oncology Annual Meeting, May 31-June 4, 2019; Chicago, Illinois. Poster 334.
2. Hall ET, Zhang J, Kim EJ, Economic analysis of alternative pembrolizumab and nivolumab dosing strategies at an academic cancer center. Presented at: American Society of Clinical Oncology Annual Meeting, May 31-June 4, 2019; Chicago, Illinois. Abstract 6504.