A study published by Williams et al in JNCCN—Journal of the National Comprehensive Cancer Network found that direct costs for patients with metastatic breast cancer increased when their treatment differed from recommendations found in the NCCN Clinical Practice Guidelines in Oncology® (NCCN Guidelines®). Previous studies have found that guideline-discordant care results in higher health-care costs overall, but this is the first study to look specifically at the cost burden for patients.
“We thought that it was important to explore potential differences in out-of-pocket costs, since financial toxicity is a growing issue among patients with metastatic breast cancer,” explained Courtney P. Williams, MPH, of the Division of Hematology and Oncology, O’Neal Comprehensive Cancer Center at the University of Alabama Birmingham. “We found about one in five women received an anticancer treatment that wasn’t listed within the NCCN Guidelines. Those women were responsible for higher out-of-pocket costs—including deductibles, coinsurance, and copayments—in the year following their metastatic breast cancer diagnosis than those receiving an anticancer treatment listed within the guidelines. This finding is especially important for older patients, [who] made up about 75% of our sample, since financial and psychological distress could be worse for patients living on a fixed income.”
“We found about one in five women received an anticancer treatment that wasn’t listed within the NCCN Guidelines. Those women were responsible for higher out-of-pocket costs—including deductibles, coinsurance, and copayments—in the year following their metastatic breast cancer diagnosis than those receiving an anticancer treatment listed within the guidelines.”— Courtney P. Williams, MPH
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Methods
The retrospective study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to look at patient costs for 3,709 women diagnosed with metastatic breast cancer between 2007 and 2013 who survived for at least 1 year after diagnosis. Treatment regimens were matched to the version of the NCCN Guidelines® for Breast Cancer that were available at the exact treatment date. The definition of guideline-concordant care varied depending on date due to frequent guideline updates.
Results
The median patient cost for the year postdiagnosis was $5,171 for care that fit within contemporary NCCN Guidelines vs $7,421 for care that deviated from them. Both overtreatment and undertreatment—as defined by the guidelines—ultimately resulted in higher patient costs.
In adjusted models, guideline-discordant treatment was significantly associated with $1,841 higher patient costs in the first year from index diagnosis date compared with guideline-concordant care. Patient cost responsibility differed by category of guideline discordance, with those receiving nonapproved bevacizumab having the highest cost responsibility (β = $3,330; 95% confidence interval = $1,711–$4,948).
Nearly 17% of the 3,709 patients included in the study received guideline-discordant care.
Commentary
Matthew P. Goetz, MD
“The observation that out-of-pocket costs may be greater for guideline-discordant care is important for both patients and physicians to understand, especially when many guideline-discordant treatments may not improve clinical outcomes,” commented Matthew P. Goetz, MD, of the Mayo Clinic Cancer Center, Member of the NCCN Guidelines Panel for Breast Cancer, who was not involved in this study. “Clinical trials should be prioritized as a way to offer patients access to new drugs/treatments that might not otherwise be available to them, while limiting out-of-pocket expenses.”
“NCCN Guidelines exist to provide recommendations based on scientific evidence and expert opinion,” said Dr. Williams. “Although there will always be circumstances where off-guideline treatment is warranted, physicians should aim to comply with current guidelines for the safety of the patient, both physically and psychologically, as well as to decrease adverse outcomes such as financial toxicity.”
Disclosure: For full disclosures of the study authors, visit jnccn.org.
