ASCO Tool Shows Price Does Not Indicate Value

Lowell E. Schnipper, MD, FASCO

ASCO unveiled a drug valuation methodology that found no added health benefit from a $9200 per month trial chemotherapy regimen compared with an $800 per month standard-of-care therapy. It was just a demonstration of the conceptual drug valuation tool, but ASCO hopes to develop the framework into a practical system later on.

“Nobody’s ever developed a well-codified assessment of how to value a cancer treatment. We wanted to focus on the health benefit or lack thereof that a new treatment provides,” said Lowell E. Schnipper, MD, FASCO, chair of ASCO’s Value in Cancer Care Task Force, in a press conference June 22.

The announcement came shortly after doctors from Memorial Sloan Kettering Cancer Center (MSKCC) made public their tool for estimating prices for drugs, called DrugAbacus. It creates prices based on relative values users ascribe to the toxicity, clinical benefit, and novelty of the drugs in question.

A key distinction between the ASCO framework, which remains a work in progress, and DrugAbacus is that ASCO’s model does not factor the cost of a drug into its overall scores for drug value.

“Our tool really is intended to guide a discussion between the doctor and the patient,” said Richard Schilsky, MD, FASCO, chief medical officer for ASCO. “Our intent is for this tool to be very patient centric. But I think the key here is that we’re now seeing the whole oncology community intensely focusing on the question of value. There will be multiple ways in which it can be interpreted. Collectively, the more we talk about this the more we will be able to deliver a much better understanding to patients about what they get from a new treatment compared to what they’re expected to spend for it.”

In recent weeks, the European Society of Medical Oncology has also come out with a drug valuation system.

The development of these drug measuring tools comes amid growing frustration among physicians and patients over the soaring cost of newer medications, which can reach $30,000 for a one-month supply. At ASCO’s annual meeting in Chicago this year, Leonard Saltz, MD, chief of gastrointestinal oncology at MSKCC, called current drug pricing “unsustainable,” in what some considered an unusually forthright assertion for the plenary address in which it was made.

DrugAbacus allows doctors and the general public to generate fair market prices for 54 commonly used oncologic drugs, whereas ASCO on Monday provided a handful of examples involving trials of certain drugs and drug combinations. ASCO applied metrics to gauge the “net health benefit” (NHB) of drugs used in those investigations. Points are awarded for clinical benefit and toxicity, and the cost of the drug regimens is given but is not factored into the overall scores. The examples involved drugs and drug combinations used in treatment for metastatic non-small cell lung cancer (mNSCLC), advanced multiple myeloma, metastatic castration-resistant prostate cancer, and adjuvant therapy for women with human epidermal growth factor receptor2—positive breast cancer.

ASCO considered drug values in advanced treatment (adjuvant) as well as curative settings. One limitation of the methodology is that the most reliable comparisons can be made only between regimens examined in a particular trial. ASCO said data are still too limited to allow comparisons of regimens between trials, as there are too many variables, but that larger data sets will likely make such comparisons possible in the near future. “There is currently no valid way to compare regimens that have not been compared head to head in clinical trials,” ASCO wrote in its report on the system.

Price Is Not a Predictor of Value

Source: American Society of Clinical Oncology.

One example compared a test combination of bevacizumab (Avastin), paclitaxel, and carboplatin versus the control arm of carboplatin and paclitaxel in first-line treatment of mNSCLC. The bevacizumab combination afforded 12.3 months overall survival (OS) benefit versus 10.3 for the control arm, but toxicity was higher, as was price: $11,908 per month for the experimental treatment versus $182 for standard of care. ASCO awarded the trial therapy an NHB score of 16 out of a possible 130 points.

A second example given, also for first-line treatment of metastatic non-small cell lung cancer, involved a test of cisplatin and pemetrexed versus cisplatin and gemcitabine (control). ASCO found no difference in OS or toxicity and noted that the pemetrexed arm cost $9193 per month versus $812 for standard therapy. ASCO awarded an NHB score of 0 out of a possible 130 for the trial therapy.

“The highest priority of ASCO is making clinically meaningful progress against cancer through research and the delivery of high-quality care to all patients with cancer. As we strive to reach this goal, an essential prerequisite is achieving a rational relationship between the health benefit of an intervention and its cost,” ASCO wrote in the report, which was published in the Journal of Clinical Oncology.

DrugAbacus does not allow pricing comparisons involving combinations of drugs or provide clarity on what types of uses are being judged. Actual drug costs can vary greatly from those provided by DrugAbacus. For example, blinatumomab (Blincyto) came on the market at $64,260 for a one-month supply and is actually worth $12,612, based on the value of a life-year being $120,000 and toxicity being 15% on a scale of up to 30%, according to DrugAbacus.

DrugAbacus sometimes calculates that a drug is worth more than it was priced at market entry. Obinutuzumab (Gazyva) is given a DrugAbacus price of $14,468 and arrived on the market at $5,973.

Schilsky said the discussion on how to develop the ASCO model is now open for outside input and that future versions will incorporate more data and allow greater flexibility in judging drug values.

“We envision sometime in the future to have a software that is available, utilizing this data framework or one just like it, that’s curated with many comparative trials, such that it would be very easy for a patient to see for a given indication what the treatment options are,” Schilsky said.

Schnipper LE, Davidson NE, Wollins DS, et al. American Society of Clinical Oncology statement: a conceptual framework to assess the value of cancer treatment options [published online June 22, 2015]. J Clin Oncol. doi: 10.1200/JCO.2015.61.6706.