Scott A. Soefje, PharmD, MBA, BCOP
Pancreatic cancer is one of the few cancers that is on the rise, and this means that the overall cost of treating this disease is also climbing. In addition to that, the limitations of current therapies in this space have prompted the development of new agents that typically come with higher price tags. The result is a gathering storm of higher incidence and higher cost. Invevitably, these factors will prompt difficult cost-based choices of therapies; however, the changing scenario in pancreatic cancer is leading to calls for earlier screening that may head off some of the expense of treating this difficult tumor type.
Treatments for pancreatic cancer include surgery, which is available to less than 20% of new patients, and, for advanced disease, chemotherapy with gemcitabine with nab-paclitaxel (Abraxane) or with leucovorin/fluorouracil/irinotecan/oxaliplatin (FOLFIRINOX), which can increase overall survival (OS) by a few months. Economic and outcome analyses of clinical data have found no significant difference in OS between the 2 regimens, although FOLFIRINOX carries a much higher rate of serious adverse effects, limiting its use to patients with good performance status. In 2017, the FDA approved immunotherapy for patients with microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR) solid tumors, which occur in approximately 1% of pancreatic cancer diagnoses. Several immunotherapies and targeted therapies are currently in clinical trials and may significantly alter the trajectory of the disease. However, they typically cost more than $100,000 per year.
With an estimated 44,330 deaths in 2018, pancreatic cancer is moving up rapidly from its current position as the fourth-leading cause of cancer-related mortality.1
Diagnosis is typically made when the cancer is advanced or has spread to distant parts of the body. Thus, less than 20% of patients are eligible for curative surgical treatment.2
Instead, the primary treatment is chemotherapy with or without radiation and, on the horizon, targeted therapy or immunotherapy. Individuals with advanced pancreatic cancer have a very poor prognosis, with a relative 5-year survival rate of 8.5% overall, largely due to the generally late diagnosis of the disease. Patients with local disease (10.0%) have a 5-year survival rate of just 34.3%.3
Between 2004 and 2013, the pancreatic cancer incidence rate increased about 1% in white individuals, although it remained stable in black individuals.2 The increase is particularly evident in younger individuals. An analysis of the National Inpatient Sample database found a 75% increase in the rate of pancreatic cancer discharges between 1997 and 2012 in those aged 18 to 44 years, with an overall increase of 55% in women and 31% in men.4
By 2030, pancreatic cancer is expected to become the second-leading cause of cancer-related death in the United States.5
The most recent analysis of direct medical costs related to the total care of pancreatic cancer is based on 5262 patients with the disease in a managed care population matched to 15,786 controls between 2001 and 2010. Mean total all-cause health-care costs per-member, per-month (PMPM), including those for office visits, inpatient visits, emergency department visits, and inpatient stays, were $15,480 versus $1001 for the control group (all P
<.001), with inpatient stays being the highest cost driver ($9917 PMPM). In addition, costs were significantly higher during treatment for metastatic and advanced cancer compared with the initial treatment phase of nonmetastatic disease ($21,637 vs $10,358, respectively; P
Inpatient costs, which drive overall costs for treatment, are rising. An analysis of data from 1997 to 2012 in the National Inpatient Sample database found that total costs nearly tripled during that time, from $24,000 per hospitalization to $68,000, even as the mean length of stay dropped by 19% (from 9.6 to 7.8 days; P
<.001); also, inpatient mortality declined by 6%. The number of hospital discharges also increased (28,862 in 1997 to 36,625 in 2012; P