Value of Evidence-Based Cancer Care

Aug 16, 2013
Adherence to evidence-based guidelines could save $8,000 per cancer patient each year.
  • Cancer

Fighting cancer is expensive. Research from the National Cancer Institute estimates the national direct cost of cancer is $124.6 billion annually, and high-cost specialty medications are a significant driver of cancer treatment expenditures. Drug spending on cancer therapies grew nearly 26% in 2012, and a three-year forecast from Express Scripts predicts prescription drug spending for cancer will grow by 77% over the next three years, becoming the third highest category of drug spend overall.

Affordability and cost-effectiveness of treatment are important issues for plan sponsors seeking a sustainable path forward for comprehensive cancer care for their members. In our recent update to, we examined how following evidence-based guidelines impacts treatment costs for breast cancer to see if that behavior could lead to more cost-effective care.

Well-Established Guidelines for Cancer Care

We focused our research on chemotherapy for female breast cancer patients. One of the three most prevalent cancer types, breast cancer has well-established therapies and treatment protocols, and recent estimates suggest that 90% of female breast cancer patients live at least five years after successful treatment.

Cancer-therapy guidelines help physicians manage complex treatments by suggesting appropriate clinical pathways that include combinations, sequences and doses of cancer medications. They also consider patient-related factors – including age and menopausal status – as well as disease-specific inputs such as cancer stage at diagnosis and the presence of biomarkers, such as epidermal growth factor receptor 2 (HER2), which helps to guide treatment course.

Potential Savings

Using 2009 and 2010 integrated medical and pharmacy claims, we compared the cancer drug regimens (injectable and oral) for 1,384 newly diagnosed female breast cancer patients ages 18 to 63 with 2012 NCCN recommendations to determine on-guideline or off-guideline status. We used 2012 guidelines to account for treatment with newer therapies, which may have been in practice in 2009 or 2010 but had not yet made their way into evidence-based guidelines. We determined a patient’s HER2-positive status based on use of Herceptin or other HER2-targeted therapies.

Approximately 1 in 5 patients receiving chemotherapy for breast cancer was treated off-guideline. On-guideline treatment rates varied by HER2 biomarker status. Among all patients, 21.1% of patients were treated off-guideline, and nearly 63% of patients receiving off-guideline therapy were HER2-negative.

Looking at costs, the research showed that direct medical costs associated with treating breast cancer were 11.8% higher for patients treated off-guideline. On average, each patient incurred an additional $7,959 in annual treatment costs when evidence-based guidelines were not followed. Also, annual drug costs billed solely through the pharmacy benefit were slightly higher for patients whose treatment did not adhere to guidelines.

Differences Between On Guideline And Off Guideline Treatment

Evidence-Based Decision Support

Express Scripts’ oncology decision-support module, available through ExpressPAth, helps physicians sift through the evolving research and treatment landscape for cancer. Oncologists can access a clinical library of more than 1,700 evidence-based treatment regimens and 10,000 clinical trials for more than 120 cancer types. ExpressPAth also provides real-time information about a patient’s coverage and clinical rules to help doctors make optimal prescribing decisions, while an analytics-driven engine ensures that every dollar spent is appropriate for the patient’s treatment.

While further research on the cost-effectiveness of guidelines can give us a clearer picture on potential cost-savings, payers can implement solutions now to help ensure their patients receive the safest and most effective care possible.

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Lab Staff
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