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

Caroline Helwick

March 2012, Vol 3, No 2 - 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. Hershman, MD, Columbia University, New York, reported an analysis of Medicare data showing that the use of CSFs in the first cycle of dose-dense chemotherapy (ie, chemotherapy given every 2 weeks, not every 3 weeks) skyrocketed in response to published reports of its benefit. The use of CSFs among pa tients with stage I to III breast cancer increased accordingly, from 13% before 2002 to 68% between 2002 and 2005; the use of pegfilgrastim, in particular, jumped from 4% to 85%, she noted. "We are very quick in oncology to adopt, and we never pull back," Dr Hershman said. "If we have to make decisions in terms of controlling costs, we should not be giving drugs that are costly and have no benefit" for specific subpopulations of patients.

Her study identified 10,773 patients in the SEER-Medicare database aged ≥65 years who were diagnosed with early breast cancer between 1998 and 2005 and had at least 1 chemotherapy claim. Of these, 5266 patients had a claim for CSF use during therapy, and such claims increased substantially over time. For patients with ER-negative breast cancer, the dose-dense approach plus CSF was estimated to cost $19.5 million annually but was cost-saving in terms of event-free survival (ie, recurrences, deaths). For ER-positive patients, however, there was no savings in life-years, and annual costs rose to nearly $40 million for patients aged >65 years. Incorporating patients of all ages, the annual costs for the ER-positive population was estimated to exceed $86 million, Dr Hershman reported. Thomas J. Smith, MD, of Johns Hopkins University, Baltimore, who chaired the session where the study was presented, commented that the only thing the $40 million was buying in the ER-positive Medicare group was toxicity. "You are not buying any disease benefit," he agreed, suggesting further that dose-dense chemotherapy in elderly patients with ER-positive tumors should be put on the "do not use" list.