Value-Based Cancer Care Issues


March 2012, Vol 3, No 2

Wilshire Oncology Medical Home Pilot: Reengineering Cancer Care

Best Practices

Interview with Linda Bosserman, MD, Clinical Oncologist and President of Wilshire Oncology Medical Group, La Verne, CA BEST PRACTICES

Over the past several years, Wilshire Oncology has transformed its patient care to patient-centered medical home management, working with the largest payer in California. Value-Based Cancer Care (VBCC) asked Dr Bosserman to describe the new pilot and what has led to this reengineering of cancer care.

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Everolimus Has Minimal Economic Impact on Treatment of Pancreatic NETs

Caroline Helwick

Gasterol Intestinal Symposium

San Francisco, CA—Using a prediction model to analyze the impact of adding targeted agents to the treatment of pancreatic neuroendocrine tumors (pNETs), everolimus (Afinitor) had a minimal overall impact on healthcare expenditures, by reducing infusions and surgical procedures costs, according to a study presented at the 2012 Gastrointestinal Cancers Symposium. For patients with advanced pNETs, the median overall survival is typically approximately 2 years. [ Read More ]

AMA Delegates and Oncologists Balk at ICD-10 Implementation

Caroline Helwick

Health Policy

New Orleans, LA—According to the American Medical Association (AMA) and many oncologists, the International Classification of Diseases, Tenth Revision (ICD-10) diagnostic coding system will be a needless and expensive burden to oncology practices, without enhancing patient care. ICD-10 is being developed by the World Health Organization. The Centers for Medicare & Medicaid Services (CMS) ordered the switch in 2009 as part of carrying out the Health Insur ance Portability and Accountability Act. [ Read More ]

External Beam Radiation More Toxic, Costlier than Brachytherapy or Prostatectomy

Wayne Kuznar

Genitourinary Cancers Symposium

San Francisco, CA—In a retrospective long-term comparative analysis of 3 prostate cancer treatment strategies, treatment with external beam radiation therapy (EBRT) was more toxic and costlier than prostatectomy and brachytherapy, according to Cleveland Clinic researchers who presented their data at the 2012 annual Genitourinary Cancers Symposium. In most other studies, the reported treatment-related toxicity data cover a follow-up period of only 5 years, said lead investigator Jay P. Ciezki, MD, Staff Physician, Cleveland Clinic. [ Read More ]

FDA Updates Imatinib’s Label to 36 Months of Use after Removal of GIST

FDA Approvals, News & Updates

The US Food and Drug Admin - istration (FDA) approved an updated label for imatinib (Gleevec; Novartis) for the use of the drug in adults after the surgical removal of CD117-positive gastrointestinal stromal tumors (GIST). The FDA now recommends extending treatment with imatinib to 36 months instead of the current standard of 12 months. This approval, processed under a priority review, highlights the new data from a phase 3 clinical trial showing an increased overall survival (OS) in patients using imatinib for 36 months compared with 12 months.

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House Introduces Bill to Expedite FDA Drug Review

FDA Approvals, News & Updates

A new House bill—the Drug Shortage Prevention Act (H.R. 3839)— received bipartisan support to expedite the FDA review of drugs in shortage, improve communication within the agency and with stakeholders about possible shortages, and increase Drug Enforcement Administration (DEA) quotas for medications in short supply. This legislation includes the following short-term fixes to the drug shortages:

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BRAF Inhibitors Linked to squamous-Cell Carcinoma in Patients with RAS Mutations

In the Literature

As many as 15% to 30% of patients who receive BRAF inhibitors (eg, vemurafenib, dabrafenib) for the treatment of metastatic melanoma develop nonmelanoma skin cancers. Data from a new study suggest that this paradoxical effect may be caused by squamous-cell carcinoma cell lines with RAS mutation that proliferate on exposure to these drugs (Su F, et al. N Engl J Med. 2012;366:207-215).A molecular analysis identified oncogenic mutations, including HRAS, KRAS, NRAS, CDKN2A, and TP53, in lesions of patients in 3 phase 1-3 studies. [ Read More ]

Statins Have Protective Effects Against Hepatocellular Cancer in HBV Infection

In the Literature

Several studies have suggested that statins may have protective effects against cancer. The results of the first study to investigate the association between statin therapy in patients with chronic hepatitis B virus (HBV) infection and the risk for hepatocellular carcinoma (HCC) were recently published (Tsan YT, et al. J Clin Oncol. 2012;30:623-630). This population-based study involved 33,413 patients with HBV infection who were tracked between 1997 and 2008 to identify those who developed HCC. [ Read More ]

Family History of Gastric Cancer Associated with Improved Survival in Patients with Advanced Cancer

In the Literature

Family History of Gastric Cancer Associated with Improved survival in Patients with Advanced Cancer Family history of gastric cancer increases the risk for the disease and its recurrence. Different studies provided conflicting evidence regarding the impact of family history of the disease on the chance for survival after gastrectomy. A new study has now investigated the prognosis of patients with gastric cancer who have a family history of the disease and have undergone gastrectomy (Han MA, et al. J Clin Oncol. 2012;30:701-708).

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Ruxolitinib Boosts Quality-of-Life Outcomes in Myelofibrosis

In the Literature

The treatment options for myelofibrosis are very limited, with ruxolitinib the potent Janus kinase (JAK) 1 and 2 inhibitor, being the first and only drug approved specifically for this condition late last year. This study compared its efficacy and safety with the best available therapy for patients with myelofibrosis (Harrison C, et al. N Engl J Med. 2012;366:787-798). A total of 219 patients with primary myelofibrosis were randomized to therapy with ruxolitinib or to best available therapy. [ Read More ]

UK Researcher Charges NICE of Misapprehending Value of Costly Cancer Drugs

Value Propositions

Professor Jonathan Waxman, of Imperial College London, an expert in prostate cancer who founded the Prostate Cancer Charity in England and helped garner support for cancer treatment, has denounced the refusal of the UK National Institute for Health and Clinical Excellence (NICE) to approve the 2 new and expensive prostate cancer drugs approved last year in the United States, saying that NICE "has overregulated and proscribed drugs that offer real advances to people with cancer." He charges that NICE has blocked the approval of several new cancer drugs because of the agency's f [ Read More ]

Prostate Cancer Foundation Promotes Innovation in Young Investigators

Value Propositions

The Prostate Cancer Foundation (PCF) is expanding its efforts to encourage innovation in prostate cancer research. Its 2012 Young Investigator Awards have already funded 15 research grants internationally in the attempt to attract best innovations in the field. Each award recipient receives $225,000 during a 3-year period. In addition, each recipient institution matches the funding dollar for dollar, bringing each award to a total of $450,000 for every recipient. [ Read More ]

Online Genetic Testing Registry New Tool from NIH

Value Propositions

An online tool launched by the National Institutes of Health (NIH) will help patients, providers, and researchers navigate the rapidly growing landscape of genetic testing, many of them associated with cancer therapy. The Genetic Testing Registry (GTR) is available at www.ncbi.nlm. nih.gov/gtr/ and can be accessed by the public. "It is a tremendous resource for all who are struggling to make sense of the complex world of genetic testing," said NIH Director Francis S. Collins, MD, PhD. The GTR will be updated frequently, using data submitted by genetic test providers. [ Read More ]

Despite Lack of Value, Many Providers Recommend Ovarian Cancer Screening

Value Propositions

Results of a new survey of primary care physicians (PCPs) show that 1 in 3 PCPs believe that ovarian cancer screening is safe and effective, contrary to current evidence. The survey was published in the February 7, 2012, issue of Annals of Internal Medicine. Substantial evidence suggests that such universal screening is unnecessary and may involve risks associated with surgeries and other procedures because of frequent false-positive test results, as well as the associated unnecessary costs of such testing. [ Read More ]

Cancer Center Launches Personalized Medicine Institute

Value Propositions

Moffitt Cancer Center in Tampa, FL, has announced it is launching its Personalized Medicine Institute to advance the fight against cancer, and implementing the promise of personalized cancer care medicine by focusing on innovative biotechnology with its biotechnology subsidiary M2Gen. Moffitt’s Board Chairman Robert Rothman said that “the time is now, because cancer research and treatment is at an inflection point that requires the right mix of visionary leadership and collaboration to realize the promise of personalized cancer care for patients everywhere.”

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Novel Biologics Will Reshape Cancer Therapy by 2018, Affordability Key Challenge

Value Propositions

Researchers at Espicom Business Intelligence, a medical and pharmaceutical market analysis company, predict that the development of novel biologic approaches to drug therapy will bring "a sea change" to the approach to cancer therapy, by focusing on controlling solid tumors and the introduction of new drugs that target new pathways. These drugs could be on the market in the next 5 years, the researchers suggest, and that is expected to change the face of cancer therapy, based on current directions in biologic drug research. [ Read More ]

Personalized Vaccine Promising When Added to Sunitinib in Patients with Metastatic Renal-Cell Carcinoma

Wayne Kuznar

Genitourinary Cancers Symposium

San Francisco, CA—A personalized form of immunotherapy added to sunitinib (Sutent) treatment prolonged survival to beyond 30 months in almost half of patients with newly diagnosed, unfavorable-risk metastatic renal-cell carcinoma (mRCC), according to the results of an open-label phase 2 study presented at the 2012 Genitourinary Cancer Symposium. Only approximately 1 in 10 patients with unfavorable-risk mRCC treated with sunitinib, the standard first-line treatment for clear-cell mRCC, survive past 30 months. [ Read More ]

Dose Escalation of Axitinib as Second-Line Treatment of mRCC May Be Needed to Optimize Outcome

Wayne Kuznar

Genitourinary Cancers Symposium

San Francisco, CA—The dosage of axitinib, the standard second-line treatment for metastatic renal-cell carcinoma (mRCC), should be uptitrated in those patients who fail to achieve therapeutic blood levels on the standard 5-mg daily dosage, according to a new analysis of an international randomized trial presented at the 2012 Genitourinary Cancers Symposium. [ Read More ]

A Large Subset of Patients with Metastatic Prostate Cancer Go Untreated

Genitourinary Cancers Symposium

San Francisco, CA—More than 1 in 10 patients with metastatic prostate cancer never receive anticancer treatment for their disease, according to an examination of the National Cancer Database. Lack of private health insurance and lower income play a role in the lack of anticancer treatment, based on a new analysis. Alexander C. Small, a fourth-year medical student at Mount Sinai School of Medicine, New York City, sought to characterize the population of patients with advanced prostate cancer who did not receive treatment. [ Read More ]

Many Patients with mRCC Ineligible for Clinical Trials

Wayne Kuznar

Genitourinary Cancers Symposium

San Francisco, CA—A large number of patients with metastatic renal-cell carcinoma (mRCC) are ineligible for clinical trials and their clinical outcomes are inferior to those of patients who are trial eligible, according to a study presented at the 2012 Genitouri nary Cancers Symposium. The data were presented by the International mRCC Database Con sorti um, a group that analyzed data from 17 international cancer centers on consecutive series of patients with mRCC. Clinical trials have strict eligibility criteria to maintain internal validity. [ Read More ]

Nonpharmacologic Strategies Have Mixed Results in Prostate Cancer Prevention

Phoebe Starr

Genitourinary Cancers Symposium

San Francisco, CA—Nonpharmacologic strategies for prevention of cancer are potentially attractive and costeffective, but success stories are few. According to 2 separate studies presented at the recent Genitourinary Cancers Symposium, vigorous exercise prevented recurrence of prostate cancer and reduced mortality, whereas long-term vitamin E supplementation at commonly used doses actually increased the risk of prostate cancer in otherwise healthy men.

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For Metastatic Breast Cancer, Nab-Paclitaxel Requires Less Growth Factor Support

Caroline Helwick

Breast Cancer

San Antonio, TX—In a retrospective utilization and cost analysis, nab-paclitaxel (Abraxane) therapy was associated with substantially lower total use of prophylactic colony-stimulating factor (CSF) than docetaxel (Taxotere) and paclitaxel (Taxol) in the treatment of breast cancer. The study was reported at the 2011 San Antonio Breast Cancer Sympo sium by Rex W. Force, PharmD, Professor and Director of Research, Family Medicine and Pharmacy Practice, Idaho State University, and Partner, ImproveRX, LLC, and colleagues. [ Read More ]

Oncotype DX Assay Cost- Effective for Patients with ER-Positive Breast Cancer

Breast Cancer

San Antonio, TX—Assessing all eligible patients with breast cancer for recurrence risk with the 21-gene Oncotype DX assay at diagnosis could save $330.8 million annually by avoiding ineffective chemotherapy, according to data presented at the 2011 CTRC-AACR San Antonio Breast Cancer Symposium. This analysis involved nearly 200,000 estrogen receptor (ER)-positive tumor samples. The Oncotype DX assay, which is approved in this subgroup of patients with breast cancer, yields a risk score for disease recurrence. [ Read More ]

New Data Suggest Oncotype DX Unnecessary in Some Cases of Low-Grade Cancer

Rosemary Frei, MSc

Breast Cancer

Grapevine, TX—A New Jersey research team is making the case for relying less on the Oncotype DX test for breast-cancer prognosis and instead focusing on conventional pathological analyses. Pathologists at Saint Barnabas Medical Center, Livingston, NJ, and Monmouth Medical Center, Long Branch, NJ, found that in a retrospective review of 90 cases, 88% of those who had the following 3 characteristics were in the Oncotype DX low-risk category:

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Dose-Dense Chemotherapy plus Growth Factors in Elderly ER-Positive Patients Unnecessary, Costly

Caroline Helwick

Breast Cancer

San Antonio, TX—Women with estrogen receptor (ER)-positive breast cancer are unlikely to benefit from dosedense chemotherapy, but many are receiving this type of treatment, which involves the use of colonystimulating factors (CSFs), that is, growth factors. Limit ing the use of these therapies in a population that is unlikely to benefit from it, would save nearly $40 million annually, suggests a study presented at the 2011 CTRC-AACR San Antonio Breast Cancer Symposium. Dawn L. [ Read More ]

For Pancreatic Cancer, Neoadjuvant Chemoradiation Cost-Effective Compared with Surgery First

Caroline Helwick

Gasterol Intestinal Symposium

San Francisco, CA—For resectable pancreatic cancer, administering chemo - therapy and radiation before surgery results in better outcomes and lower costs than performing surgery first, reported researchers from M.D. Anderson Cancer Center, Houston. "Compared with a surgery-first approach, the neoadjuvant approach eliminates an ineffectual, costly, and potentially morbid treatment in patients with early metastases or a prohibitive function status. It is associated with improved survival, and it costs less per patient," said lead investigator Daniel Erik Abbott, MD. [ Read More ]

Oncotype DX Assay Changes 29% of Treatment Decisions in Patients with Stage II Colon Cancer

Gasterol Intestinal Symposium

San Francisco, CA—Results obtained on the Oncotype DX Colon Cancer Assay led to changes in treatment decisions 29% of the time for patients with stage II colon cancer, according to a survey of community oncologists reported at the 2012 Gastrointestinal Cancers Symposium. "One of the more difficult decisions is what stage II patients to treat," said lead investigator Thomas H. Cartwright, MD, Ocala Oncology, FL. "In stage II patients, we typically rely on more subjective factors, number of lymph nodes, tumor grade, and so forth. [ Read More ]

Economic Burden of Febrile Neutropenia in NHL Exceeds $11,000 per Episode

Caroline Helwick

ASH Annual Meeting

San Diego, CA—Among patients with non-Hodgkin lymphoma (NHL), costs related to febrile neutropenia (FN) treated with hospitalization exceed $11,000 per episode, researchers reported at ASH 2011. Although the research was conducted on patients in the United Kingdom, the investigators converted costs to US dollars and noted that their findings were in keeping with previous published US studies. [ Read More ]

Long-Term Survivors of Hematopoietic Stem-Cell Transplant Pose Significant Burden to Healthcare System

Phoebe Starr

ASH Annual Meeting

San Diego, CA—Survivors of hematopoietic cell transplant (HCT) have substantial medical illnesses and psychological symptoms ≥10 years after the procedure, representing a substantial burden to our healthcare system. Long-term HCT survivors have nearly a 6-fold greater risk than their siblings of life-threatening or severe illness or death, according to a study presented at ASH 2011. [ Read More ]

Novel Oral B-Cell Receptor Inhibitor Very Effective in Chronic Lymphocytic Leukemia

Caroline Helwick

ASH Annual Meeting

San Diego, CA—A novel inhibitor of B-cell receptor signaling, PCI-32765, produced high rates of remission and was well tolerated in patients with chronic lymphocytic leukemia (CLL) whose disease was refractory to at least 2 previous treatments, reported Susan O'Brien, MD, of the University of Texas M.D. Anderson Cancer Center, Houston. "To have agents that are this effective and that are not myelosuppressive is very exciting," Dr O'Brien said. [ Read More ]

Lymphoma Treatment in Pregnancy Does Not Compromise Fetal/Maternal Outcomes

ASH Annual Meeting

San Diego, CA—The treatment of lymphoma during pregnancy does not compromise fetal outcomes or maternal health and cancer-specific survival, according to a study presented at ASH 2011 from the University of Massachusetts Medical School in Worcester. Cancer diagnosed during pregnancy is rare—20% are hematologic malignancies— and data on outcomes are scarce, said Andrew Evens, DO, who presented the findings. Dr Evens and his colleagues therefore conducted a retrospective analysis of patients treated at 9 medical centers between 1998 and 2011. [ Read More ]

Chemotherapy Superior to Radiation for Nonbulky Hodgkin Lymphoma, but Older Radiotherapy Method Was Evaluated

ASH Annual Meeting

In patients with early-stage, nonbulky Hodgkin lymphoma (HL), overall survival (OS) was superior at 12 years in patients who received standard chemotherapy compared with radiotherapy in a study conducted by the National Cancer Institute of Canada's Clinical Trials Group and the Eastern Cooperative Oncology Group. The HD.6 trial enrolled 405 patients, who were followed for a median of 11.3 years. [ Read More ]

Confusion Still Surrounds Prophylaxis for Venous Thromboembolism

Caroline Helwick

ASH Annual Meeting

San Diego, CA—Venous thromboembolism (VTE) occurs in 1% of hematologic malignancies and can lead to fatal pulmonary emboli, postthrombotic syndromes, bleeding as a result of anticoagulant treatment, and recurrent VTE. VTEs are potentially preventable with appropriate thromboprophylaxis, and numerous quality measures have been developed to enhance this practice. The "curve ball" is that there is "much confusion" regarding VTE prophylaxis, said Richard H. [ Read More ]

High-Risk Myelodysplastic Syndrome: First-Line Treatment Choices Often Not Supported by Evidence

Caroline Helwick

ASH Annual Meeting

A review of treatment patterns for higher-risk myelodysplastic syndrome (MDS) shows growing use of lenalidomide, despite the lack of phase 3 survival data supporting this approach, according to research conducted at the Mayo Clinic Flori da, Jacksonville, in collaboration with Xcen da, a research and consulting firm. Since 2006, lenalidomide has been approved for the treatment of anemia in lower-risk patients with MDS and deletion of chromosome 5q (del[5q]). [ Read More ]

Cryoprecipate Is Overused, an Unnecessary Expense

ASH Annual Meeting

San Diego, CA—Only 30% of cryoprecipitate was used in accordance with established guidelines in a tertiary care center, in a study presented at ASH 2011 by researchers from Beth Israel Medical Center, Newark, NJ. "Hence, it seems that opportunities may exist for lower cryo usage," said Manpreet K. Sandhu, MD, of the hematology/ oncology department at Beth Israel. The literature has suggested that blood products, including cryoprecipitate, are overused. Their appropriate indications, and cryo constituent, according to the American Association of Blood Banks, are:

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Chemotherapy Administration Sequencing Chart

Chemotherapy

Oncology pharmacists receive numerous questions regarding the sequence of chemotherapy administration. Several chemotherapy agents (eg, doxorubicin, docetaxel, paclitaxel) are extensively metabolized through the cytochrome P450 pathway, and many chemotherapy agents (eg, taxanes, platinum agents) have high degrees of protein binding. In addition, many chemotherapy agents have cell cycle–specific mechanisms of action that may increase the cytotoxicity or antagonize the mechanism of the second agent. [ Read More ]

Vismodegib: A New Treatment Option for Basal-Cell Carcinoma

Rhonda Williams

Cancer Drugs

Basal-cell carcinoma (BCC) and squamous-cell carcinoma (SCC), commonly referred to as non-melanoma skin cancers (NMSCs), are the most common types of cancers in the United States. These 2 cancers account for approximately 2 million cases of skin cancer annually.1 BCC is approximately 4 to 5 times more common than SCC.2 Although rarely metastatic, BCC and SCC can cause substantial local destruction involving extensive areas of soft tissue, cartilage, and bone, as well as disfigurement. [ Read More ]

The End of Health Insurance Companies

Ezekiel J. Emanuel

Health Policy

Here’s a bold prediction for the new year. By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by ac-countable care organizations (ACOs) —groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.

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