Treatment patterns and economic burden of metastatic and recurrent locally-advanced head and neck cancer patients

Radiotherapy quality assurance in the TROG 12.01 randomised trial and its impact on loco-regional failure

Introduction

There is no consensus as to what specifically constitutes head and neck cancer radiotherapy quality assurance (HNC RT QA). The aims of this study are to (1) describe the RT QA processes used in the TROG 12.01 study, (2) review the RT QA processes undertaken for all patients with loco-regional failure (LRF), and (3) provide prospective data to propose a consensus statement regarding the minimal components and optimal timing of HNC RT QA.

Materials and methods

All patients undergoing RT QA in the original TROG 12.01 study were included in this substudy. All participating sites completed IMRT credentialling and a clinical benchmark case. Real-time (pre-treatment) RT QA was performed for the first patient of each treating radiation oncologist, and for one in five of subsequent patients. Protocol violations were deemed major if they related to contour and/or dose of gross tumour volume (GTV), high dose planning target volume (PTVhd), or critical organs of risk (spinal cord, mandible, and brachial plexus).

Results

Thirty HNROs from 15 institutions accrued 182 patients. There were 28 clinical benchmark cases, 27 pre-treatment RT QA cases, and 38 post-treatment cases. Comprehensive RT QA was performed in 65/182 (36%) treated patients. Major protocol violations were found in 5/28 benchmark cases, 5/27 pre-treatment cases, and 6/38 post-treatment cases. An independent review of all nine LRF cases showed major protocol violations in four of nine cases.

Conclusion

Only pre-treatment RT QA can improve patient outcomes. The minimal components of RT QA in HNC are GTVs, PTVhd, and critical organs at risk. What constitutes major dosimetric violations needs to be harmonised.

Comparison of medical resource consumption between oral cavity squamous cell carcinoma with and without sarcopenia: A nationwide population-based cohort study

PURPOSE

No study has compared long-term medical resource consumption between patients with oral cavity squamous cell carcinoma (OCSCC) with and without sarcopenia receiving curative surgery.

PATIENTS AND METHODS

Generalized linear mixed and logistic regression models were employed to evaluate the number of postoperative visits and medical reimbursement for head and neck cancer or complications and the number of hospitalizations for treatment-related complications over 5 years after curative surgery, respectively.

RESULTS

The mean difference (95% CI) in total medical claims amounts between the nonsarcopenia and sarcopenia groups were new Taiwan dollars (NTD) 47 820 (35 864-59 776, p < 0.0001), 11 902 (4897-18 908, p = 0.0009), 17 282 (10 666-23 898, p < 0.0001), 17 364 (9644-25 084, p < 0.0001), and 8236 (111-16 362, p = 0.0470) for the first, second, third, fourth, and fifth years, respectively.

CONCLUSION

The long-term medical resource consumption was higher in the sarcopenia group than in the nonsarcopenia group.

Sociodemographic correlates of head and neck cancer survival among patients with metastatic disease

BACKGROUND

To describe sociodemographic factors associated with head and neck cancer (HNC) survival among patients with distant metastatic disease.

METHODS

We retrospectively analyzed national data for 2889 adult patients with metastatic HNC (2007-2015). We used Fine and Gray competing risks proportional hazard models, stratified by oropharyngeal cancer status, controlled for sociodemographic factors (age, sex, race/ethnicity, marital status, and insurance status), and accounted for multiple testing.

RESULTS

Median survival time was 11 months (15 months for patients married/partnered; 13 months for patients with non-Medicaid insurance; P < .01). Among patients with oropharyngeal cancer, being married/partnered was associated with lower mortality hazard (sdHR_{divorced/separated} = 1.37, 97.5% confidence interval [CI] = 1.07, 1.75; and sdHR_{never married} = 1.43, 97.5% CI = 1.14, 1.80), as was having non-Medicaid insurance (sdHR_uninsured = 1.44, 97.5% CI = 1.02, 2.04).

CONCLUSIONS

Health insurance and marital status are sociodemographic factors associated with survival among HNC patients with distant metastatic disease, especially in oropharyngeal cases.

Cost-effectiveness analysis of nivolumab for the treatment of squamous cell carcinoma of the head and neck in the United States

Aim: To assess the cost-effectiveness of nivolumab monotherapy for recurrent/metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN) in the US.Methods: We constructed a cohort-based partitioned survival model for three health states (progression-free, progressed disease, and death). Using overall survival and progression-free survival data from the nivolumab and investigator's choice (IC) arms of the CheckMate 141 study, the proportion of patients in each health state was estimated by parametric modeling over a 25-year period. Cost, utility, adverse event, and disease management data inputs were obtained from relevant literature and applied to patients in each health state. A scenario analysis was conducted assuming increased uptake of subsequent immunotherapies. A one-way deterministic sensitivity analysis assessed the impact of variation in multiple parameters. A probabilistic sensitivity analysis in which probabilistic distributions were applied to each input during 1,000 model iterations was also conducted.Results: Total costs incurred were higher with nivolumab ($101,552) than with IC ($38,067). Nivolumab was associated with a higher number of life-years (LY; 1.21) and quality-adjusted life-years (QALYs; 0.89), compared with IC (0.68 and 0.42, respectively). The incremental cost-effectiveness ratio for nivolumab compared with IC was $134,438 per QALY, and this remained qualitatively similar when increased uptake of subsequent immunotherapies was assumed ($129,603 per QALY). Sensitivity analyses supported these findings.Conclusions: These results suggest that, at a willingness-to-pay threshold of $150,000 per QALY, nivolumab is a cost-effective option for therapy of SCCHN in the US.

Real-world treatment patterns for patients with metastatic head and neck squamous cell carcinoma treated with immuno-oncology therapy

BACKGROUND

Real-world use of immuno-oncology (IO) therapies (nivolumab and pembrolizumab) in metastatic head and neck squamous cell carcinoma (mHNSCC) has not been well studied.

METHODS

mHNSCC patients treated with an IO therapy were identified from a large US claims database from 2016 to 2017. Treatment patterns before and after initiation of IO therapy (index date) were described.

RESULTS

Among 416 mHNSCC patients, 85% had ≥1 regimen prior to IO therapy. Ninety-seven percent of patients initiated IO as monotherapy and 3% initiated IO combined with another systemic treatment. One hundred seventeen (28%) patients had a subsequent regimen, usually chemotherapy (n = 58, 50%) or IO monotherapy (n = 27, 23%), of which 22 patients restarted the same IO therapy and 5 switched to another IO monotherapy.

CONCLUSION

The majority of mHNSCC patients initiated IO as a monotherapy. Approximately half of patients with a subsequent regimen received chemotherapy and one-fourth received IO monotherapy.

Comparison of the Financial Burden of Survivors of Head and Neck Cancer With Other Cancer Survivors

Importance

Head and neck cancer (HNC) is more common among socioeconomically disenfranchised individuals, making financial burden particularly relevant.

Objective

To assess the financial burdens of HNC compared with other cancers.

Design, Setting, and Participants

In this retrospective review of nationally representative, publicly available survey, data from the Medical Expenditure Panel Survey were extracted from January 1, 1998, to December 31, 2015. A total of 444 867 adults were surveyed, which extrapolates to a population of 221 503 108 based on the weighted survey design. Data analysis was performed from April 18, 2018, to August 20, 2018.

Exposures

Of 16 771 patients with cancer surveyed (weighted count of 10 083 586 patients), 489 reported HNC (weighted count of 261 631).

Main Outcomes and Measures

Patients with HNC were compared with patients with other cancers on demographics, income, employment, and health. Within the HNC group, risk factors for total medical expenses and relative out-of-pocket expenses were assessed with regression modeling. Complex sampling methods were accounted for with weighting using balanced repeated replication.

Results

A total of 16 771 patients (mean [SD] age, 62.3 [18.9] years; 9006 [53.7%] female) with cancer were studied. Compared with patients with other cancers, patients with HNC were more often members of a minority race/ethnicity, male, poor, publicly insured, and less educated, with lower general and mental health status. Median annual medical expenses ($8384 vs $5978; difference, $2406; 95% CI, $795-$4017) and relative out-of-pocket expenses (3.93% vs 3.07%; difference, 0.86%; 95% CI, 0.06%-1.66%) were higher for patients with HNC than for patients with other cancers. Among patients with HNC, median expenses were lower for Asian individuals compared with white individuals ($5359 vs $10 078; difference, $4719; 95% CI, $1481-$7956]), Westerners ($8094) and Midwesterners ($5656) compared with Northwesterners ($10 549), and those with better health status ($16 990 for those with poor health vs $6714 for those with excellent health). Higher relative out-of-pocket expenses were associated with unemployment (5.13% for employed patients vs 2.35% for unemployed patients; difference, 2.78%; 95% CI, 0.6%-4.95%), public insurance (5.35% for those with public insurance vs 2.87% for those with private insurance; difference, 2.48%; 95% CI, -0.6% to 5.55%), poverty (13.07% for poor patients vs 2.06% for high-income patients), and lower health status (10.2% for those with poor health vs 1.58% for those with excellent health).

Conclusions and Relevance

According to this study, HNC adds a substantial, additional burden to an already financially strained population in the form of higher total and relative expenses. The financial strain on individuals, assessed as relative out-of-pocket expenses, appears to be driven more by income than by health factors, and health insurance does not appear to be protective.

Cost-effectiveness Analysis of Nivolumab for Treatment of Platinum-Resistant Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck

Background

The CheckMate 141 trial found that nivolumab improved survival for patients with recurrent or metastatic head and neck cancer (HNC). Despite the improved survival, nivolumab is much more expensive than standard therapies. This study assesses the cost-effectiveness of nivolumab for the treatment of HNC.

Methods

We constructed a Markov model to simulate treatment with nivolumab or standard single-agent therapy for patients with recurrent or metastatic platinum-refractory HNC. Transition probabilities, including disease progression, survival, and probability of toxicity, were derived from clinical trial data, while costs (in 2017 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios (ICERs), expressed as dollar per quality-adjusted life-year (QALY), were calculated, with values of less than $100 000/QALY considered cost-effective from a health care payer perspective. We conducted one-way and probabilistic sensitivity analyses to assess model uncertainty.

Results

Our base case model found that treatment with nivolumab increased overall cost by $117 800 and improved effectiveness by 0.400 QALYs compared with standard therapy, leading to an ICER of $294 400/QALY. The model was most sensitive to the cost of nivolumab, though nivolumab only became cost-effective if the cost per cycle decreased from $13 432 to $3931. The model was not particularly sensitive to assumptions about survival. If one assumed that all patients alive at the end of the CheckMate 141 trial were cured of their disease, nivolumab was still not cost-effective (ICER $244 600/QALY).

Conclusion

While nivolumab improves overall survival, at its current cost it would not be considered a cost-effective treatment option for patients with HNC.

A Real-World Claims Analysis of Costs and Patterns of Care in Treated Patients with Glioblastoma Multiforme in the United States

BACKGROUND

Patients with glioblastoma multiforme (GBM) have a poor prognosis and high likelihood of recurrence. Routine care for incident cases in the United States involves surgical resection, followed by radiation therapy (RT) with concurrent and adjuvant temozolomide. Real-world data reporting the treatments and health care burden associated with GBM are limited.

OBJECTIVE

To assess patterns of care, health care resource utilization (HCRU), and costs associated with treatment of GBM in the United States.

METHODS

This study is a retrospective claims database analysis. Adult patients with a GBM diagnosis (index date) between January 1, 2010, and June 30, 2016, who had undergone brain surgery within 90 days of the index date, had received temozolomide and/or RT up to 90 days after index date, and had at least 6 months of continuous enrollment before the index date, were identified. Patients were excluded if they had (a) another primary cancer within 6 months pre-index, (b) secondary brain metastases, or (c) received temozolomide and/or RT pre-index. Baseline characteristics, treatments, HCRU, and costs were reported. First-line therapy began upon first receipt of RT and/or temozolomide after index date; second-line therapy began when a new drug was added > 28 days after initiation of first-line therapy or when there was a treatment gap > 90 days. Treatment regimens, duration of treatment (corrected group prognosis method), HCRU, and costs were reported descriptively in the 0- to 6-month and 7- to 12-month periods following initiation of first-line and second-line therapy.

RESULTS

Baseline characteristics were comparable between patients receiving temozolomide and/or RT. Patients receiving RT without chemotherapy tended to be older, be retired, and have more baseline comorbidities. Of the 4,071 patients receiving first-line therapy for GBM, most (73.0%) received temozolomide + RT; 24.4% received RT; and 2.5% received temozolomide monotherapy. Of those receiving first-line therapy, 1,283 (31.5%) patients subsequently received second-line therapy: 39.4% received bevacizumab monotherapy; 28.9% received bevacizumab combination therapy (temozolomide, 45.2% of patients; irinotecan, 24.3%; and temozolomide + lomustine, 15.4%); 15.5% received temozolomide monotherapy; and 13.7% received other systemic cancer therapies. The proportion of patients with hospitalizations increased from 2.9% (4-6 months pre-index) to 20.8% in the 3 months before the index date (likely due to diagnostic procedures) and 28.1% in the first 6 months after index (likely due to surgery) and then decreased to 13.3% in the 7- to 12-month period after index. Mean total per-patient costs at 6 and 12 months were $117,325 and $162,550 (first line) and $126,128 and $243,833 (second line). Costs in all time periods were largely driven by costs of RT/systemic cancer therapy.

CONCLUSIONS

Most patients with newly diagnosed GBM received treatment according to recommendations. However, relatively few patients received second-line therapy, and the HCRU burden and costs associated with both lines of therapy were substantial. Novel therapies for GBM are required to improve treatment options and outcomes in these patients.

DISCLOSURES

This study was funded by Bristol-Myers Squibb (Princeton Pike, NJ). Neither honoraria nor payments were provided for authorship. Norden received consultancy fees relating to this study from Bristol-Myers Squibb. Dastani, Korytowsky, Le, Singh, and You are employees of Bristol-Myers Squibb. Dastani and Korytowsky are shareholders of Bristol-Myers Squibb. Bobiak was an employee of Bristol-Myers Squibb at the time of this study. Preliminary data from this study were previously presented at the International Society for Pharmacoeconomics and Outcomes Research 22nd Annual International Meeting in Boston, MA, May 20-24, 2017.

Pattern of planned systemic therapy usage in newly diagnosed, nonmetastatic squamous cell carcinoma of the head and neck in a commercially insured population in the United States

BACKGROUND

We analyzed systemic therapy plans submitted for commercially insured patients with untreated, newly diagnosed squamous cell carcinoma of the head and neck (SCCHN) to investigate patterns of practice.

METHODS

Consecutive chemotherapy treatment plans were submitted using Eviti Connect (https://www.marylandphysicianscare.com/content/dam/centene/maryland/pdfs/evitiConnectFactSheet.pdf) portal for preauthorization between June 1, 2011, and June 30, 2015, were analyzed.

RESULTS

A total of 387 treatment plans were submitted for 340 patients; 68 and 272 patients were from academic centers and community practices, respectively. Single agent cisplatin (57%), cetuximab (18%), and carboplatin (9%) were the most commonly proposed regimens concurrent with definitive radiotherapy (RT). The frequency of cetuximab use was not significantly different between academic centers and community practices. A clinical trial was proposed in only 15% of patients.

CONCLUSION

Among commercially insured patients with newly diagnosed, nonmetastatic SCCHN, the choice of systemic therapy in initial treatment plans was not significantly different between academic centers and community practices. Clinical trials are underutilized and should be encouraged.

Cost-Effectiveness Analysis of Intensity Modulated Radiation Therapy Versus Proton Therapy for Oropharyngeal Squamous Cell Carcinoma

PURPOSE

To compared the cost-effectiveness of intensity modulated proton beam therapy (PBT) and intensity modulated radiation therapy (IMRT) in the management of stage III-IVB oropharynx cancer (OPC).

METHODS AND MATERIALS

A Markov model was constructed to compare IMRT with PBT for a 65-year-old patient with stage IVA OPSCC. We assumed PBT led to a 25% reduction in long-term xerostomia, short-term dysgeusia, and the need for gastrostomy tube. Fewer dental complications were also expected with PBT. Incremental cost-effectiveness ratios (ICERs) were calculated, and value of information analyses were performed. The societal willingness-to-pay was defined as $100K per quality-adjusted life year (QALY).

RESULTS

The ICERs for PBT for favorable human papillomavirus (HPV)-positive OPC were $288,000/QALY and $390,000/QALY in the payer perspective (PP) and societal perspective, respectively. Under nearly every scenario, PBT was not cost-effective, with ICERs above $150,000/QALY in the PP. The ICERs for HPV-negative OPC were typically greater than $250K/QALY in both perspectives. For HPV-positive patients, the ICER was less than $100,000/QALY in the PP only in younger patients who experienced a 50% reduction in both xerostomia and gastrostomy use. On probabilistic sensitivity analyses, there were 0% and 0.4% probabilities that PBT was cost-effective for 65- and 55-year old patients, respectively. The value of information was zero or negligible for all ages and perspectives at willingness-to-pay of $100,000/QALY and only meaningful in the PP for younger patients at a willingness-to-pay of $150,000/QALY.

CONCLUSIONS

Intensity modulated proton beam therapy was only cost-effective in the PP if assumed to achieve profound reductions in long-term morbidity for younger patients; it was never cost-effective in the societal perspective. Prospective data are needed (and may be valuable) to better characterize the comparative toxicities of these treatments but are unlikely to change this calculation, except potentially in the most favorable cohort of patients.

Patient Characteristics and Costs in Recurrent or Refractory Head and Neck Cancer: Retrospective Analysis of a Community Oncology Database

PURPOSE

The goal of this study was to describe patient characteristics, health resource utilization (HRU), and costs associated with treating recurrent or refractory head and neck cancer (HNC) among patients with disease progression in the community oncology setting.

METHODS

This retrospective observational study was conducted by using data from the Vector Oncology Data Warehouse. Patients had been diagnosed with locally advanced or metastatic (stage III-IVc) HNC between January 1, 2007, and October 1, 2015. Patients also had evidence of at least 1 systemic anticancer therapy regimen following the diagnosis of advanced HNC, with at least 1 disease progression. Costs, treatment patterns, and HRU were evaluated beginning with diagnosis of advanced HNC through 3 lines of therapy. Costs of surgery or radiation were not available for inclusion in the analysis. Total cost for the study period and cost per month were analyzed by using a generalized linear regression model.

FINDINGS

The study included 462 patients (median age, 61 years; range, 26-99 years); of these, 81% were male, 77% were white, and 21% were black. At initial diagnosis, the most frequent tumor locations were the hypopharynx/larynx (31%) and the oropharynx (31%). Human papilloma virus testing was most frequent among the oropharynx group (22% tested, 52% positive). Overall, 42% were current tobacco users and 22% were current or past alcohol abusers/excessive users. Platinum-based combination therapies were the most frequently administered chemotherapy in both first (42%) and second (40%) lines of treatment. Through the overall study period (mean, 20.5 months), 74% of patients were hospitalized, 19% had an emergency department visit, and 100% had an office visit. The overall mean (SD) duration of hospital stay was 12.6 days, and the median number of office visits per patient was 35. The mean monthly health care cost for the overall study period was $14,391 (95% CI, 12,739-16,044). Hospitalization costs represented ~57% of the total expenditures. Statistically significant predictors of higher overall cost included primary tumor location in the oral cavity, history of alcohol abuse/excess use, use of cetuximab, and higher comorbidity index. Older age and being stage IV versus other stages of disease at diagnosis were associated with lower overall cost.

IMPLICATIONS

These data suggest that costs of care in patients with recurrent or refractory HNC are related to patient characteristics and treatment patterns. Identification of factors contributing to the costs of care in HNC may provide a useful foundation for developing strategies to control rising costs.

Value considerations in the treatment of head and neck cancer: radiation, chemotherapy, and supportive care

The management of head and neck cancer has advanced in many areas, including but not limited to diagnostic imaging and response assessment, radiation delivery, surgical approaches, combined-modality therapy, as well as new drug discovery. These advances have become widely used, however, the associated improvements in outcomes of interest compared with other options may at times be modest in magnitude or supported by limited data. In addition, the price tag of these advancements is often high. There is a growing mandate to look at existing data to identify insights into how to improve the value of care and to better understand the comparative effectiveness of one intervention versus another with regard to tumor control, quality of life, and other important outcomes; such insights become particularly important when considerable disparities exist in related costs. We review selected issues in radiotherapy, chemotherapy and supportive care applicable to the management of head and neck cancer and relevant to ascertaining the value of care.

The economic burden of head and neck cancer: a systematic literature review

BACKGROUND

This systematic literature review aimed to evaluate and summarize the existing evidence on resource use and costs associated with the diagnosis and treatment of head and neck cancer (HNC) in adult patients, to better understand the currently available data. The costs associated with HNC are complex, as the disease involves multiple sites, and treatment may require a multidisciplinary medical team and different treatment modalities.

METHODS

Databases (MEDLINE and Embase) were searched to identify studies published in English between October 2003 and October 2013 analyzing the economics of HNC in adult patients. Additional relevant publications were identified through manual searches of abstracts from recent conference proceedings.

RESULTS

Of 606 studies initially identified, 77 met the inclusion criteria and were evaluated in the assessment. Most included studies were conducted in the USA. The vast majority of studies assessed direct costs of HNC, such as those associated with diagnosis and screening, radiotherapy, chemotherapy, surgery, side effects of treatment, and follow-up care. The costs of treatment far exceeded those for other aspects of care. There was considerable heterogeneity in the reporting of economic outcomes in the included studies; truly comparable cost data were sparse in the literature. Based on these limited data, in the US costs associated with systemic therapy were greater than costs for surgery or radiotherapy. However, this trend was not seen in Europe, where surgery incurred a higher cost than radiotherapy with or without chemotherapy.

CONCLUSIONS

Most studies investigating the direct healthcare costs of HNC have utilized US databases of claims to public and private payers. Data from these studies suggested that costs generally are higher for HNC patients with recurrent and/or metastatic disease, for patients undergoing surgery, and for those patients insured by private payers. Further work is needed, particularly in Europe and other regions outside the USA; prospective studies assessing the cost associated with HNC would allow for more systematic comparison of costs, and would provide valuable economic information to payers, providers, and patients.

Incremental and comparative health care expenditures for head and neck cancer in the United States

OBJECTIVES/HYPOTHESIS

Determine the incremental costs associated with head and neck cancer (HNCa) and compare the costs with other common cancers.

STUDY DESIGN

Cross-sectional analysis of a healthcare expenditure database.

METHODS

The Medical Expenditure Panel Survey is a national survey of US households. All cases of HNCa were extracted for 2006, 2008, and 2010. The incremental expenditures associated with HNCa were determined by comparing the healthcare expenditures of individuals with HNCa to the population without cancer, controlling for age, sex, education, insurance status, marital status, geographic region, and comorbidities. Healthcare expenditures for HNCa were then compared to individuals with lung cancer and colon cancer to determine relative healthcare expenditures.

RESULTS

An estimated 264,713 patients (annualized) with HNCa were identified. The mean annual healthcare expenditures per individual for HNCa were $23,408 ± $3,397 versus $3,860 ± $52 for those without cancer. The mean adjusted incremental cost associated with HNCa was $15,852 ± $3,297 per individual (P < .001). Within this incremental cost, there was an increased incremental outpatient services cost of $3,495 ± $1,044 (P = .001) and an increased incremental hospital inpatient cost of $6,783 ± $2,894 (P = .020) associated with HNCa. The annual healthcare expenditures per individual fell in between those for lung cancer ($25,267 ± $2,375, P = .607) and colon cancer ($16,975 ± $1,291, P = .055).

CONCLUSIONS

Despite its lower relative incidence, HNCa is associated with a significant incremental increase in annual healthcare expenditures per individual, which is comparable to or higher than other common cancers. In aggregate, the estimated annual costs associated with HNCa are $4.20 billion.