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.
Breast cancer specialist Eric P. Winer, MD, Dana-Farber Cancer Institute, Boston, introduced the presentation by commenting, “If we don’t take control as the people providing the cancer care, we will lose all control.”
In 2010, the United States spent $16.5 billion on breast cancer care (Table 1). “Most of the money, by far, is spent at the end of life,” Dr Elkin observed.
An earlier investigation based on 2002 US dollars (Warren et al. J Natl Cancer Inst. 2008;100:888-897) showed that the initial phase of cancer care averages $21,000, although the cost goes much higher for many patients: chemotherapy averages $12,800; surgery, $5700; radiation, $4500; and other inpatient expenditures total $16,700. Of these, surgery accounts for the highest percentage (25%) of the total cost, topping $261 million. Chemotherapy accounts for 15% and reaches $157 million.
“Altogether, extrapolating to total spending, breast cancer costs the country $1.06 billion” annually, she said.
It is no surprise that the rising price of new drugs contributes to the escalating costs of cancer care. Translated into 2010 dollars, that increase over time is stark. Tamoxifen, approved in 1977, costs $100 per month in today’s dollars, whereas letrozole, approved in 1997, costs double that amount. Paclitaxel, approved in the 1992, costs $3000 a month, but nab-paclitaxel increased the taxane expenditure to about $7000.
“Why are costs increasing?” Dr Elkin asked. “Price of drugs and quantity are both factors.”
New technology results in more expensive treatments and more patients eligible for treatment, largely because the associated toxicity and risks are diminished as treatments evolve. The projected spending for 2020 shows that breast cancer is still associated with the highest cost of care among the common tumor types. “How high that goes depends on assumptions about trends, incidence, survival, and cost,” she said.
She described an example in which ixabepilone, added to capecitabine in taxane/anthracycline–resistant metastatic breast cancer, has been shown to increase response rates, reduce disease progression by 25%, and extend progression-free survival by 1.6 months. However, it adds $4200 (in 2008 dollars) to each cycle of treatment; therefore, for the average 5 cycles in the metastatic setting, ixabepilone provides a very small—although significant—benefit, costing payers $21,000.
“Do you think this drug is worth the cost?” she asked oncologists. “Healthcare spending must be prioritized,” she suggested.
To make good decisions, information about value is needed. A cost-effectiveness (or cost-utility) analysis can help estimate value for the money, she said. It measures effectiveness in quality-adjusted life years (QALYs) and produces an incremental cost-effectiveness ratio (ICER). The cost-effectiveness of various breast cancer interventions varies tremendously (Table 2).
“What is considered a good value for the money depends on the willingness to pay for the health gain,” Dr Elkin said. “In the United States, there are no strict criteria, but the common perception is that less than $50,000 per QALY is a low ICER and a good value, $50,000 per QALY to $100,000 per QALY is a judgment call, and more than $100,000 per QALY is a high ICER that must be justified on clinical grounds.”
“But should we adjust for inflation?” she asked. The $50,000 cut-point proposed in 1982, and adjusted to 2007 dollars, would equal $197,000 per QALY.
“The $100,000 as a benchmark may also be keeping people resistant to the notion of cost-effectiveness analysis,” she suggested. “The rule of thumb is probably too low, and it is certainly outdated.”
Dr Elkin noted that cost-effectiveness analyses are not used much for decision-making in the United States, but they are used in many other countries. “But let’s be clear,” she said; “cost-effective does not necessarily mean cost-saving. Most medical interventions do not save money, and most result in net monetary expenditure.”
Dr Elkin insists that the questions that must still be answered are:
