On-Pathway Regimens Are Associated With Significant Cost Savings for Treatment of Solid Tumors

Findings from a cross-institutional study suggest that on-pathway regimens led to significant cost savings for patients with cancer, despite the rate of hospitalizations and immune-related adverse events (irAES) being similar between on-pathway and off-pathway regimens.1 According to the results, which were published in the Journal of Clinical Oncology, prescribing on-pathway regimens led to an average $17,589 reduction in total health care cost per patient (95% CI, –$23,790 to –$11,388; P < .001) and a $22,543 reduction in chemotherapy cost per patient (95% CI, –$27,666 to –$17,420; P < .001).¹

The rate of hospitalization for any cause was highest among on-pathway patients with melanoma (adjusted odds ratio [aOR], 1.679; 95% CI, 1.115-2.529; P = .013), yet the rate of treatment-related hospitalization was similar between the 2 groups, at 25.2% vs 22.9%, respectively (aOR, 1.080; P = .201). The rates of irAEs were also comparable between the 2 arms, at 75.2% vs 74.6%, respectively (aOR, 0.961; P = .497).¹

“Among patients who received first-line cancer treatment for metastatic solid tumors, use of CCQP [Cancer Care Quality Program]-endorsed on-pathway treatment regimens was associated with significant cost savings,” the investigators wrote in the study.¹ “Overall, there was a significant reduction in total health care cost for patients prescribed with on-pathway regimens, driven mainly by the lower cancer drug costs for this group.”

Oncology clinical pathways have been developed to combat the rise of cancer drug costs and variation in quality of care.² Approximately 60 health insurance plans have adopted these pathways, which comprise a subset of evidence-based regimens selected for their efficacy, toxicity, and costs. Expert panels review the pathways quarterly and update them when necessary. The CCQP is one such pathway and was launched in July 2014 by Aim Specialty Health.³ Of note, physicians are encouraged to use this pathway; they receive incentive pay of $350 per patient per month for prescribing on-pathway regimens.¹

Investigators sought to evaluate the toxicity and cost outcomes for patients with metastatic cancer who were prescribed an on-pathway regimen. They looked at emergency department (ED) visits, supportive care medication administration, and AEs to assess toxicity outcomes, as well as medical costs, pharmacy costs, and out-of-pocket patient costs to assess treatment expenditure.

Investigators collected claims and authorization data for patients with 9 metastatic tumor types—melanoma, breast, lung, colorectal, pancreatic, kidney, bladder, gastric, and uterine cancer—from the CCQP data and registry files between January 1, 2019, through October 31, 2021. These data were linked to the Healthcare Integrated Research Environment Database to gain additional information on patient characteristics, their health care plan, and the costs of care.¹

The study parameters defined a treatment-related hospitalization or ED visit as at least 1 inpatient or ED claim related to any of the following AEs: anemia, nausea, dehydration, neutropenia, pain, pneumonia, fever, sepsis, cough, fatigue, constipation, appetite loss, dysuria, flushing, or neuropathy. Immune-related AEs included complications such as endocrinopathies, hepatitis, and myocarditis.

The study included data from 8357 patients, 5453 of whom (65.3%) received on-pathway regimens. Throughout data collection, the proportion of on-pathway patients became smaller, starting at 74.3% in 2018 and landing at 59.8% in 2021. The mean patient age was similar for both cohorts (60.1 vs 59.6 years; P =.056), and the on-pathway group included fewer women (54.6% vs 57.3%; P = .021).¹

Patients who were prescribed an on-pathway regimen experienced more all-cause hospitalizations (36.4%) compared with patients treated with an off-pathway regimen (31.8%; aOR, 1.154; P = .008). The rates of all-cause ED visits and treatment-related ED visits were also higher in this group (27.7% and 18.1%) than their counterparts (23.3% and 15.0%). The aOR was 1.161 in both arms (P = .011 and P = .032, respectively).¹

“Interestingly, although treatment-related hospitalizations were similar, there were slightly more all-cause hospitalizations in the on-pathway arm, which may be driven primarily by patients with melanoma,” the authors wrote.¹ “With its high efficacy but known toxicities, higher use of ipilimumab [Yervoy] among patients with melanoma receiving on-pathway regimens may have driven this increase; 34% of on-pathway vs 18% of off-pathway patients with melanoma had treatment containing ipilimumab.”

The out-of-pocket costs for patients who were prescribed on-pathway regimens were $274 less than for their off-pathway counterparts (95% CI, –$506 to –$42; P = .021). There were no statistically significant differences between the 2 groups in terms of pharmacy costs and nonchemotherapy costs (P > .05).

In addition, on-pathway treatments for patients with bladder, breast, and lung cancer were associated with significant reductions in total health care spending. The cost savings associated with each of these cancer types were $50,489, $21,734, and $16,409, respectively (P ≤ .001).¹ Bladder, breast, colorectal, and lung cancers were linked to significant savings in cancer drug costs ($75,151, $17,388, $16,404, and $16,233, respectively; P < .001).

Although no significant difference was reported in the remaining cancer types, there were increased total health care savings reported for patients with pancreatic ($33,957), colorectal ($6039), and uterine cancer ($3600). Total cancer drug spending was also reduced, though not significantly, for patients with gastric (–$34,320), uterine (–$17,061), and pancreatic cancer (–$7207).

Of note, authors cited that sample sizes were small for gastric and uterine cancers, therefore those analyses were underpowered.¹

Excluding the cancer drug costs, the total spending was similar between the 2 groups for all subtypes except for colorectal cancer, for which on-pathway regimens were associated with $10,076 of additional costs (95% CI, $585 to $19,566; P = .037).¹

The use of supportive care was reported to be greater among patients in the on-pathway group who had bladder cancer (aOR, 4.602; P < .001) and colorectal cancer (aOR, 4.465; P < .001). The authors explained that the 4-fold difference could be attributed to the on-pathway regimens used, including oxaliplatin and irinotecan, which are associated with gastrointestinal toxicities.

However, patients in the on-pathway group who had breast cancer (aOR, 0.668; P = .001) or lung cancer (aOR, 0.550; P < .001) received fewer supportive care drugs. The rate of any supportive care use, regardless of disease type, was 81.3% for on-pathway patients, and 79.5% for off-pathway patients (aOR, 0.913; P =.195).¹

Overall, the investigators maintained that the findings support prescribing on-pathway regimens for patients with metastatic solid tumors; however, they noted that trends in prescribing patters did shift over the course of the analysis. “We observed a decrease in on-pathway prescribing over time during our study period,” they wrote.¹ “Although the reason for this is unclear, we hypothesize that the COVID-19 pandemic may have influenced the way that practices participated in the program [due to] changes in staffing and workflows. Additionally, the recent emergence of many new treatment options may have contributed to off-pathway prescribing in later years.”

References

1. Liu Y, Mullangi S, Debono D, et al. Association between oncology clinical pathway utilization and toxicity and cost outcomes in patients with metastatic solid tumors. JCO Oncol Pract. Published online June 29, 2023. doi:10.1200/OP.23.00199
2. Clinical pathways. American Society of Clinical Oncology. Accessed July 11, 2023. bit.ly/3q5a40O
3. Cancer care quality program. Carelon. Accessed July 11, 2023. bit.ly/43D5mFb