Management of Long-Term Cancer Care Costs
Oral cancer treatments provide new opportunities for improved overall survival rates, but patients are increasingly responsible for higher out-of-pocket costs as they self-manage their therapy.
The cancer care landscape is continuously evolving. In the past decade, more than 25% of oncology drugs in the development pipeline were oral antineoplastic agents, and this percentage is expected to grow.1
Additionally, new molecular entities and new drug indications that have been approved include dual therapy regimens, some of which involve at least 1 oral antineoplastic agent. Oral cancer treatment options and multiple drug regimens provide new opportunities in cancer care with improved overall survival rates.
These opportunities lead to a shift in care from the in-patient setting to the out-patient setting, and patients are increasingly responsible for higher out-of-pocket costs as they self-manage their therapy. This paradigm shift has resulted in various challenges for the health care team, while they work to successfully care for the cancer patient.
These challenges include, but are not limited to, medication adherence and financial toxicity. Patients often assume that oral anticancer treatments have less toxicity than infused chemotherapy. This misperception can frequently lead to ineffective management of side effects, which may result in more office or emergency department visits, thus increasing overall health care costs.
Additionally, many patients do not fully understand the importance of taking their medication as prescribed. For example, missing an occasional dose is not viewed as something that could ultimately decrease progression-free survival or prevent a patient from entering remission.
This assumption makes managing patients and their medications even more difficult for those patients taking long-term antineoplastic agents to treat their cancer. Poor adherence may be the primary reason that certain cancer patients have an inability to obtain an adequate molecular response, as seen in a 2010 study by Marin et al.2
For example, variability was noted in patients with chronic myeloid leukemia (CML), and the level of molecular response achieved with imatinib (Gleevec) therapy suggesting variability exists in the patient’s therapy adherence. A strong correlation between adherence rates of ≤ 90% or > 90% and the 6-year probability of obtaining » a major or complete molecular response was noted in 87 patients with CML administered imatinib. Similarly, a cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer suggests that women who were <80% adherent had a 10% increased risk of death.3
It is important to note that the rate of adherence year over year is likely to decrease. For example, a cohort of early-stage breast cancer patients starting adjuvant tamoxifen showed overall mean adherence rate percentages decrease over time.4
Medication counseling in patients on long-term maintenance therapy with antineoplastics should be continuous and does not end after the patient’s first time to fill. A rising challenge among patients on an oral anticancer regimen includes managing financial toxicity. Financial toxicity can be defined as “the objective financial consequences of cancer, as well as the subjective financial concerns that come along with expensive health care.”5
The average annual cost of cancer treatment prior to 2000 was $10,000. Now, with recently approved anticancer agents, this amount has increased to $100,000 or more.6 These average annual costs continue to rise with the evolution of combination therapy, in both office-administered and patient self-administered treatment regimens.
Combination therapy of nivolumab (Opdivo) and ipilimumab (Yervoy) was originally approved for patients with BRAF V600 wild-type unresectable or metastatic melanoma. In 2016, the combination received expanded FDA-approval in patients regardless of BRAF mutational status. This indication was granted accelerated approval based on progression-free survival. This treatment regimen is administered as an infusion in the physician’s office.
Collectively, the annual price tag of a melanoma treatment regimen including nivolumab and ipilimumab would cost $256,000. If purchased individually, the 2 drugs carry a list price of approximately $300,000.7
Fortunately, patients typically are not responsible for the full cost of treatment. However, with these higher costs, the patient’s out-of-pocket expense will likely increase. Furthermore, payers may require an increase in documentation to justify coverage, which increases the administrative burden for the health care team.
New combination anticancer regimens are not limited to office-administered medications. In 2015, an oral self-administered treatment regimen including ixazomib (Ninlaro), lenalidomide (Revlimid) and dexamethasone was approved for the treatment of multiple myeloma in patients who have received at least 1 prior therapy.8
These new regimens are exciting for treatment advances, but come with a high price tag that may affect how effectively they are used. Anticancer combination treatment options may involve both office-administration and patient self-administration.
“Multiagent therapy with newer proteasome inhibitors such as ixazomib or carfilzomib (Kyprolis), and with monoclonal antibodies such as daratumumab (Darzalex) added to lenalidomide, can boost the monthly drug costs to $30,000 to $40,000,” wrote the authors of a July 2016 article in MedPage Today.9
Depending on a patient’s insurance coverage, their financial responsibility may range well above 10% to 20% of the drug costs. These examples indicate how financial toxicity has become a major concern for the patient, as well as the health care team, when treating cancer patients.
The high cost of the medications in these treatment regimens raise concerns about adherence. These regimens are cyclic and depend upon multiple agents administered at specific days during the cycle. Careful collaboration across the entire health care team is vital.
The current anticancer treatment options are increasing survival rates, as more patients are living longer with cancer. These trends reflect the chronicity of cancer, and in some cases, indicate that patients are requiring anticancer medications for a longer duration.
While patients are on therapies longer, challenges with financial toxicity and adherence increase, as well. The specialty pharmacy will continue to play an increasing role in the collaboration of care for a cancer patient.
Regardless of whether a patient is new to therapy or picking up his or her refill, the specialty pharmacy often includes the last health care team member to speak with a patient prior to the start of their therapy. It is during these interactions that the specialty pharmacy can access a patient’s adherence behavior and identify factors that may affect it.
When the primary barrier to adherence includes cost of therapy, the specialty pharmacy can assist in securing funding that supports treatment costs. Furthermore, the specialty pharmacy is positioned to connect patients with additional resources that may help with the indirect costs that are often associated with anticancer treatment.
For example, additional financial support may include travel and/or housing grants. According to the Family Reach Foundation annual report, more than 50% of the grants they awarded were for housing (mortgage and rent) assistance to patients with cancer.10
Not only can financial toxicity create tremendous stress for the cancer patient—in extreme cases requiring bankruptcy—it may be tied to poor patient outcomes and even increased mortality.11 It is difficult to discern whether financial toxicity directly correlates to diminished patient outcomes because of distress or if it contributes to poorer adherence, thus resulting in negative patient outcomes.
In either case, the role of the specialty pharmacy is vital in addressing this concern. As the landscape of cancer treatment continues to evolve and side effects associated with treatment are discussed with the cancer patient, the concept of financial toxicity must also be addressed and monitored, along with its impact on medication adherence. The impact of these changes in the cancer care space reaches beyond the specialty pharmacy.
Collaboration of care across the entire health care team is of the upmost importance to the success of anticancer treatment. It is during this paradigm shift that the specialty pharmacy must be consistently incorporated as a critical member of the health care team. By working together, not only will cancer patients have the best choice for treatment, but they will be able to better afford costs associated with their treatment without financial distress. 
About the Authors
Jennifer Powers, PharmD, is Walgreens senior manager, Oncology Disease StateMatthew Farber, MA, is Walgreens senior director, Oncology Disease State
