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: firstname.lastname@example.org
RocqueGB, WilliamsCP, JacksonBE, . Impact of nonconcordance with NCCN Guidelines on resource utilization, cost, and mortality in de novo metastatic breast cancer. J Natl Compr Canc Netw2018;16:1084–1091.
RocqueGB, WilliamsCP, JacksonBE, . Impact of nonconcordance with NCCN Guidelines on resource utilization, cost, and mortality in de novo metastatic breast cancer. J Natl Compr Canc Netw 2018;16:1084–1091.3018142010.6004/jnccn.2018.7036)| false
RocqueGB, WilliamsCP, KenzikKM, . Concordance with NCCN treatment guidelines: relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer2018;124:4231–4240.
RocqueGB, WilliamsCP, KenzikKM, . Concordance with NCCN treatment guidelines: relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer 2018;124:4231–4240.3031754710.1002/cncr.31694)| false
ZafarSY, McNeilRB, ThomasCM, . Population-based assessment of cancer survivors’ financial burden and quality of life: a prospective cohort study. J Oncol Pract 2015;11:145–150.2551571710.1200/JOP.2014.001542)| false
WarrenJL, KlabundeCN, SchragD, . Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 2002;40(Suppl 8):IV-3–18.10.1097/00005650-200208001-00002)| false
DaneseMD, LindquistK, DoanJ, . Effect of central nervous system metastases on treatment discontinuation and survival in older women receiving trastuzumab for metastatic breast cancer. J Cancer Epidemiol2012;2012:819210.
DaneseMD, LindquistK, DoanJ, . Effect of central nervous system metastases on treatment discontinuation and survival in older women receiving trastuzumab for metastatic breast cancer. J Cancer Epidemiol 2012;2012:819210.2257065710.1155/2012/819210)| false
StokesME, ThompsonD, MontoyaEL, . Ten-year survival and cost following breast cancer recurrence: estimates from SEER-Medicare data. Value Health 2008;11:213–220.10.1111/j.1524-4733.2007.00226.x18380633)| false
FrankB. 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.)| false
CharlsonME, PompeiP, AlesKL, . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.355871610.1016/0021-9681(87)90171-8)| false
RomanoPS, RoosLL, JollisJG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol 1993;46:1075–1079; discussion 1081–1090.841009210.1016/0895-4356(93)90103-8)| false
ContiRM, BernsteinAC, VillaflorVM, . Prevalence of off-label use and spending in 2010 among patent-protected chemotherapies in a population-based cohort of medical oncologists. J Clin Oncol2013;31:1134–1139.
ContiRM, BernsteinAC, VillaflorVM, . 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;31:1134–1139.10.1200/JCO.2012.42.7252)| false
MonteroAJ, AvanchaK, GlückS, . A cost-benefit analysis of bevacizumab in combination with paclitaxel in the first-line treatment of patients with metastatic breast cancer. Breast Cancer Res Treat2012;132:747–751.
MonteroAJ, AvanchaK, GlückS, . 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;132:747–751.2220086710.1007/s10549-011-1919-y)| false
HughesKS, SchnaperLA, BerryD, . Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004;351:971–977.1534280510.1056/NEJMoa040587)| false
KellyRJ, FordePM, BagheriA, . Measuring the impact of chemotherapy cost discussions between patients and providers at the time of prescribing [abstract]. J Clin Oncol 2013;31(Suppl):Abstract 257.10.1200/jco.2013.31.31_suppl.257)| false
SchnipperLE, DavidsonNE, WollinsDS, . American Society of Clinical Oncology statement: a conceptual framework to assess the value of cancer treatment options. J Clin Oncol 2015;33:2563–2577.10.1200/JCO.2015.61.670626101248)| false
SchnipperLE, DavidsonNE, WollinsDS, . Updating the American Society of Clinical Oncology value framework: revisions and reflections in response to comments received. J Clin Oncol 2016;34:2925–2934.10.1200/JCO.2016.68.2518)| false
ErtenMZ, DavidoffAJ, ZuckermanIH, . The effect of supplemental medical and prescription drug coverage on health care spending for Medicare beneficiaries with cancer. Value Health 2014;17:15–21.10.1016/j.jval.2013.11.00324438713)| false