Value As A Decision Driver In Cancer Care: Are We There Yet?
By Lynne Lederman, PhD
The official theme of this year’s American Society of Clinical Oncology (ASCO) Annual Meeting was Illumination and Innovation: Transforming Data into Learning. However, a prominent theme that quickly emerged was “value.” For the first time at ASCO, value was the subject of two presentations during the Plenary Session1, 2 as well as an education session3 and a health services research and quality of care session.4
With the topic of value so prominent at the meeting, we saw and heard many discussions on the value of incremental gains in cancer care. In particular, we sat in on a discussion between Maria Whitman, Managing Principal, Specialty Therapeutics and Oncology, ZS Associates, a global firm focused on improving business performance through sales and marketing solutions, and Michael Kolodziej, MD, National Medical Director, Oncology Solutions, Aetna, about value as a decision-driver in cancer care. Ms. Whitman also commented on a survey conducted during ASCO by M3 Global Research of 94 medical or hematologic oncologists practicing in community or academic settings who attended the annual meeting.
Value Includes Clinical Benefit Plus Therapeutic and Financial Toxicities
Dr. Kolodziej said that having a conversation about value in cancer care is a big step in the right direction because the cost of cancer care needs to be addressed. “I think we want to recognize that there is a budget. We’ve unfortunately gotten in a groove where every innovation is a wonderful innovation. I think what we really should be focusing on is how do we pay for things that really, really make a difference? And the thing about immunotherapy is, it is clear for some patients it really, really makes a difference.”
In his plenary presentation,1 Leonard B. Saltz, MD, of Memorial Sloan Kettering Cancer Center, discussed the value of therapy—what is gained in efficacy but at what toxicity and how much the regimen costs. The most prominent example at the meeting was the nivolumab plus ipilimumab regimen, which showed terrific efficacy, but which is estimated to cost about $300,000 (a patient with typical co-pays of 20% would have to pay out-of-pocket $60,000). If all patients with any metastatic cancer in the US received 1 year of a similarly priced drug, Dr. Saltz said, this could translate into $174 billion in drug costs. This price tag doesn’t include adjuvant therapy, surgery, or other treatments. With the cost of pembrolizumab, estimated to be even higher, this could run up to $1M per patient per year.
Dr. Saltz said prices do not seem to reflect innovation, efficacy, or development costs. “Cancer drug prices are not related to the value of drugs, but rather are based on what has come before and what the market will bear. This,” he said, “is unsustainable.” He suggested a starting point in the value conversation, involving the pharmaceutical and biotechnology industries, payers, government, patients, and oncologists, should include considering an upper limit to the cost of care of each patient with cancer.
Whereas sometimes, “less [therapy] is more,” Dr. Saltz observed that sometimes “more is more.” For example, elective neck dissection in early stage oral cancers.5 He noted the study of nivolumab plus ipilimumab in metastatic melanoma,6 emphasizing that the median progression-free survival of 11.5 months for the combination is impressive for a disease once thought incurable. However, he said, “I have a major problem: these drugs cost too much. We can’t discuss value unless we include benefit and toxicities as well as cost.”
According to M3 survey respondents, drug therapy is the biggest driver to unnecessary costs in patient treatment, followed by hospitalization (Figure 1). Ms. Whitman commented, “At ASCO, there was an unprecedented level of conversation around the rising cost of cancer care overall, which includes balancing choices and eliminating waste. The shifting focus on outcomes can help reduce expense items across the value equation, which includes drug therapy selection, but also includes hospitalizations and excess diagnostic testing, which increase the total cost of care.”
Cost was a deciding or influencing factor in treatment decisions in the past 6 months for most of the surveyed physicians (Figure 2). “A few years ago, cost was discussed as an ‘all else being equal’ consideration. Today we see cost – and in particular drug cost – more top of mind for oncologists and entering the discussion in a more deliberate way, for example through pathway guidance or more direct discussions around costs to patients. But is value a consistent driver yet? There are a number of initiatives underway to address cost transparency to enable more effective decision making at the physician-patient level.” Ms. Whitman said.
Potential Solutions to the Cost Dilemma
Lowell E. Schnipper, MD, Chair, ASCO Task Force on Value in Cancer Care, discussed ASCO’s Value Initiative: A Case-Based Approach, in an education session.7 The focus of ASCO’s value framework will be to support informed, shared decision-making between doctor and patient using a tool to individualize information, including clinical benefit, toxicity, and costs. ASCO will publish a framework to assess the value of cancer treatment options in the Journal of Clinical Oncology in late June of this year.
An economic analysis was presented by Deborah Schrag, MD, MPH, Dana-Farber Cancer Institute, Boston, Massachusetts, from the CALGB (Alliance)/SWOG 80405 study in patients with KRAS wild-type colorectal cancer.8 The conclusion was that the combination of chemotherapy plus bevacizumab cost much less than the combination of chemotherapy plus cetuximab, with similar survival and quality-adjusted survival. About a 45% reduction in the average selling price of cetuximab would be required to equal bevacizumab costs as used in the clinical study. While Dr. Schrag made no recommendations, Dr. Saltz suggested adopting “pay for performance” for drugs or tiered coverage pegged to efficacy.
Dr. Kolodziej suggested that transparency ultimately will require looking at how therapeutic decision making influences total cost of care. Most survey respondents were neutral that drug therapies alone provide the number one opportunity for cost containment in cancer care, suggesting that there is more to cost containment than controlling drug costs. For example, hospitalizations also contribute to costs. Dr. Kolodziej said that in a pilot study with Texas Oncology among patients with Medicare Advantage, those over age 70 with non-small cell lung cancer have a higher rate of hospitalization, and longer stays, which should be a part of the shared decision-making process between patient and provider. “If you don't discuss the possibility of hospitalization, you’re not making an informed decision.” The data that are being collected can be used to further personalize therapy, make good therapeutic decisions for patients, and make good financial decisions for everyone in the healthcare ecosystem. Ms. Whitman observed that this illustrates that value is a “holistic conversation.”
Among those respondents who did have a strong opinion, more agreed than disagreed that drug therapy is the number one target for cost containment in cancer care (Figure 3). Ms. Whitman pointed out, “The pace of innovation is exciting and the clinical achievements will continue to drive us forward in the fight against cancer, and we can expect value to be a consistent part of the equation moving forward. Twenty-seven percent of oncologists surveyed strongly agree advancements like novel drugs or novel drug combinations will force considerations of cost as a decision criterion in therapy selection.”
There are a number of value proposals. One of the most prominent concerns the use of biomarkers to identify patients for whom therapy will achieve the greatest outcomes. For Dr. Kolodziej, the most interesting abstract is one that discusses a marker for response. He cited in particular the presentation on the use of mismatch repair defects to predict response to the checkpoint inhibitor pembrolizumab in patients with previously treated, progressive, metastatic tumors.9 As advice to drug manufacturers, he said, “Regulatory end points are regulatory end points. They are not necessarily clinically meaningful end points, or end points that will distinguish you as this value equation is applied to your product. Think a little bit about how much an investment in a companion diagnostic or a biomarker is going to distinguish your product and give you an opportunity to have preferential placement on a therapeutic decision pathway.”
The majority of respondents in the survey reported that the biggest positive impact in driving value in cancer care is the availability of biosimilars and use of biomarkers (Figure 4). Biosimilars were not mentioned in the value discussions, but Ms. Whitman noted that biosimilars are hotly debated, and that any time more options become available, there is the potential to reduce cost. For biomarkers, she said, “The availability of identifiable biomarkers enables a stronger value choice for the therapy that can really make a difference for the targeted patients they benefit.”
Anthem’s Payment Plan
Another value proposition involves the use of pathways to address controlling the cost of care while improving patient outcomes. Jennifer Malin, MD, PhD, Staff Vice President, Clinical Strategy at Anthem, presented a poster10 and talk11 from the payer perspective on Anthem’s new payment model. This model relies on treatment pathways12 to promote quality, affordable, and accessible cancer care. The Anthem Cancer Care Quality Program based enhanced reimbursement to oncology practices on following nationally acknowledged and peer-reviewed cancer treatment guidelines and pathways. Between 63% and 72% of patients were given an approved regimen, depending on tumor type, vs. 40% to 50% before initiation of the program. Although Anthem found that their payment model was feasible, there are no data on clinical outcomes or how non-registered patients were treated. Additional interventions may be needed to increase participation and adherence to pathways.
Ms. Whitman agreed that the value conversation “is a broad conversation, because it involves many parts, has to be linked to outcomes, and involve a collaborative solution among payers, providers, and manufacturers.” And, as Dr. Kolodziej added, patients, who matter more than anyone else, will have to be part of this discussion. The patients, Ms. Whitman concluded, are why we are all here. With ASCO and other organizations tackling the value topic, it is clear that we are only at the beginning of what will be continuing conversations about value in cancer care.
About the Contributors
ZS is the world’s largest firm focused exclusively on improving business performance through sales and marketing solutions, from customer insights and strategy to analytics, operations and technology. More than 3,000 ZS professionals in 21 offices worldwide draw on deep industry and domain expertise to deliver impact where it matters for clients across multiple industries. To learn more, visit www.zsassociates.com or follow us on Twitter (@ZSAssociates) and LinkedIn.
M3 Global Research provides the most comprehensive and highest quality market research recruitment and support services available to the global healthcare industry with relationships with over 2.5 million physicians in more than 70 countries worldwide. M3 Global Research operates an ISO 26362 certified panel with the highest quality data collection and project management capabilities that cover the spectrum of quantitative and qualitative techniques utilized today. In addition to market research, M3 Global Research provides valued services to today’s medical professionals that include medical education, ethical drug promotion, clinical development, job recruitment, and clinic appointment services. M3 has offices in Tokyo, Washington D.C., Fort Washington, PA, Rochester, NY, San Mateo, CA, Oxford, London, and Seoul.
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- Parsons HM, Partridge AH, co-chairs. Health services research and quality of care session. ASCO Annual Meeting, 2015
- D’Cruz A et al. Elective versus therapeutic neck dissection in the clinically node negative early oral cancer: A randomised control trial (RCT). J Clin Oncol 33, 2015 (suppl; abstr LBA3)
- Wolchok JD et al. Efficacy and safety results from a phase III trial of nivolumab (NIVO) alone or combined with ipilimumab (IPI) versus IPI alone in treatment-naive patients (pts) with advanced melanoma (MEL) (CheckMate 067). J Clin Oncol 33, 2015 (suppl; abstr LBA1)
- Schnipper LE. ASCO’s value imitative: a case-based approach. The value proposition in oncology: different approaches to understanding value in cancer care. ASCO Annual Meeting Education Session, 2015
- Schrag D et al. Cost of chemotherapy for metastatic colorectal cancer with either bevacizumab or cetuximab: an economic analysis of CALGB/SWOG 80405. Health services research and quality of care session, ASCO 2015
- Le DT et al. PD-1 blockade in tumors with mismatch repair deficiency. J Clin Oncol. 2015; 33 (suppl; abstr LBA100)
- Malin J, et al. Impact of enhanced reimbursement on provider participation a cancer care quality program and adherence to cancer treatment pathways in a commercial health plan. J Clin Oncol 33, 2015 (suppl; abstr 6571). Available at: http://freepdfhosting.com/4cabfc650b.pdf
- Malin J. Case considerations: value from the payer perspective. The value proposition in oncology: different approaches to understanding value in cancer care. ASCO Annual Meeting Education Session, 2015
- Anthem. Cancer Care Quality Program Treatment Pathways. April 1, 2015. Available at: https://anthem.aimoncology.com/pdf/pathways/Cancer_Pathways_Clinical_Detail.pdf