Value-Based Cancer Care Issues


February 2012, Vol 3, No 1

Ventura County Hematology Oncology Specialists: Efficiencies Crucial for Economic Viability

Best Practices

Ventura County Hematology Oncology Specialists has so far managed to avoid many of the financial difficulties facing a large number of community cancer practices. Value-Based Cancer Care asked Dr Parsa and Ms Rivera to discuss what makes their practice successful from a clinical and a business perspective.

VBCC: When was the practice established, and what are some of the services you offer?

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Bosutinib Shows Superior Results in CML

Neil Canavan

ASH Annual Meeting

San Diego, CA—The newest data presented from the BELA (Bosutinib Efficacy and Safety in Chronic Myeloid Leukemia) trial show a superior cumulative complete cytogenetic response rate (CCyR) for bosutinib versus the standard-of-care agent, imatinib, when used as frontline treatment for patients with chronic myeloid leukemia (CML), with 87% and 81% response rates at 24 months.

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The Cost of Cancer Care: How Can We Spend Better?

Caroline Helwick

Breast Cancer

San Antonio, TX—One of the few clinical science symposia at the 2011 CTRC-AACR San Antonio Breast Cancer Symposium focused not on clinical issues but on delineating the economic issues facing oncologists.

Elena B. Elkin, PhD, Center for Health Policy and Outcomes, Memorial Sloan-Kettering Cancer Center, New York, reviewed the unprecedented concerns regarding health expenditures, calling for more cost-effectiveness analyses and more realistic thresholds for cost-effectiveness.

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The Promise of Molecular Profiling

Caroline Helwick

VBCC Perspectives

At the 2012 Gastrointestinal Cancers Symposium, Value-Based Cancer Care (VBCC) asked Al B. Benson, III, MD, FACP, Professor of Medicine, Associ­ate Director for Clinical Investi­gations, Robert H. Lurie Compre­hensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Immediate Past President, ACCC, and editorial board member of VBCC, to discuss the growing importance of molecular profiling in cancer care.

VBCC: Where is the field of molecular profiling at this point, and where is it heading?

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Molecular Profiling for Stage II Colon Cancer

Meeting Highlights

San Francisco, CA—Approximately 80% of patients with stage II colon cancer will be cured by surgery alone, but 20% will still relapse. Oncologists struggle with the question of which patients could benefit from adjuvant chemotherapy to reduce this risk, and which patients can be safely observed, without further treatment.

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The Health Burden of Multiple Myeloma: Subcutaneous Bortezomib a New, Convenient Route of Administration Option

Rhonda Williams

Cancer Drugs

In 2011, the American Cancer Society projected there would be 20,520 cases of newly diagnosed multiple myeloma (MM) and 10,610 deaths from the disease that year.1 MM is an incurable hematologic cancer marked by great heterogeneity, in terms of its biology and clinical course. Morbidity and survival rates vary widely, even in the age of novel, molecularly based targeted therapies. Many factors account for differences in prognoses among patients with MM, including genomic aberrations in the plasma cells of the myeloma neoplasm. [ Read More ]

Mammography Use Increases When Copays Are Dropped

Breast Cancer

San Antonio, TX—When copayments were eliminated, annual screening mammography rates among insured rural women improved significantly, researchers from Duke University Comprehensive Cancer Center reported at the 2011 CTRC AACR San Antonio Breast Cancer Symposium.

“Cost-sharing for high-value healthcare services may have unintended negative consequences,” said Jeffrey M. Peppercorn, MD, MPH, Associate Professor, Duke University School of Medicine, Durham, NC.

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Paying for Quality: Increasing Shift Toward Value-Based Healthcare

Health Policy

On November 30, 2011, the Office of the Inspector Gen­eral (OIG) of the US Depart­ment of Health and Human Services issued an advisory opinion (No. 11-18) to the web-based physician practice service provider athenahealth, tacitly approving the company’s new online service athenaCoordinator. The athenaCoordinator is a cloud-based physician referral tool that monetizes, in some instances, the “referral transaction” between a referring physician and a “trading partner.”

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Building a National Patient Advocacy Network in Oncology

Rose Gerber

Patient Advocacy

Formed in 2003, the Community Oncology Alliance (COA), led by Executive Director Ted Okon, has been well established nationally as the only nonprofit organization advocating solely for community oncologists and their patients. As a result, COA has a very strong presence on Capitol Hill, representing its physicians and community center practice administrators from all across the country. [ Read More ]

Promising Data for New DNA Stool Testing, at Low Cost

Meeting Highlights

San Francisco, CA—The “eradication” of colorectal cancer (CRC) may be a step closer, based on promising data for stool DNA testing, said David A. Ahlquist, MD, Mayo Clinic, Rochester, MN, at the 2012 Gastroin­testinal Cancers Symposium.

Suggesting that his claim is “not too bold, and not hyperbole,” Dr Ahlquist explained that stool DNA testing using next-generation technology is:

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Serum-Based Immunoassay May Detect Pancreatic Cancer Early

Meeting Highlights

San Francisco, CA—A serum-based enzyme immunoassay using the PAM4 antibody, combined with the serum marker CA19-9, detected stage I pancreatic cancer in nearly two thirds of patients analyzed in a study presented at the 2012 Gastrointestinal Cancers Symposium. It also demonstrated high discriminatory power with respect to benign pancreatitis.

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Significant Cost of Treating Myeloproliferative Neoplasms

Neil Canavan

ASH Annual Meeting

A new cost analysis of the management of the 3 subtypes of myeloproliferative neoplasms (MPNs)—myelofibrosis, poly­cythemia vera, and essential thrombocythemia—shows that associated medical and pharmaceutical expenses for patients with these hematologic disorders in patients with cancer are 2 to 6 times that of matched patients without cancer. Outpatient visits for MPN accounted for more than 50% of the total costs incurred by patients with cancer.

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Ponatinib Overcomes Hard-to-Treat T315I Mutation in Patients with CML/ALL

Neil Canavan

ASH Annual Meeting

Preliminary data from the phase 2 PACE (Ponatinib Ph+ALL and CML Evaluation) trial show that ponatinib (Ariad Pharmaceuticals) can overcome the difficult-to-treat T315I mutation in patients with chronic myeloid leukemia (CML). Currently, patients with this genetic mutation have no effective treatment options.

In PACE, the tyrosine kinase inhibitor (TKI) ponatinib achieved a 47% major cytogenetic response (MCyR). For patients with the T315I mutation, ponatinib induced a 65% MCyR. This drug was specifically designed to overcome the T315I mutation.

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Investigational Blinatumomab Puts BiTE on Acute Lymphoblastic Leukemia

ASH Annual Meeting

The novel agent blinatumomab more than doubled the complete response (CR) rate in patients with relapsed/refractory B-precursor acute lymphoblastic leukemia (ALL) compared with standard therapies.

Blinatumomab is a member of the BiTE (bispecific T-cell engager) drug class, a bispecific monoclonal antibody designed to direct the cytotoxic T-cells of the host’s immune system, via CD3, to attack CD19-expressing cancer cells.

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Next-Generation Proteasome Inhibitors Cause Less Peripheral Neuropathy

Caroline Helwick

ASH Annual Meeting

The first-generation proteasome inhibitor bortezomib changed the treatment paradigm of multiple myeloma. Data are now maturing for the next-generation agent carfilzomib, with US Food and Drug Administration approval expected soon. Several novel agents in this class are also in the pipeline. These second-generation agents appear to be as effective as bortezomib but less neurotoxic, according to studies presented at ASH 2011.

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First Cost Analysis of Long-Term Management of CML

Neil Canavan

ASH Annual Meeting

Few analyses to date have as­sessed the long-term costs associated with the management of chronic myeloid leukemia (CML). At ASH 2011, Shrividya Iyer, PhD, of Pfizer, presented results of a retrospective analysis performed by a group of researchers at Pfizer and the Eliassen Group that looked at information from the Thomson Reuters MarketScan Commercial Claims and Encounters Database, and the Medicare Supple­mental Database. Medical claims for the years 2002-2009 were used for 2583 patients with CML who had ≥2 claims associated with a CML diagnosis.

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First Randomized Comparison of Catheter-Directed Thrombolysis versus Standard Care for DVT Prophylaxis

Neil Canavan

ASH Annual Meeting

In the first comparative trial of its kind, the Catheter-Directed Venous Thrombolysis (CaVenT) study determined that treating a clot directly with the recombinant, antithrombotic agent alteplase reduced the frequency of postthrombotic syndrome (PTS) and im­proved long-term outcome in patients with proximal deep-vein thrombosis (DVT) compared with standard anticoagulation methods.

PTS can greatly affect a patient’s quality of life: 1 in 4 patients with DVT will experience PTS, despite having been treated according to current clinical guidelines.

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Eribulin Associated with Less Neuropathy than Ixabepilone

Breast Cancer

San Antonio, TX—In a randomized phase 2 study of patients with metastatic breast cancer, peripheral neuropathy was less likely to occur in patients receiving eribulin mesylate than with ixabepilone.

“Peripheral neuropathy is a big problem in the treatment of breast cancer. Across the spectrum, patients have it, and we don’t know how to treat it,” said Linda T. Vahdat, MD, Weill Cornell Medical College in New York, who presented the study at the 2011 CTRC-AACR San Antonio Breast Cancer Symposium.

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Direct-to-Consumer Genetic Testing: Concerns Trump Benefits at This Point

Caroline Helwick

Health Policy

Miami, FL—Direct-to-consumer (DTC) marketing of genetic tests represents personalized medicine in evolution. High-throughput genetic technologies have made it possible to evaluate individuals at a relatively affordable price, but a number of technologic, social, regulatory, and ethical issues must first be settled before DTC genetic testing takes personalized medicine to new heights.

At the 2011 Best of ASCO meeting, Gary H. Lyman, MD, MPH, Director of Comparative Effectiveness and Outcomes Research, Duke University School of Medicine, Durham, NC.

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Americans Willing to Pay Hundreds of Dollars Out of Pocket for Cancer Risk Tests

Rosemary Frei, MSc

Health Policy

American adults would be willing to pay a median of $263 for a perfect prostate cancer prediction test and $232 for a perfect breast cancer prediction test, according to a recent survey (Neumann PJ, et al. Health Econ. 2012;21:238-251). This is even when—according to this hypothetical scenario presented to participants in the survey—respondents were told that if the test results were positive the disease could not be prevented, but the person could access treatments when the disease occurred.

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Comparative Effectiveness Analysis of 3 Radiation Therapies for Prostate Cancer

Wayne Kuznar

Genitourinary Cancers Symposium

San Francisco, CA—A new, large comparative effectiveness analysis of 3 techniques for delivering radiation therapy for the treatment of localized prostate cancer supports intensity-modulated radiation therapy (IMRT) as the current standard, said Ronald Chen, MD, MPH, Assistant Professor of Radiation Oncology, University of North Carolina (UNC), Chapel Hill, and Research Fellow, Sheps Center for Health Services Research, UNC at the 2012 annual Genitourinary Cancers Symposium.

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Two Mechanistically Distinct Agents Lead to Impressive Survival Improvements in Advanced Prostate Cancer

Genitourinary Cancers Symposium

San Francisco, CA—Two treatments sig­nificantly extended survival in men with metastatic castration-resistant pros­tate cancer (CRPC) in separate phase 3 clinical trials reported at the 2012 Genitourinary Cancers Symposium.

The hope is that the 2 treatments, one an injectable alpha pharmaceutical (radium-223 chloride) and the other a novel antiandrogen drug (MDV3100), can be used either sequentially or in combination to further boost survival in men with CRPC and bone metastases.

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Array of Treatments for Metastatic Prostate Cancer, but Can We Afford Them?

Phoebe Starr

Genitourinary Cancers Symposium

New York, NY—Men with castration-resistant prostate cancer (CRPC) now have several different treatments that improve their survival—docetaxel (Taxo­-tere), cabazitaxel (Jevanta), abiraterone (Zytiga), and sipuleucel-T (Provenge). The newest potential therapy to improve survival in this group of pa­tients is the radiopharmaceutical radium-223 (Alpharadin), which is currently under US Food and Drug Admin­istration review.

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Physician-Led Approach Can Cut Unnecessary Testing in Prostate Cancer

Caroline Helwick

Prostate Cancer

Feedback from their peers helped physicians refrain from ordering unnecessary tests for patients with newly diagnosed cancer, according to a recent study (Miller DC, et al. J Urol. 2011;186:844-849. Epub 2011 Jul 23).

Physicians ordered fewer tests after becoming more aware of practice guidelines and being presented with comparative data on tests they and their colleagues ordered. The program also improved the quality of care by reducing variations in practice patterns.

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Which Patients with Prostate Cancer Should Receive Hormone Therapy in Addition to Radiation?

Phoebe Starr

Prostate Cancer

Miami, FL—Although several studies have shown that the addition of androgen-deprivation therapy (ADT) to radiation improves disease-free survival (DFS) in men with intermediate-risk prostate cancer, this is a heterogeneous group of patients, and it is not clear whether they should all receive ADT plus radiation, or whether the benefit is confined to a specific subset of patients.

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Bevacizumab Delays Progression, May Extend Survival in Ovarian Cancer

In the Literature

Two phase 3 international clinical studies show that initiating therapy with bevacizumab in combination with standard chemotherapy extends progression-free survival (PFS) in women with advanced ovarian cancer, and women at high risk for disease progression may live longer with the addition of bevacizumab to standard therapy (Burger RA, et al. N Engl J Med. 2011;365:2473-2483; Perren TJ, et al. N Engl J Med. 2011;365:2484-2496).

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33 States Not Prepared to Cover Patients in Clinical Trials by 2014

In the Literature

In an attempt to eliminate insurance coverage status as a barrier to clinical trial enrollment, the Affordable Care Act of 2010 (ACA) requires that by January 2014, all payers in all states must cover routine medical costs associated with patient participation in approved clinical trials.

A new study reveals, however, that most states either have laws that do not properly comply with these regulations or have no laws or
agreements regarding clinical trial (phases 1-4) insurance coverage (Kircher SM, et al. J Clin Oncol. Epub December 27, 2011).

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Chemotherapy-Induced Structural Brain Changes Linked to Cognitive Function

In the Literature

Findings from a longitudinal study of impaired cognitive functioning and cerebral white matter integrity in women who receive chemotherapy for breast cancer suggest that chemotherapy-induced structural changes in the brain are correlated with impaired cognitive functioning (Deprez S, et al. J Clin Oncol. 2012;30:274-281).

In a Dutch study involving 69 premenopausal women, 34 women with early-stage breast cancer who were exposed to chemotherapy were compared with 16 women with early-stage breast cancer who were not exposed to chemotherapy, and with 19 matched healthy controls.

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Erivedge First Drug Ever for Metastatic Basal-Cell Carcinoma

FDA Approvals, News & Updates

The US Food and Drug Admin­istration (FDA) approved vismodegib (Erivedge; Hoffmann–La Roche), a hedgehog pathway inhibitor, for the treatment of basal-cell carcinoma (BCC) in adults with locally advanced disease who are not candidates for surgery or radiotherapy and in those with metastatic disease. Approved under a priority review, oral vismodegib is the first FDA approved drug with an indication for this condition. 

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Subcutaneous Bortezomib a New Therapeutic Option

FDA Approvals, News & Updates

The FDA approved a new, subcutaneous route of administration for the proteasome inhibitor bortezomib (Velcade; Millennium) as an alternative method to the previously approved intravenous (IV) form of the drug in all the FDA indications. Bortezomib is indicated for the treatment of multiple myeloma (MM) and of mantle-cell lymphoma in patients who have received at least 1 previous therapy.

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Topical Gel for Actinic Keratosis

FDA Approvals, News & Updates

The apoptotic topical gel ingenol mebutate (Picato; Leo Pharma) has received FDA approval for the treatment of actinic keratosis, a precancerous condition that can progress to squamous-cell carcinoma.

In 4 phase 3 studies involving >1000 patients with actinic keratosis, 60% to 68% of those with lesions on the face and scalp and 44% to 55%
of those with lesions on the trunk and extremities demonstrated ≥75% clearance after receiving ingenol. Among those who received placebo, only 7% to 8% demonstrated ≥75% clearance.

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Bosutinib NDA Accepted for CML

FDA Approvals, News & Updates

The FDA has accepted a New Drug Application (NDA) for bosutinib (Pfizer), an oral dual Src and Abl tyrosine kinase inhibitor, as a second-line therapy for adult patients with previously treated Philadelphia chromosome–positive (Ph+) chronic myeloid leukemia (CML).

The submission was based on efficacy and safety data from a single-arm study of bosutinib in more than 500 patients with previously treated Ph+ CML, including those who were resistant or intolerant to imatinib or had previously received dasatinib or nilotinib. (January 27, 2012)

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Gleevec Approved for Children with Acute Lymphoblastic Leukemia

FDA Approvals, News & Updates

The US Food and Drug Admini­s­tration (FDA) approved a new indication for imatinib (Gleevec; Novartis) for the treatment of children with newly diagnosed Philadelphia chromosome–positive (Ph+) acute lymphoblastic leukemia (ALL), the most common type of pediatric cancer.

Approximately 2900 children are diagnosed with Ph+ ALL annually in the United States. Imatinib, a tyrosine kinase inhibitor, should be used in combination with chemotherapy for the treatment of children with Ph+ ALL.

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