ASCO 2017: Same-Day Dosing Cuts Costs

Researchers achieved cost savings and cut down on the amount of drug they had to throw away by pooling drug vials and dosing all patients with a given disease on the same day of the week, according to data released ahead of the 2017 ASCO Annual Meeting.

Additional study results to be presented at ASCO show that the clinical value of newly launched agents appears to be declining relative to rising costs of novel drugs, dose reductions don’t result in savings on oral oncolytics, and expanded indications for drugs constitute a financial risk for clinics enrolled in bundled or shared savings plans.

Dosing Patients in Batches for Savings

The ASCO meeting is from June 2-6 next week in Chicago.Researchers in Canada achieved significant cost savings using an expensive agent whose minimum size vials were larger than necessary for average patient dosing by scheduling dosing for all patients on the same weekday.¹ Any unused drug was saved and used to treat other patients.

The study, conducted at the Princess Margaret Cancer Center in Toronto, Canada, focused on use of the taxane cabazitaxel (Jevtana) for patients with metastatic castrate resistant prostate cancer (mCRPC). The drug costs $96.70 Canadian dollars (CAD) per mg and comes prepackaged in 60 mg single-dose vials, a quantity higher than the average prescribed dose. The researchers said that despite a discount offered by Sanofi to help cover the costs of drug wastage, many centers still cannot afford to administer the drug.

“We investigated whether aggressively batching patients on the same day and allowing for excess drug to be used for subsequent patients can result in cost savings,” the authors wrote. From September 2015 to September 2016, all mCRPC patients receiving cabazitaxel at Princess Margaret were treated only on Mondays. Patients were dosed according to clinical parameters, and hospital staff tracked the number of vials used and the amount of drug wasted.

During the trial period, 28 patients received cabazitaxel therapy until disease progression or toxicity. In total, they underwent 117 individual treatment sessions administered on 53 treatment days. With the batching system, 91 cabazitaxel vials were used, in comparison with 117 vials that would have been required with standard practice. As a result, 26 vials were unopened, and the hospital saved $149,760 CAD, a 22.2% cost reduction over 1 year.

During the study, $121,154 CAD worth of cabazitaxel was wasted, compared with $251,808 CAD worth of drug that would have been wasted without batching, for a savings of $130,656 CAD.

Value of Drugs Declines Relative to Cost

The authors concluded that batching with cabazitaxel at a single treatment center was feasible and resulted in significant reduction in wastage. “This approach could be applied to centers with adequate patient volumes to save costs and reduce a key barrier to the use of cabazitaxel. A similar strategy can also be applied to other drugs across the field of oncology and has similar implications for cost savings,” they wrote.A research team in Toronto has concluded that the rising cost of new oncology drugs actually exceeds their added clinical benefit.² In fact, the value of novel agents appears to be decreasing, they said.

Noting an average 10% annual increase in the price of new drugs from 1995 to 2013, researchers from the Sunnybrook Health Sciences Centre and the Odette Cancer Centre sought to determine whether the clinical benefit of new drugs was keeping pace with rapidly growing drug prices.

The researchers studied novel drugs from randomized controlled trials (RCTs) whose data was used to inform FDA drug approvals from January 2006 to August 2015. For each drug, only the first FDA-approved indication was studied. The clinical benefit of drugs was measured with ASCO’s Value Framework and the ESMO Magnitude of Clinical Benefit Scale. Drug launch prices were obtained from Red Book, an online compendium of drug price and benefit information. Drug costs were based on a 28-day supply.

The study included 40 RCTs, and whereas the 28-day drug costs were significantly associated with the FDA approval year, with an average 8.5% increase each year, the ASCO and ESMO clinical benefit scores (26 and 3, respectively) were not statistically associated with FDA approval year (P = .73 and P = .86).

Dose Reductions Don’t Result in Savings

The authors concluded that “the rising cost of novel oncology drugs over time is not associated with an increase in their clinical benefit, suggesting a decrease in their value over time.”Researchers from the same Canadian institutions sought to determine whether dose reductions resulted in lower costs for oral oncolytics. Whereas there is a general expectation that the cost of drugs should go down with dose reduction, decreased dosing of oral cancer drugs generally does not result in lower costs, they concluded.³

The researchers studied the impact of dose reductions in cases of linear pricing, under which distributors reduce prices based on lower strength of tablets, and flat pricing, under which prices remain the same despite the reduced strength of pills. “In general, dose reduction did not decrease the cost per 28 days of drug for drugs using flat pricing per tablet, but [costs were] proportionally reduced in drugs using linear pricing,” the authors wrote.

Also, the researchers assumed that under a flat-pricing scenario, the actual cost of drugs could increase with a lower dosage because more tablets may be required.

For their analysis, the researchers included 17 drugs for 20 indications. There were 3 drugs for hematological cancers and 14 for solid cancers, and 59% of these drugs were available in multiple strengths. Five were available on a flat-pricing basis, 5 on a linear-pricing basis, and the remainder were available in a single strength tablet.

The researchers concluded that dose reductions generally increased the cost per mg for drugs using flat pricing per tablet, with a mean increase of 82% (range: 25%-200%) at dose level -1 and 100% (range: 0%-200%) at dose level -2. Dose reduction generally had no effect on the cost per mg of drug for drugs in the case of linear pricing except for lenalidomide, which researchers said had increased costs due to minimal price variation between the highest and lowest tablet strengths.

Expanded Drug Indications Constitute a Financial Risk

The Canadian Agency for Drugs and Technologies in Health, Toronto, also participated in the study.Finally, researchers at the Center for Cancer and Blood Disorders in Fort Worth, Texas, and the University of Pittsburgh Medical Center concluded that bundled rate and shared savings plans hold considerable financial risk for providers when indications for existing drugs are expanded to new, larger populations of patients.⁴

The study was based on the premise that new payment models in oncology will likely include accepting risk on drug costs. The recent label expansion for pembrolizumab (PB) in 1st-line non—small cell lung cancer (NSCLC) for >50% PD-L1 expression is an example of this risk, the authors said. “A broader indication in the future will likely result in use of PB for almost all 1st-line patients.”

The researchers reviewed actual treatment information in 1st line, maintenance (MT), and 2nd lines of therapy in non-squamous mutation-negative NSCLC for a 12-month period ending in November 2016. They calculated a hypothetical alternative where PB received full 1st line and maintenance indication given with pemetrexed and carboplatin. They assumed 2nd line patients received either docetaxel or ramucirumab/docetaxel.

The total Medicare (MC) cost in the actual arm (n =208) was $13.9 million, $12.2 million, and $11.6 million for 1st, MT, and 2nd line treatments, respectively. The total MC cost in the hypothetical arm (n = 208) was $25.5 million, $25.7 million and $6.4 million for 1st, MT, and 2nd lines of care, respectively.

The researchers found that total costs increased $19.8 million (52.5%), or $95,346 per patient.

References

1. Fallah-Rad N, Lee R, Ng P, et al. Strategies to minimize wastage of expensive drugs in expensive times: cabazitaxel, a single center experience. J Clin Oncol 35, 2017 (suppl; abstr e18297)
2. Saluja R, McDonald E, Arciero VS, et al. Examining the relationship between cost of novel oncology drugs and their clinical benefit over time. J Clin Oncol 35, 2017 (suppl; abstr 6598).
3. Truong J, Chan KK, Mai H, et al. The impact of pricing strategy on the cost of oral anti-cancer drugs during dose reductions. J Clin Oncol 35, 2017 (suppl; abstr e18312).
4. Page RD, Ellis PG, Lokay K, Barry A. Expanding indications of existing drugs and associated costs under risk reimbursement models. J Clin Oncol 35, 2017 (suppl; abstr e18306).