Other Strategies To Improve Cost-effectiveness

In 2012, physicians at Memorial Sloan Kettering Cancer Center (MSKCC) opted to take an expensive drug off its formulary — an unprecedented move for a major cancer center. When ziv-aflibercept was approved for the treatment of metastatic colorectal cancer, it was initially priced at $11,063 — more than twice the cost of bevacizumab, then available at about $5000 per month and which provided similar benefits as the new drug.6

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Writing an op-ed in the New York Times, 3 MSKCC physicians explained the action: “new” is not “better” and current mechanisms are unable to control the “runaway price of new cancer drugs…But if no one else will, leading cancer centers and other research hospitals should,” they wrote. Following this, the manufacturer cut the drug’s price in half.

Peter B. Bach, MD, MAPP, director of the Center for Health Policy and Outcomes at MSKCC, whose work focuses on the cost and value of cancer treatment, provided insights into the cost of therapy for aRCC in perspective that accompanied CheckMate 025.7 He estimated that nivolumab would cost Medicare beneficiaries $65,000 and commercially insured patients twice as much.

“Expensive drugs can still seem deceptively cost-effective,” Dr Bach wrote. He noted that in the case of aRCC, everolimus cost $41,000 for the course of treatment, which made the incremental cost of nivolumab $24,000; it actually cost $65,000. He also pointed out that the cost of treating a patient did not take into account prior therapies the patient would have received nor the expensive treatments that would be provided when disease progressed.

A petition signed by more than 100 noted oncologists across the country indicated that “simple and measured incremental actions can improve the situation and allow market forces to work better.”8 Action items included creating a mechanism that would propose a fair price to new drugs based on value, allowing Medicare to negotiate drug prices, allowing importation of cancer drugs for personal use, passing legislation to prevent delaying access to generic drugs (pay-for-delay), and encouraging organizations that represent cancer specialists and patients to consider value of drugs/treatments when formulating guidelines.

Some organizations have developed several value frameworks, which can be used to determine the value of a therapeutic regimen.

Dr Bach created DrugAbacus, a tool to “determine appropriate prices for cancer drugs based on what experts tend to list as possible components of a drug’s value.” It’s a proof-of-concept tool and includes drugs approved between 2001 and 2013.9  

The National Comprehensive Cancer Network (NCCN) Evidence Blocks provide recommendations based on treatment’s value. For subsequent therapy following progression on first-line therapy in aRCC, the NCCN provided Category 1 recommendation for cabozantinib, nivolumab, axitinib, and the combination of lenvatinib and everolimus, in that preferred order.10

The American Society of Clinical Oncology (ASCO) Value Framework uses a scoring algorithm for clinical benefit, toxicity, tail of the survival curve, palliation, QoL, and treatment-free interval. The net health score for each therapeutic regimen is then considered in relation to the cost.11

RELATED: Dual Immunotherapy Active vs Sunitinib for PD-L1+ Advanced RCC

With patients having to pay high out-of-pocket costs under the current insurance system, research shows that patients will stop taking their medications even if they are effective, Dr Bach wrote. “The high costs of cancer care also drive patients to bankruptcy.” In the future, affordability vs effectiveness of treatment is likely to feature upfront in the dialogue between physicians and their patients.


  1. Wan XM, Peng LB, Ma JA, Li YJ. Economic evaluation of nivolumab as a second-line treatment for advanced renal cell carcinoma from US and Chinese perspectives. Cancer. 2017 Mar 16. doi: 10.1002/cncr.30666 [Epub ahead of print]
  2. Motzer RJ, Escudier B, McDermott DF, et al. Nivolumab versus everolimus in advanced renal cell carcinoma. N Engl J Med. 2015;373:1803-13.
  3. Matter-Walstra K, Schwenkglenks M, Aebi S, et al for the Swiss Group for Clinical Cancer Research. A cost-effectiveness analysis of nivolumab versus docetaxel for advanced nonsquamous NSCLC including PD-L1 testing. J Thoracic Oncol. 2016;11(11):1846-1855.
  4. Ristau BT, Geynisman DM. Patient-reported and cost-effectiveness outcomes are key to determining the optimal therapeutic sequence for patients with metastatic renal cell carcinoma. Eur Urology. 2017;71:210-2.
  5. Wiecek W, Karcher H. Nivolumab versus cabozantinib: comparing overall survival in metastatic renal cell carcinoma. PLoS ONE. 2016;11(6):e0155389.
  6. Bach PB, Saltz LB, Wittes RE. In cancer care, cost matters. The New York Times website. http://www.nytimes.com/2012/10/15/opinion/a-hospital-says-no-to-an-11000-a-month-cancer-drug.html. Published October 14, 2012. Accessed March 2017.
  7. Bach PB. New math on drug cost effectiveness. N Engl J Med. 2015;373:1797-9.
  8. Tefferi A, Kantarjian H, Rajkumar SV, et al. In support of a patient-driven initiative and petition to lower the high price of cancer drugs. Mayo Clinic Proc. 2015;90(8):996-100.
  9. Evidence driven drug pricing project. Memorial Sloan Kettering Cancer Center website. http://www.drugabacus.org/. Accessed March 19, 2017.
  10. National Comprehensive Cancer Center Evidence Blocks. NCCN website. https://www.nccn.org/evidenceblocks/. Accessed March 19, 2017.
  11. Schnipper LE, Davidson NE, Wollins DS, et al. Updating the American Society of Clinical Oncology Value Framework: revisions and reflections in response to comments received. J Clin Oncol. 2016;34(24):2925-34.