Guideline Discordance and Patient Cost Responsibility in Medicare Beneficiaries With Metastatic Breast Cancer

Restricted access

Background: Treatment for metastatic breast cancer (MBC) that is not concordant with the NCCN Guidelines for Breast Cancer has been associated with higher healthcare utilization and payer costs. However, a significant knowledge gap exists regarding the impact of guideline-discordant care on patient cost responsibility. This study examined this question among patients with MBC in the year postdiagnosis. Methods: This retrospective cohort study used data from the SEER-Medicare linked database from 2000 through 2013. Guideline discordance, defined by year-specific NCCN Guidelines, was assessed for first-line antineoplastic treatment and grouped into discrete categories. Patient cost responsibility (deductibles, coinsurance, copayments) in women with MBC were summed for all medical care received in the year postdiagnosis. The difference in patient cost responsibility by guideline discordance status was estimated using linear mixed-effect models. Results: Of 3,709 patients with MBC surviving at least 1 year postdiagnosis, 17.6% (n=651) received guideline-discordant treatment. Median cost responsibility in the year postdiagnosis for patients receiving guideline-discordant treatment was $7,421 (interquartile range [IQR], $4,359–$12,983) versus $5,171 (IQR, $3,006–$8,483) for those receiving guideline-concordant care. In adjusted models, guideline-discordant treatment was significantly associated with $1,841 higher patient costs in the first year from index diagnosis date (95% CI, $1,280–$2,401) 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% CI, $1,711–$4,948). Conclusions: Deviations from current treatment guidelines may have implications on patient healthcare cost responsibility. Additional research is needed to fully understand the mechanisms underlying how guideline deviation leads to greater costs for patients with MBC.

Submitted January 8, 2019; accepted for publication April 30, 2019.Previous presentation: This work was presented as an oral presentation at the Society for Medical Decision Making 40th Annual North American Meeting; October 13–17, 2018; Montreal, Quebec, Canada.Author contributions: Study concept/design: Williams, Rocque. Provision of study material or patients: Rocque. Data collection/assembly: Williams, Azuero. Data analysis and interpretation: Williams, Azuero, Kenzik, Rocque. Manuscript writing: All authors. Final approval of manuscript: All authors.Disclosures: Dr. Rocque has disclosed that she has received grant/research support from CareVive, Genentech, and Pfizer, and consulting fees/honoraria from Pfizer and Roche. All remaining authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.Correspondence: Courtney P. Williams, MPH, Division of Hematology and Oncology, University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL 35294. Email: courtneyphillips@uabmc.edu
  • 1.

    Newcomer LN, Malin JL. Payer view of high-quality clinical pathways for cancer. J Oncol Pract 2017;13:148–150.

  • 2.

    Gradishar WJ, Anderson BO, Abraham J, . NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Version 2.2019. Accessed July 31, 2019. To view the most recent version, visit NCCN.org.

  • 3.

    Gradishar WJ, Anderson BO, Balassanian R, . NCCN Guidelines Insights: Breast Cancer. Version 1.2016. J Natl Compr Canc Netw 2015;13:1475–1485.

  • 4.

    Rocque GB, Williams CP, Jackson BE, . Impact of nonconcordance with NCCN Guidelines on resource utilization, cost, and mortality in de novo metastatic breast cancer. J Natl Compr Canc Netw 2018;16:1084–1091.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Rocque GB, Williams CP, Kenzik KM, . Concordance with NCCN treatment guidelines: relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer 2018;124:4231–4240.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Zafar SY, Abernethy AP. Financial toxicity, part I: a new name for a growing problem. Oncology (Williston Park) 2013;27:80–149.

  • 7.

    Kaisaeng N, Harpe SE, Carroll NV. Out-of-pocket costs and oral cancer medication discontinuation in the elderly. J Manag Care Spec Pharm 2014;20:669–675.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Zafar SY, McNeil RB, Thomas CM, . Population-based assessment of cancer survivors’ financial burden and quality of life: a prospective cohort study. J Oncol Pract 2015;11:145–150.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Warren JL, Klabunde CN, Schrag D, . Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 2002;40(Suppl 8):IV-3–18.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Danese MD, Lindquist K, Doan J, . Effect of central nervous system metastases on treatment discontinuation and survival in older women receiving trastuzumab for metastatic breast cancer. J Cancer Epidemiol 2012;2012:819210.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Stokes ME, Thompson D, Montoya EL, . Ten-year survival and cost following breast cancer recurrence: estimates from SEER-Medicare data. Value Health 2008;11:213–220.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Frank B. Definitions of “cost’ in Medicare utilization files. Research Data Assistance Center. Available at http://resdac.umn.edu/sites/resdac.umn.edu/files/Definitions%20of%20%27Cost%27%20in%20Medicare%20Utilization%20Files%20(Slides).pdf. Accessed May 21, 2019.

    • Search Google Scholar
    • Export Citation
  • 13.

    Klabunde CN, Potosky AL, Legler JM, . Development of a comorbidity index using physician claims data. J Clin Epidemiol 2000;53:1258–1267.

  • 14.

    Charlson ME, Pompei P, Ales KL, . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–619.

  • 16.

    Romano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol 1993;46:1075–1079; discussion 1081–1090.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Conti RM, Bernstein AC, Villaflor VM, . Prevalence of off-label use and spending in 2010 among patent-protected chemotherapies in a population-based cohort of medical oncologists. J Clin Oncol 2013;31:1134–1139.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    Urban RR, He H, Alfonso-Cristancho R, . The cost of initial care for Medicare patients with advanced ovarian cancer. J Natl Compr Canc Netw 2016;14:429–437.

  • 19.

    Bullock AJ, Hofstatter EW, Yushak ML, . Understanding patients’ attitudes toward communication about the cost of cancer care. J Oncol Pract 2012;8:e50–58.

  • 20.

    Meisenberg BR, Varner A, Ellis E, . Patient attitudes regarding the cost of illness in cancer care. Oncologist 2015;20:1199–1204.

  • 21.

    Irwin B, Kimmick G, Altomare I, . Patient experience and attitudes toward addressing the cost of breast cancer care. Oncologist 2014;19:1135–1140.

  • 22.

    Montero AJ, Escobar M, Lopes G, . Bevacizumab in the treatment of metastatic breast cancer: friend or foe? Curr Oncol Rep 2012;14:1–11.

  • 23.

    Montero AJ, Avancha K, Glück S, . A cost-benefit analysis of bevacizumab in combination with paclitaxel in the first-line treatment of patients with metastatic breast cancer. Breast Cancer Res Treat 2012;132:747–751.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Garreau JR, Delamelena T, Walts D, . Side effects of aromatase inhibitors versus tamoxifen: the patients’ perspective. Am J Surg 2006;192:496–498.

  • 25.

    Vogel CL, Cobleigh MA, Tripathy D, . First-line Herceptin monotherapy in metastatic breast cancer. Oncology 2001;61(Suppl 2):37–42.

  • 26.

    Townsley CA, Selby R, Siu LL. Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials. J Clin Oncol 2005;23:3112–3124.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Muss HB, Berry DA, Cirrincione CT, . Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med 2009;360:2055–2065.

  • 28.

    Hughes KS, Schnaper LA, Berry D, . Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004;351:971–977.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Jolly TA, Williams GR, Bushan S, . Adjuvant treatment of older women with invasive breast cancer. Womens Health (Lond) 2016;12:129–146.

  • 30.

    Jolly T, Williams GR, Jones E, . Treatment of metastatic breast cancer in women aged 65 years and older. Womens Health (Lond) 2012;8:455–471.

  • 31.

    Kelly RJ, Forde PM, Elnahal SM, . Patients and physicians can discuss costs of cancer treatment in the clinic. J Oncol Pract 2015;11:308–312.

  • 32.

    Henrikson NB, Tuzzio L, Loggers ET, . Patient and oncologist discussions about cancer care costs. Support Care Cancer 2014;22:961–967.

  • 33.

    Neumann PJ, Palmer JA, Nadler E, . Cancer therapy costs influence treatment: a national survey of oncologists. Health Aff (Millwood) 2010;29:196–202.

  • 34.

    Kelly RJ, Forde PM, Bagheri A, . Measuring the impact of chemotherapy cost discussions between patients and providers at the time of prescribing [abstract]. J Clin Oncol 2013;31(Suppl):Abstract 257.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Chandra A, Shafrin J, Dhawan R. Utility of cancer value frameworks for patients, payers, and physicians. JAMA 2016;315:2069–2070.

  • 36.

    Schnipper LE, Davidson NE, Wollins DS, . American Society of Clinical Oncology statement: a conceptual framework to assess the value of cancer treatment options. J Clin Oncol 2015;33:2563–2577.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Schnipper LE, Davidson NE, Wollins DS, . Updating the American Society of Clinical Oncology value framework: revisions and reflections in response to comments received. J Clin Oncol 2016;34:2925–2934.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Erten MZ, Davidoff AJ, Zuckerman IH, . The effect of supplemental medical and prescription drug coverage on health care spending for Medicare beneficiaries with cancer. Value Health 2014;17:15–21.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Wan Y, Gao X, Mehta S, . Indirect costs associated with metastatic breast cancer. J Med Econ 2013;16:1169–1178.

  • 40.

    Arozullah AM, Calhoun EA, Wolf M, . The financial burden of cancer: estimates from a study of insured women with breast cancer. J Support Oncol 2004;2:271–278.

    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 1455 1454 70
PDF Downloads 364 364 15
EPUB Downloads 0 0 0