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Colorectal cancer treatment costs in US double those for Canada
CHICAGO — Colorectal cancer treatment for patients who lived in western Washington State cost more than twice as much as treatment for individuals with the same malignancy who lived in a demographically similar region in Canada, according to study results presented at ASCO Annual Meeting.
“Despite significantly higher costs, patients in western Washington did not [achieve better outcomes] than those who received treatment in British Columbia,” Todd Yezefski, MD, senior fellow at Fred Hutchinson Cancer Research Center and University of Washington School of Medicine, said during a press conference. “Another way to say it is, they got the same bang for more buck.”
Little research has directly compared health care costs, utilization and outcomes between patients who received similar systemic treatments in Canada’s single-payer health system and the United States’ multipayer system.
Yezefski and colleagues used cancer registry and claims data to compare utilization and cost of treatment for metastatic colorectal cancer between geographically close, demographically similar patients in western Washington State and British Columbia. Researchers expressed all costs in 2009 U.S. dollars.
Investigators also assessed survival outcomes between groups.
Researchers used two sources — the BC Cancer Agency Database and a regional database that links western Washington SEER data to claims from two large commercial insurers — to identify 2,197 patients aged 18 years or older diagnosed with metastatic colorectal cancer in 2010 or later.
Nearly three-quarters (73.8%; n = 1,622) lived in British Columbia.
Median age was slightly higher in the British Columbia group (66 years vs. 60 years) because Yezefski and colleagues were not able to access claims data for Medicare recipients in the United States.
Both groups were primarily white, although they had sizable Asian populations.
A higher percentage of patients from British Columbia were men (57% vs. 48%; P < .01). Education and income levels were comparable.
The most common initial systemic treatment for patients in British Columbia was FOLFIRI chemotherapy — which consists of irinotecan, 5-FU and folinic acid — and bevacizumab (Avastin, Genentech). The most common first-line regimen for patients in western Washington was FOLFOX chemotherapy, which consists of oxaliplatin, 5-FU and folinic acid.
A higher percentage of patients in western Washington than British Columbia underwent initial systemic treatment (79% vs. 68%; P < .01). This may be due to the younger age of the U.S. cohort, Yezefski said.
Mean monthly per-patient costs for first-line treatment were significantly higher for those in western Washington ($12,345 vs. $6,195; P < .01). This difference persisted for all regimens assessed.
Mean lifetime monthly costs for systemic therapy also were significantly higher for patients in western Washington ($7,883 vs. $4,830; P < .01).
Despite the higher costs, median OS among those who received systemic treatment did not differ significantly between regions (21.4 months for western Washington vs. 22.1 months for British Columbia).
Among those who did not undergo systemic treatment, median OS was 5.4 months for those in western Washington and 6.3 months for those in British Columbia.
“Drug prices in Canada are generally set by the government,” Yezefski said. “In the United States, we believe that if Medicare is allowed to negotiate drug prices with pharmaceutical companies, drug prices can be lower, and private insurance often will follow suit.”
Yezefski and colleagues acknowledged their current findings are skewed toward younger patients who are not insured through Medicare.
“We plan to continue this work by recruiting Medicare patients in the Washington cohort, which will hopefully increase the age and make the two groups a little more comparable,” he said. “[We also intend to look] at other aspects of health care utilization, such as total duration of chemotherapy, hospital use, radiation receipt and surgery.” – by Mark Leiser
Reference:
Yezefski T, et al. LBA3579. Presented at: ASCO Annual Meeting; June 1-5, 2018; Chicago.
Disclosure: Fred Hutchinson Cancer Research Center and BC Cancer Agency funded this study. Shankaran reports research funding to her institution from Amgen, Bayer, Bristol-Myers Squibb and Merck. Yezefski reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.
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This study shows we need to continue to look at the structure of the health care system in the United States. The results convey that this compartmentalized, broken down insurance system can actually translate to higher costs.
In this study, the most common treatment administered in the United States was FOLFOX. This regimen did not include the biological therapy, bevacizumab, that was used in the most common regimen in Canada.
The universal health care system is delivering perhaps more guideline-concordant treatment, which includes bevacizumab in the metastatic setting, and yet it has lower costs than the nonuniversal system.
This abstract does not tell us how much of the costs are related to hospitalization or physician visits, and how much of the costs are for actual treatment. Are there differences in the delivery of care? In other words, did we do more clinic visits for patients in the United States and are we doing more labs, or is it just the cost of treatment that is different?
However we look at it, it basically goes back to the source of the problem: When you have a health care system that is fragmented, it will affect the delivery of care, the outcomes perhaps, and the costs.
One of the arguments against a universal health care system is that it will result in inferior outcomes. In this study, the fact OS was very similar between the two populations is evidence that universal or generalized health care systems are perhaps not going to be inferior for health care delivery. It also is important to remember health coverage is not there for discovery. It is there to deliver something that already has been established. If that is the mission, then a universal system is not worse than the fragmented health care system we have.
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This study demonstrates it is possible to get equally good outcomes at lower cost in other health care systems. The United States is probably the only country in the world in which we actually have no real way of constraining the cost of health care. The FDA does not consider drug price in any of its deliberations about safety or efficacy, and whether drugs should be allowed to enter the market. Once they are on the market, Medicare is generally required by law to pay for the cost of these drugs. Private insurers typically follow suit, and there really is no way to put the brakes on the system. That is not the case in most other health care systems in the world. There typically is a regulatory body that determines whether a drug is sufficiently safe and effective to be made available to the relevant population, and then there is another agency — either a government agency or a government-appointed body — that does some sort of health technology or value assessment to determine whether the health care system can actually afford to introduce the drug into that particular population. That was the hypothesized reason why, in Canada, you can get what would generally be considered a very expensive treatment regimen in the United States at half the cost of what it takes to deliver a similar regimen in the U.S. and still get equivalent outcomes.
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It is well-known that costs of health care in the U.S. are higher than most countries and that the U.S. is at the top of the list for dollars spent on health care as a percentage of gross domestic product in the entire world. It is, therefore, not surprising that the monthly cost of chemotherapy for metastatic colorectal cancer in western Washington is higher — approximately twofold higher — compared with British Columbia across the Canadian border.
It is reassuring that the clinical outcomes are very similar with median OS of 21 to 22 months in both places. These numbers are somewhat lower than what has been considered the latest median OS in metastatic colorectal cancer of around 30 months.
The study documents a growing problem related to the cost of cancer drugs; the problem tends to affect those in lower socioeconomic status within the population. It would be interesting to get similar data for many other cancers and treatments, including immune checkpoint therapy, chimeric antigen receptor T-cell therapy and targeted therapy. It is interesting that, in the present study, the drugs being used have been around for many years and yet we still see the differences. Clearly the cost of drugs is a hot topic and requires solutions to address the serious issue of affordability of care at a particularly vulnerable time when facing a cancer diagnosis with often poor outcomes.
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