It is widely acknowledged that the costs of cancer care are much higher in the United States than in Canada, with outcomes that are thought to be similar. A new study presented at the 2018 ASCO Annual Meeting supports that view, by documenting and quantifying the differences in health-care costs and outcomes between demographically similar regions of the United States and Canada for patients with metastatic colorectal cancer.1
Understanding these differences may help us improve care and potentially lower health-care costs.— Todd Yezefski, MD
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The upshot of the study was that care for metastatic colorectal cancer costs twice as much per patient in the United States than it does in Canada, and survival is no better on the U.S. side of the border. Specifically, monthly costs for first-line chemotherapy per patient averaged $12,345 in Western Washington State vs $6,195 in British Columbia, and survival was similar at about 22 months.
“The differences in costs are dramatic, and outcomes are similar in the United States,” said lead author Todd Yezefski, MD, a senior fellow at Fred Hutchinson Cancer Research Center (Fred Hutch) and the University of Washington School of Medicine in Seattle. “To our knowledge, this is the first study to directly compare treatment cost and use along with health outcomes in two similar populations treated in different health-care models. Understanding these differences may help us improve care and potentially lower health-care costs.”
The study was based on an analysis of health claims from 1,622 Canadian patients and 575 U.S. patients and represents a collaboration between Fred Hutch and the British Columbia Cancer Agency. Patients enrolled in the study were diagnosed with colorectal cancer after 2010 in both geographic areas. Costs were converted into U.S. dollars according to value in 2009.
Hagen F. Kennecke, MD
The U.S. data came from private insurers: Premera Blue Cross and Regence Blue Shield. The Canadian data were based on BC Cancer Agency data from Vancouver province covered by a single-payer system. The investigators worked separately on each side of the border to analyze the data. “The raw data never crossed the border. It wasn’t mixed,” said Hagen F. Kennecke, MHA, MD, Medical Director, Virginia Mason Cancer Institute, Seattle, who led the BC Cancer Agency team, according to a news release from Fred Hutch.
The two patient populations had similar demographics, except patients in British Columbia were older (median = 66 vs 60 years) and more likely to be male (57% vs 48%), and more patients in the United States received chemotherapy (79% vs 68%) and may reflect a higher level of treatment intensity in the U.S. setting. Among patients on both sides of the border who did not receive chemotherapy, survival was somewhat shorter. Median overall survival was 5.4 months in Western Washington and 6.1 months in British Columbia.
First-line cost of chemotherapy per month was $12,345 per patient in the United States and $6,195 in British Columbia. FOLFOX (leucovorin, fluorouracil [5-FU], and oxaliplatin) was the most common chemotherapy regimen used in Western Washington, whereas FOLFIRI (leucovorin, 5-FU, and irinotecan) plus bevacizumab (Avastin) was the most common regimen used in British Columbia.
The mean cost of the most common first-line chemotherapy was $11,814 and $8,992 per month, respectively. The mean lifetime cost of chemotherapy per month was $7,883 and $4,830, respectively.
The median overall survival with systemic therapy was 21.4 months in the United States and 22.1 months in British Columbia. The median overall survival for all patients enrolled in the trial (treated and untreated) was 17.4 months and 16.9 months, respectively.
“Patients in Washington State did not do any better in than those in British Columbia. They got the same bang for more buck. The drug prices in Canada are set by the government. We believe if Medicare were allowed to negotiate with drug makers, costs in the United States could be lowered,” Dr. Yezefski said.
The next steps are a planned expanded analysis that includes data from older adults in Washington State, as well as utilization and costs of other treatments for colorectal cancer, such as radiation and surgery. They would also like to evaluate quality of life and symptom burden between different populations.
Gary H. Lyman, MD, MPH, FASCO
Polls show the idea of a single-payer health-care system has gained traction among the U.S. population, and this study adds fuel to the fire. “Obviously the most glaring findings [of this study] are for costs, which is not surprising but nevertheless demonstrates once more that you don’t have to spend what the United States spends on health to achieve outcomes that are at least as good as here,” said Gary H. Lyman, MD, MPH, FASCO, Co-Director of the Hutchinson Institute for Cancer Outcomes Research, in a news release from Fred Hutch. ■
DISCLOSURE: Drs. Yezefski, Kennecke, and Lyman reported no conflicts of interest.
1. Yezefski T, Le D, Chen L, et al: Comparison of chemotherapy use, cost, and survival in patients with metastatic colorectal cancer in Western Washington and British Columbia. 2018 ASCO Annual Meeting. Abstract LBA3579. Presented June 3, 2018.
Richard L. Schilsky, MD
“This study shows us that it is possible to get equally good outcomes with lower costs. In the United States, we have no real way to constrain the costs of health care, including the cost of drugs. The U.S. Food and Drug Administration does not consider drug price...!-->!-->