NCCN Drug Affordability Ratings Miss the Mark in Lung Cancer

August 2018 Vol 11, Special Issue - Lung Cancer
Wayne Kuznar

Chicago, IL—The drug affordability rating in the National Comprehensive Cancer Network (NCCN) Evidence Blocks are inconsistent with real-world total episode of care costs, according to Scott D. Ramsey, MD, PhD, Director, Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA. He presented the results of a recent analysis at ASCO 2018.

For first-line regimens for the treatment of advanced non–small-cell lung cancer (NSCLC), regimens given an affordability rating of 2 (expensive) by the NCCN had lower total healthcare costs—on a per-patient per-member (PPPM) basis—than regimens assigned an affordability rating of 3 (moderately expensive), and approximately the same cost as those with an affordability rating of 4 (inexpensive).

"This study suggests that oncologists may be rating affordability based on the cost of cancer drug treatment alone instead of the overall episode level," said Dr Ramsey.

"Study results suggest that affordability ratings from the NCCN Evidence Blocks need further refinement and validation in order to prevent misrepresentation of value during the treatment decision-making process," he said.

The NCCN has adopted a systems-­based approach to affordability, which it defines as the overall cost of the regimen based on drug cost, supportive care, infusions, toxicity management, and probability of inpatient hospitalization. Drug affordability is based on the knowledge and per­ception that NCCN panel members have of the overall cost of a regimen, using a scale of 1 (very expensive) to 5 (very inexpensive).

Real-World Costs versus NCCN Ratings

To assess the correlation between real-­world costs of NCCN-recommended systemic therapies and their affordability ratings, Dr Ramsey and colleagues estimated the mean PPPM costs that included inpatient, outpatient, emergency department, urgent care, and pharmacy costs for each NSCLC regimen from the start of the treatment, adjusted for patient characteristics.

The analysis included 15,574 patients with advanced NSCLC and 31 unique NCCN-recommended treatment regimens. The mean PPPM cost across all treatment regimens was $22,782, and the median PPPM cost was $16,412. The mean PPPM cost per regimen ranged from $12,188 to $66,996.

In pairwise comparisons, the mean PPPM was $40,084 for regimens with an NCCN affordability rating of 1, which was approximately $19,200 higher than the mean PPPM for regimens with an affordability rating of 2, approximately $15,000 higher than those with an affordability rating of 3, and approximately $19,700 higher than those with an affordability rating of 4 (P <.001 for all comparisons).

However, the mean PPPM for regimens with an affordability rating of 2 was lower than that for regimens with an ­affordability rating of 3—$20,854 versus $24,857, respectively. Furthermore, regimens with affordability ratings of 2 and 4 had virtually identical mean PPPMs ($20,854 vs $20,349, respectively).

Regimens targeting EGFR mutations or ALK rearrangements had affordability ratings that were different from those for generic chemotherapy, despite having similar mean PPPM costs—EGFR/ALK, $13,665-$27,782 with an affordability rating of 2; and chemotherapy, $16,175-$28,195 with an affordability rating of 3 to 4.

The mean PPPM costs for a regimen by affordability had low correlation, which was not statistically significant, according to Dr Ramsey and colleagues.

"It's not really clear what the NCCN measures," said Dr Ramsey. "What we've found by comparing it [NCCN Evidence Blocks] with real-world data is that they seem to be estimating drug costs. But for patients and for systems, it's total healthcare costs from the start of whatever regimen you're focusing on that matter; we've found that these blocks don't correlate well with that measure," he said. The Evidence Blocks are "not really reliable estimates of the cost of care," he added.

"We hope that NCCN rethinks their methodology, and it becomes more transparent," Dr Ramsey continued. His group looked at regimens for only NSCLC, so the affordability ratings for regimens for other cancer types may better reflect the cost of the total episode, he noted.

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