According to a study led by UNC Lineberger Comprehensive Cancer Center and UNC Gillings School of Global Public Health researchers, administering common chemotherapy drugs in a particular order for some types of metastatic breast cancer can help lower overall costs and improve the value of care while preserving quality of life.
The study’s results appeared Sept. 2, 2022, in the Journal of Clinical Oncology.
To forecast how a fictitious group of 10,000 patients with particular forms of metastatic breast cancer would react to various chemotherapy regimens and delivery systems, the researchers created three alternative computer models.
For this trial, the patient’s cancer was either triple-negative breast cancer or had become endocrine resistant, meaning it was no longer responding to hormone treatments. There are numerous chemotherapy options available right now to treat metastatic breast cancer.
Although there isn’t much conclusive research on the optimum way to administer the medications, oncologists have certain preferences for which ones to employ early in treatment. To decide which chemotherapy medications would be best to use in the trial, the researchers consulted oncologists and other professionals.
The researchers then made the assumption that if a patient started therapy with one drug, they would switch to a second-choice treatment once their cancer stopped responding to the first drug or if the side effects weren’t bearable, mimicking clinical practice and based on available data.
The goal of the trial was to see whether administering the medications in one order vs another could keep the patient on therapy for an equivalent amount of time while reducing their risk of side effects and/or financial burden.
“The cost of cancer drugs in the U.S. has rapidly increased, even for generics. As a society, we urgently need more strategies to reduce cancer drug costs without compromising outcomes, and our analysis provides quantifiable evidence to help providers choose lower priced, but equally effective sequences of drugs,” said Stephanie B. Wheeler, PhD, MPH, professor of health policy & management at UNC Gillings and associate director of community outreach and engagement at UNC Lineberger and corresponding author of the article. “More spending on cancer care does not necessarily confer greater health benefits.”
The costs tallied in this study included lost productivity as well as patient-borne medical and non-medical expenses. In this simulation, virtually all of the women would have finished the first three rounds of treatment after two years, but around one-third of the women would have passed away from the cancer.
In that scenario, I hope our study will help expand the framework that we use to make these decisions from one where we just think about the biologic action of the drug to one where we also consider the bigger picture of what the treatment experience is like for the patient, including their financial burden, investment of time, and side effects. The most potent drug isn’t always the next best choice depending on what the patient values and wants to accomplish with their treatment.
Katherine E. Reeder-Hayes
The majority of the cost difference was caused by drug savings because the number of productivity days lost to illness was comparable across chemotherapy regimens. Depending on the therapies they had already had for prior instances of breast cancer, the patients in the simulation were divided into three groups.
Outcomes in the three groups were:
- Treatment with paclitaxel, capecitabine, followed by doxorubicin corresponded to the highest expected gains in quality of life and lowest costs for patients who had not previously received the common chemotherapy drug categories, including a taxane (for example, paclitaxel) or an anthracycline (for example, capecitabine).
- Treatment with carboplatin, then capecitabine, then eribulin corresponded to the highest predicted gains in quality of life and lowest costs for patients who had previously had a taxane and an anthracycline medication.
- The most cost-effective treatment sequences started with capecitabine or doxorubicin, then were followed by eribulin for patients who had previously received a taxane but not an anthracycline.
“The drugs we studied are already recommended and reimbursed for the treatment of metastatic breast cancer, but the optimal sequencing of them has been unclear, which has led to considerable variation in physician preference and practice. Our study suggests that treatment sequencing approaches that minimize costs early may improve the value of care,” Wheeler said. “The implications of this study are fairly straightforward for medical oncologists and those developing value-based clinical pathways to implement in practice now.”
UNC Lineberger’s Katherine E. Reeder-Hayes, MD, MBA, MSc, section chief of breast oncology and associate professor of medicine at UNC School of Medicine and one of the study’s authors, said the treatment choices for metastatic breast cancer are constantly changing, and new options for targeted therapy have emerged even since this study was conducted.
Many physicians and patients discover that there are no longer any targeted therapies that match the molecular profiles of their cancers, leaving them with a limited selection of chemotherapy medications that may feel quite similar to one another or have a muddled balance of benefits and drawbacks.
“In that scenario, I hope our study will help expand the framework that we use to make these decisions from one where we just think about the biologic action of the drug to one where we also consider the bigger picture of what the treatment experience is like for the patient, including their financial burden, investment of time, and side effects,” Reeder-Hayes added. “The most potent drug isn’t always the next best choice depending on what the patient values and wants to accomplish with their treatment.”
In the future, the researchers plan to create a financial navigation software to help patients better manage their out-of-pocket expenses for cancer treatment. Patients, carers, and physicians have all expressed satisfaction with how effectively this program works.
To determine how well the intervention performs in various care contexts, the team is currently scaling it up in nine rural and non-rural oncology offices around North Carolina. For this project, cancer patients who want financial assistance managing the cost of their cancer care are being sought out.
