There could be few people happier than executives at Express Scripts, CVS and other pharmacy benefit managers after publication of US oncologists’ cancer-drug value framework.
The document published by Asco should give the bean-counters ammunition in their cost pushback, as once a drug’s value can be established on a 0-100 scale a calculation should help PBMs argue for a lower price in many cases. Such a calculation can be done quickly and easily, for instance by using data from EvaluatePharma's drug pricing module (see table below).
The article published in the Journal of Clinical Oncology does not itself make any explicit price conclusions, nor does it calculate value for many drugs. It does give experts a worksheet that allows them to make assessments based on clinical trial results – with survival data and safety and tolerability profiles used to make the calculation.
The scale gives marks out of 100, though agents for palliative use are eligible for up to 30 extra points. A total of 80 points are in the clinical benefit domain, and 20 for the toxicity, in addition to the palliation points in cases where that applies.
Drugs that were given illustrative calculations were: Avastin, Alimta, Gemzar and Tarceva in non-small cell lung cancer; Velcade in multiple myeloma; Zytiga, Xtandi and Jevtana in prostate cancer; and Herceptin in breast cancer.
For all the hype surrounding these advancements, their scores are surprisingly modest – the highest “net health benefit” (NHB) being Herceptin’s 48 out of 100 in adjuvant treatment of Her2-positive breast cancer when combined with doxorubicin, cyclophosphamide and paclitaxel. A 39% reduction in the risk of death combined with a similar toxicity profile to the chemotherapy drugs alone accounted for the score.
A fellow Roche drug, Avastin, looked less impressive, scoring 16 of 130 when combined with paclitaxel and carboplatin in non-small cell lung cancer. A two-month survival benefit over the chemotherapy control was offset by a greater number of grade 3-5 toxicities. Another of the Swiss group’s drugs, Tarceva, looks better in that setting, scoring 44 of 130.
At an annual cost of $144,162 in lung cancer, according to EvaluatePharma’s Sales, Volume & Price data, Avastin is the clear outlier in this analysis on raw cost.
Asco was unwilling to put price explicitly into the equation, choosing simply to publish United Healthcare's monthly cost side-by-side with the NHB. Payers are not likely to be as reluctant, and have their own models, into which the Asco analysis can be incorporated. A simple analysis around the price and the Asco illustrative score draws a clearer picture of Avastin’s value, for example.
To establish a more sophisticated value score, EP Vantage took the Asco net health benefit score and divided it by the total in the scale, 100 or 130. It then drew annual cost data from the EvaluatePharma Sales Volume & Price model and divided that number by the net health benefit quotient. A higher expenditure score in this analysis suggests a poorer value based on the efficacy and safety measurement done by Asco.
In the lung cancer sector, this analysis shows that Alimta and Gemzar are incredibly expensive drugs - infinity, in mathematical terms - in that they have no value whatsoever; however, Avastin does not show itself to be a very good value either, coming in at a score of more than 1.2 million, indicating that payers shell out an enormous amount to achieve low value in lung cancer. Tarceva's low annual cost and higher NHB score show it to be a better value, with a score of less than 35,000 here, the best value of the drugs analysed.
|Value calculation based on Asco score|
|Asco NHB||Annual cost*||Expenditure score|
|*annual cost taken from EvaluatePharma Sales, Volume & Price model|
Prostate cancer provides another setting where a side-by-side comparison can be made: Zytiga won a higher score on pain relief, but its higher cost makes it look a poorer value.
Meanwhile, Herceptin’s is on the costly end of this analysis with a nearly $75,000 pricetag, but its low expenditure score makes it look a pretty good value.
This is a simple analysis, to be sure. But it paints a clearer picture of the value of cancer drugs amid the blizzard of data that the sector sees. Payers likely have internal tools that resemble the worksheets Asco provided in its framework; however, the Asco version has the imprimatur of a medical society, and the data it generates will surely have more influence in pricing negotiations.