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A regimen of nab-paclitaxel (Abraxane) and gemcitabine is a cost-effective option for the first-line treatment of patients with metastatic pancreatic cancer because it delivers a survival advantage at a price comparable to the cost of an existing combination therapy
E. Gabriela Chiorean, MD
Associate Professor, Medicine
University of Washington
Associate Member, Fred Hutchinson Cancer Research Center
A regimen of nab-paclitaxel (Abraxane) and gemcitabine is a cost-effective option for the first-line treatment of patients with metastatic pancreatic cancer because it delivers a survival advantage at a price comparable to the cost of an existing combination therapy, according to a recent health resources management study.1
E. Gabriela Chiorean, MD, lead author of the study, discussed her findings during an OncLive Peer Exchange® program entitled “Current Therapeutic Advances in Metastatic Pancreatic Cancer.”
Chiorean, an associate professor of Medicine at the University of Washington in Seattle, presented the study during the 2014 Gastrointestinal Cancers Symposium, held in January in San Francisco, California.
Investigators compared the costs and clinical outcomes of nab-paclitaxel/gemcitabine (nab- P/G) versus erlotinib (Tarceva) plus gemcitabine (E/G) using drug cost per cycle multiplied by the median cycles delivered from clinical trials for nab-P/G and E/G.
The comparison included the cost of the drugs as well as expenses related to administering the therapy and managing adverse events (AEs) of grade 3/4 severity. These costs were based on 4 months of therapy for nab-P/G versus 3.9 months for E/G as administered at a large, multisite oncology clinic.
The total cost for nab-P/G was $24,984 versus $23,044 for E/G, the researchers found (Table). However, the nab-P/G regimen is expected to deliver a greater survival benefit based on clinical trial data, brining the cost per life year (LY) gained to $15,522.
The costs of treating the malignancy are noteworthy considering that pancreatic cancer is the fourth leading cause of cancer-related mortality in the United States. Surgery is the only potentially curative option, but fewer than 20% of patients are candidates for resection.2,3
Moreover, the costs of treatment are high and increasing, healthcare experts have noted. More than 70% of cases are diagnosed in patients aged 65 years and older. Thus, in the United States, Medicare pays for a substantial portion of associated costs.
Nab-P/G is the first taxane-based therapy to show a significant improvement in overall survival (OS) in a phase III trial for patients with metastatic pancreatic cancer.1 The E/G regimen, initially approved in 2004, is among the newer options for treatment, while older chemotherapy combinations also are used.
During the Peer Exchange discussion, Chiorean noted that the costs related to treatment administration and supportive care should be considered, especially when comparing the agents in the FOLFIRINOX combination to nab- P/G. Gemcitabine, 5-fluorouracil, irinotecan, and oxaliplatin are available in generic form, making them inherently cheaper. The upfront cost for FOLFIRINOX is approximately 20% less than nab-P/G.
However, when considering the need for growth factor support, infusion costs, hydration, and the management of additional AEs, the cost associated with FOLFIRINOX is similar to nab- P/G, emphasized Chiorean.
“Overall, I think there is not much difference in the cost because you have to add the growth factor, the supportive care medications,” said Chiorean.
In her comparison of the nab-P/G versus the E/G regimens, the costs of managing AEs were similar between the two therapies (Table). Differences in the incidence of AEs of >5% were noted between nab-P/G and E/G, respectively, in neutropenia (33% vs 24%), neuropathy (17% vs 1%), and rash (0% vs 6%). The net survival advantage for nab-P/G versus E/G was 1.5 months.
Median OS gain vs G, months
Cost of administration
Cost of adverse events
Total cost of therapy
$15,522/LY gained for nab-P/G
E indicates erlotinib; G, gemcitabine; LY, life year; Nab-P, nab-paclitaxel; OS, overall survival. Chiorean EG et al. J Clin Oncol. 2014;32(suppl 3;abstr 363). Reprinted with permission.
In the phase III IMPACT study, nab-P/G demonstrated an 1.8-month, or 27%, improvement in median OS (HR = 0.72, P <.001) versus G alone.
Patients who received nab-P/G had higher 1-year OS (35% vs 22%) and improved progression-free survival (PFS) by 1.8 months (HR = 0.69, P <.01).
E/G also has shown activity in metastatic pancreatic cancer, with a 0.3-month OS benefit versus gemcitabine (HR = 0.82, P = .04), a 1-year OS of 23% versus 17%, and 0.2-months PFS benefit (HR = 0.77, P = .004) vs G.1
The choice of therapy depends on a variety of clinical factors, suggested Peer Exchange panelist Ramesh K. Ramanathan, MD, medical director at the Virginia G. Piper Cancer Center Clinical Trials Program at Scottsdale Healthcare in Arizona.
Patients with a poor performance status, multiple comorbidities, chronic heart failure, diabetes, and a previous stroke may not be able to tolerate combination therapy, said Ramanathan. For these patients, supportive care, single-agent gemcitabine, or capecitabine are reasonable options.
For patients with rapid weight loss who are deteriorating fast due to tumor bulk, nab-P/G with a focus on supportive care may reverse or slow down progression, believes Ramanathan.