Cost of Treating Colorectal Cancer Has Skyrocketed

Zosia Chustecka

November 12, 2008

November 11, 2008 — The cost of treating colorectal cancer has skyrocketed over the past 5 years or so, and the costs of new agents and regimens have risen 340-fold, compared with traditional regimens. Although increased costs of treatment have also been seen for other cancers, the situation is particularly striking for colorectal cancer, say the authors of a report published in the November issue of the American Journal of Managed Care.

The study found a wide variation in the way that colorectal cancer is being treated across the United States, resulting in huge differences in costs. "The total cost of chemotherapy to treat colorectal cancer may differ by as much as $36,999 per patient, depending on the regimen," commented senior author Gary Lyman MD, MPH, an oncologist and health outcomes researcher at the Duke University Comprehensive Cancer Center, in Durham, North Carolina.

This variation is likely to be even bigger now that monoclonal antibodies, such as cetuximab (Erbitux) and bevacizumab (Avastin), have been accepted as standard therapies to be added onto chemotherapy regimens. The study finished at the end of 2005, and so did not assess the impact of these new products, Dr. Lyman explained. It focused on chemotherapy regimens and found enormous variations in cost. "As bad as it looked then," Dr. Lyman commented in an interview, "I would guess it is even worse now."

This wide variation in cost "raises many questions about what kind of care patients are receiving and whether this economic burden is matched by significant clinical advancements, especially with regard to quality of life," he said.

Rapidly increasing costs have raised ethical questions.

"For many of these colorectal cancer patients, depending on how advanced their disease is, we may be talking about buying a few months," Dr. Lyman continued. "And these rapidly increasing costs have raised ethical questions regarding whether such sums of money should be dedicated to treatments that may prolong life by several months but not offer an increased cure rate."

Enormous Variation in Costs of Treatment

Dr. Lyman and colleagues analyzed data on 421 patients who received chemotherapy for colorectal cancer at ambulatory centers across the United States. They identified 8 commonly prescribed regimens and calculated the total cost of 6 cycles of treatment.

Total Cost of 6 Cycles of Commonly Prescribed Treatment Regimens

Chemotherapy Regimen Total Cost of Treatment ($)
5FU/LV (5-flurouracil plus leucovorin) 1,028
IFL/FOLFIRI (flurouracil/leucovorin/irinotecan) 38,027
FOLFOX (fluorouracil/leucovorin/oxaliplatin) 17,584
Irinotecan 25,287
CapeOx (capcitebine/irinotecan/oxaliplatin) 34,744
Oxaliplatin 11,593
IROX (irinotecan plus oxaliplatin) 27,134

The top 3 regimens listed in the table are the most commonly prescribed, together accounting for the majority of the patients (366 of 421 patients). Since the study was completed, fluorouracil/leucovorin/oxaliplatin (FOLFOX) has become even more popular, Dr. Lyman commented, and is currently considered the standard chemotherapy regimen for colorectal cancer in the United States. "It's not the most expensive of the regimens, but it costs more than 20 times the traditional regimen, which is quite an enormous cost," he said.

This study is one of the first to also consider the use of supportive agents, such as granulocyte-colony-stimulating factors (G-CSFs), erythropoeisis-stimulating agents (ESAs), anti-emetics, and anti-diarrheals.

The researchers found that patients treated with FOLFOX showed the greatest use of growth-factor products, with 22% receiving darbepoetin alfa (adding a weekly cost of $299), 18% receiving erythropoetin alfa ($361), 16% receiving filgrastim ($1862), and 12% receiving pegfilgrastim ($2093). "Despite the high costs associated with the G-CSFs, they may have an important role in compliance with planned courses of chemotherapy," the authors comment. "Although expensive, G-CSFs help prevent dose reductions and improve delivery of full-dose intensity, which is associated with improved survival rates for some cancers."

"As colorectal cancer treatment advances continue, it will be imperative to have contemporary and comprehensive estimates of the costs of treatment options," the authors comment. "It is imperative to develop objective measures of cost-effectiveness to support patients, clinicians, and policy makers in their quest for a rational allocation of limited healthcare delivery resources."

Dr. Lyman commented that, to date in the United States, the cost of treatment has not really influenced treatment decisions. The US Food and Drug Administration approval process prohibits taking the cost of a drug into consideration, and so do the committees that draw up disease-management guidelines, he pointed out, so it has been left to the payers, primarily the medical insurance companies, to play the role of "bad cop" and to question the cost-effectiveness of a treatment. But so far, there has been little focus on value, he continued. As the costs continue to escalate, however, society is going to have to ask whether the additional costs of the newer treatments is "worth it."

The reality is that there are limited resources, and they need to be focused on where they are going to do the most good.

"This is very relevant, although it's always difficult to talk about, because patients are desperate and want to try anything. But the reality is that there are limited resources, and they need to be focused on where they are going to do the most good," Dr. Lyman commented. "For example, if the benefit is in an early cancer setting, and the outcome is a cure that translates into another 30 to 40 years of life for the patient, then this is a different situation to that of metastatic disease, where the benefit may equal an additional 3 months of life expectancy."

One hope on the horizon, Dr. Lyman commented, is that there are promising developments in the research on prognostic and predictive markers, which will eventually help individualize treatment and may, in turn, cut costs. A prime example is the work on KRAS mutations, which identifies patients who are unlikely to respond to cetuximab.

The study was funded by Duke Comprehensive Cancer Center's Health Services and Outcomes Program, but the data came from a previous study funded by an unrestricted grant from Amgen. Dr. Lyman reports serving as a consultant and on the speakers' bureau for Amgen, and has received research grant support from Amgen and GlaxoSmithKline.

Am J Manag Care. 2008;14:11-19.

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