"Off-label" indications for oncology drug use and drug compendia: history and current status

Current challenges in health economic modeling of cancer therapies: a research inquiry

BACKGROUND

The demand for economic models that evaluate cancer treatments is increasing, as healthcare decision makers struggle for ways to manage their budgets while providing the best care possible to patients with cancer. Yet, after nearly 2 decades of cultivating and refining techniques for modeling the cost-effectiveness and budget impact of cancer therapies, serious methodologic and policy challenges have emerged that question the adequacy of economic modeling as a sound decision-making tool in oncology.

OBJECTIVES

We sought to explore some of the contentious issues associated with the development and use of oncology economic models as informative tools in current healthcare decision-making. Our objective was to draw attention to these complex pharmacoeconomic concerns and to promote discussion within the oncology and health economics research communities.

METHODS

Using our combined expertise in health economics research and economic modeling, we structured our inquiry around the following 4 questions: (1) Are economic models adequately addressing questions relevant to oncology decision makers; (2) What are the methodologic limitations of oncology economic models; (3) What guidelines are followed for developing oncology economic models; and (4) Is the evolution of oncology economic modeling keeping pace with treatment innovation? Within the context of each of these questions, we discuss issues related to the technical limitations of oncology modeling, the availability of adequate data for developing models, and the problems with how modeling analyses and results are presented and interpreted.

DISCUSSION

There is general acceptance that economic models are good, essential tools for decision-making, but the practice of oncology and its rapidly evolving technologies present unique challenges that make assessing and demonstrating value especially complex. There is wide latitude for improvement in oncology modeling methodologies and how model results are presented and interpreted.

CONCLUSION

Complex technical and data availability issues with oncology economic modeling pose serious concerns that need to be addressed. It is our hope that this article will provide a framework to guide future discourse on this important topic.

Automated detection of off-label drug use

Off-label drug use, defined as use of a drug in a manner that deviates from its approved use defined by the drug's FDA label, is problematic because such uses have not been evaluated for safety and efficacy. Studies estimate that 21% of prescriptions are off-label, and only 27% of those have evidence of safety and efficacy. We describe a data-mining approach for systematically identifying off-label usages using features derived from free text clinical notes and features extracted from two databases on known usage (Medi-Span and DrugBank). We trained a highly accurate predictive model that detects novel off-label uses among 1,602 unique drugs and 1,472 unique indications. We validated 403 predicted uses across independent data sources. Finally, we prioritize well-supported novel usages for further investigation on the basis of drug safety and cost.

Delivering high-quality and affordable care throughout the cancer care continuum

The national cost of cancer care is projected to reach $173 billion by 2020, increasing from $125 billion in 2010. This steep upward cost trajectory has placed enormous an financial burden on patients, their families, and society as a whole and raised major concern about the ability of the health care system to provide and sustain high-quality cancer care. To better understand the cost drivers of cancer care and explore approaches that will mitigate the problem, the National Cancer Policy Forum of the Institute of Medicine held a workshop entitled "Delivering Affordable Cancer Care in the 21st Century" in October 2012. Workshop participants included bioethicists, health economists, primary care physicians, and medical, surgical, and radiation oncologists, from both academic and community settings. All speakers expressed a sense of urgency about the affordability of cancer care resulting from the future demographic trend as well as the high cost of emerging cancer therapies and rapid diffusion of new technologies in the absence to evidence indicating improved outcomes for patients. This article is our summary of presentations at the workshop that highlighted the overuse and underuse of screening, treatments, and technologies throughout the cancer care continuum in oncology practice in the United States.

Off-Label and Off-NCCN Guidelines Uses of Antineoplastic Drugs in China

BACKGROUND

To evaluate off-label and off-NCCN guidelines uses of antineoplastic drugs in a major Chinese hospital.

METHODS

Totally 1122 patients were selected from July to December 2011. Then, the off-label and off-NCCN guidelines uses of antineoplastic drugs were analyzed.

RESULTS

In 798 of 1122 patients (71.12%), drugs were used for off-label. In 317 of 1122 patients (28.25%), the drugs were prescribed for off-label and off-NCCN guidelines. 2591 medical orders for 1122 patients, 1051/2591 (40.56%) medical orders were off-label; 445/2591(17.17%) medical orders were off-label and off-NCCN guidelines. In 445 off-label and off-NCCN medical orders, 399 (89.66%) were unapproved indications, 38 (8.54%) were unapproved drug concentration and 12 (2.70%) were unapproved route of administration. Percentage of off-label and off-NCCN guidelines drug uses in male was higher than that in female (21.92% vs. 11.39%, P<0.01). Compared with other lines of treatment, percentage of off-label and off-NCCN guidelines drug uses in postoperative adjuvant was the smallest (P<0.01) and percentage in three or multi-line treatments was the highest (P<0.01). The pancreatic cancer possessed the highest percentage (38.74%) of off-label and off-NCCN guidelines drug uses among all types of cancer (P<0.01).

CONCLUSION

Off-label uses of antineoplastic drugs are generally common in China hospitals based on NCCN guidelines. The fact suggests that anti-tumor treatment was relatively standard in China. Off-label and off-NCCN guidelines drug uses were mainly for individual treatment. Doctors should fully consider the adverse drug reaction, contraindication, cautions and increase the drug security monitoring. Uncorrected drug concentration should be avoided for drug risk.

Emerging trends in cancer care: health plans' and pharmacy benefit managers' perspectives on changing care models

BACKGROUND

Cancer care in the United States is being transformed by a number of medical and economic trends, including rising drug costs, increasing availability of targeted therapies and oral oncolytic agents, healthcare reform legislation, changing reimbursement practices, a growing emphasis on comparative effectiveness research (CER), the emerging role of accountable care organizations (ACOs), and the increased role of personalization of cancer care.

OBJECTIVE

To examine the attitudes of health plan payers and pharmacy benefit managers (PBMs) toward recent changes in cancer care, current cost-management strategies, and anticipated changes in oncology practice during the next 5 years.

METHODS

An online survey with approximately 200 questions was conducted by Reimbursement Intelligence in 2011. The survey was completed by 24 medical directors and 31 pharmacy directors from US national and regional health plans and 8 PBMs. All respondents are part of a proprietary panel of managed care decision makers and are members of the Pharmacy and Therapeutics Committees of their respective plans, which together manage more than 150 million lives. Survey respondents received an honorarium for completing the survey. The survey included quantitative and qualitative questions about recent developments in oncology management, such as the impact on their plans or PBMs of healthcare reform, quality improvement initiatives, changes in reimbursement and financial incentives, use of targeted and oral oncolytics, and personalized medicine. Respondents were treated as 1 group, because there were no evident differences in responses between medical and pharmacy directors or PBMs.

RESULTS

Overall, survey respondents expressed interest in monitoring and controlling the costs of cancer therapy, and they anticipated increased use of specialty pharmacy for oncology drugs. When clinical outcomes are similar for oral oncolytics and injectable treatments, 93% prefer the oral agents, which are covered under the specialty tier by 59% of the plans. The use of the National Comprehensive Cancer Network practice guidelines for coverage and reimbursement of oncologic agents is reported as "very frequent" by 10% of survey respondents, "frequent" by 21%, and "moderately frequent" by 7%. Most (66%) respondents believe that it is probable and 3% believe it is highly probable that healthcare reform will help to control oncology treatment costs, although 59% also predict an increase in utilization restrictions and 48% predict more stringent comparative effectiveness evidence requirements. The survey reveals a considerable uncertainty among health plans and PBMs about the eventual impact of ACOs on oncology care. Although 82% of those surveyed believe that measures such as increasing adherence to evidence-based treatments will achieve cost-savings, nearly half (48%) had no plans to use such measures.

CONCLUSIONS

Recent trends in healthcare legislation, rising drug costs, and changing reimbursement practices are poised to significantly alter conventional models of cancer care delivery and payment. The results of this survey indicate that health plans and PBMs anticipate greater use of evidence-based management strategies, including CER, quality initiatives, and biomarker testing for appropriate cancer therapy selection. In addition, they anticipate greater focus on cost control, with a greater role for utilization management and increased patient cost-sharing. Finally, there is a high level of uncertainty among plans and PBMs about the eventual impact of ACOs and other aspects of healthcare reform on oncology practice.

Conflict of interest disclosure in off-label oncology clinical trials

PURPOSE

We sought to determine the prevalence, reliability, and predictors of conflict of interest (COI) and funding disclosure statements for studies of anticancer targeted therapies conducted in the off-label prescribing setting.

METHODS

As a part of a federally funded systematic review, manuscripts were included in the analysis if they were used to support one of 19 indications for cancer targeted therapies that were off-label but reimbursable according to compendia published in 2006 or before. Studies were categorized according to trial design, trial results, average impact factor of journals, and presence of COI and funding disclosure statements.

RESULTS

Among the 69 included studies, prevalence of COI and funding disclosures was low, at 33% and 58% respectively; time trends showed some improvement between 2002 to 2007, but only 60% of studies had disclosures by 2007. Predictors of COI disclosure were publication in high-impact-factor journals (P < .001), large study sample size (P = .001), enrollment exclusively in the United States (P = .04), and study of the targeted therapy in combination with other agents as opposed to the study drug alone (P = .03).

CONCLUSION

Disclosure of potential sources of bias in COI and funding statements in studies of off-label indications for anticancer targeted therapies was low and did not increase substantially over time.