When treating patients with colon cancer in the community oncology setting, adherence to evidence-centered guidelines for the use of chemotherapy regimens varies by setting, with adherence rates higher in the adjuvant setting and somewhat lower in the metastatic setting, said McKesson Specialty Care Solutions’ Zhaohui Wang, MD, PhD, at the 2010 ASCO meeting.
The cost of guideline-based therapy also varies widely, ranging from $6590 to more than $40,000 (Medicare cost) in the adjuvant setting, and from $2930 to more than $50,000 in the first-line metastatic setting.
These findings came from examination of a large, US medical oncology clinical database containing data for calendar year 2009. Treatment regimen cost information was derived from Regimen Profiler, which is a web-based program that evaluates regimen-associated costs for payers, including Medicare. (For more on Regimen Profiler, see the story “New Tools Arriving to Measure and Manage Chemotherapy Care,” in the May issue of VBCC.)
The database included 2976 treatment regimens (≥1 chemotherapeutic/biologic agents administered in a repeating pattern) for patients with colon cancer who were treated in 383 community oncology practices across 45 states.
A total of 1380 adjuvant regimens and 1596 first-line metastatic regimens were analyzed. The rate of guideline adherence was 80.9% in the adjuvant setting and 76.6% in the metastatic setting.
The top 5 regimens used in the adjuvant setting were given to 80% of patients, whereas the top 5 regimens used in the first-line metastatic setting were given to only 60% of patients, said Dr Wang.
The most often used “off guideline” regimen was a combination of FOLFOX-4 (oxaliplatin, leucovorin, fluorouracil) with bevacizumab given at 10 mg/kg. The guideline recommendation is 5 mg/kg for the bevacizumab component of this combination. When bevacizumab was first approved by the US Food and Drug Administration (FDA), it was at the 10-mg/kg dose level, he noted, “but subsequent studies have failed to find a dose-response relationship between 5 and 10 mg/kg, so the guidelines recommend 5 mg/kg. Physicians who are not aware of these data may be continuing to give the FDA-approved dose even though it is considered ‘off guideline.’”
A standard course of therapy in the adjuvant setting ranged from $8124 for 5-flourouracil-leucovorin to $51,242 for CAPOX (cetuximab, oxaliplatin, capecitabine).
In the first-line metastatic setting, regimen costs ranged from $5286 for modified FOLFIRI (irinotecan, 5-fluorouracil, leucovorin) to $39,683 for CAPOX with bevacizumab on day 1, based on 3 months of therapy.
“Guideline adherence rates for cancer treatment should approach 80% to 90%, taking into account various patient-specific comorbid conditions that preclude guideline adherence,” Dr Wang told meeting attendees. Guideline adherence in the adjuvant setting, at 80.9%, approached this level but fell short in the first-line metastatic setting. “With the plethora of new agents now available in the marketplace, and phase 3 randomized trial data showing good outcomes with the use of many regimens and the widespread use of guidelines, compliance should seemingly be higher,” he said.
“One possible reason that treatment guideline adherence rates for the metastatic treatment setting are lower than the adjuvant group could be that the metastatic group is likely to have more comorbidities than the adjuvant group due to previous exposure to drugs, radiation, or surgery,” Dr Wang explained.
Few resources have been devoted to the cost of cancer care, even though programs such as Regimen Profiler are available, said Dr Wang.
