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Value-Based Approach to Managing Adverse Events in Myeloma

Value-Based Care in Myeloma - Side Effect Management, Multiple Myeloma
Atheer A. Kaddis, PharmD
Senior Vice President
Sales and Business Development
Diplomat Specialty Pharmacy
Fint, MI

Over the past decade, the use of bortezomib, lenalidomide, and thalidomide, with or without autologous stem cell transplant, has significantly im proved outcomes for patients with multiple myeloma (MM). Several of the regimens now listed as category 1 recommendations by the National Comprehensive Cancer Network (NCCN) for the treatment of MM include 1 or more of these agents.1 Category 1 designation refers to uniform NCCN consensus that the intervention is appropriate based on high-level evidence. Individuals treated with new, more effective regimens are now surviving twice as long as those treated only a decade ago with therapies such as melphalan plus prednisone.2

These advances are truly revolutionary, as it is rare to see the emergence of therapies that can cause such a paradigm shift in the natural course of an incurable disease like MM. However, this excitement comes at a hefty price; namely, the direct and indirect costs associated with treatment. As a side note, this dilemma is not relegated exclusively to myeloma. We are now seeing new oncology therapies enter the market with a minimum of $100,000 per course of therapy, as evidenced by the targeted agents ipilimumab, for the treatment of melanoma, and brentuximab, for the treatment of lymphoma.3,4 This rise in the cost of therapy is not surprising; it was inevitable, as we have witnessed in the treatment of other disease states such as multiple sclerosis.5

The main article in this publication provides an excellent overview of side effects associated with bortezomib, lenalidomide, and thalidomide. I think it is important for clinicians and payers to focus considerable attention on the prevention and management of myelosuppression and venous thromboembolism (VTE), as they represent 2 ends of the spectrum as it relates to overall costs associated with care. Myelosuppression as a complication of myeloma therapy cannot be overlooked. Granulocyte colony-stimulating factors are often required to manage this adverse event, and their use can significantly increase the overall cost of treatment. The addition of erythropoiesis-stimulating agents to lenalidomide-based therapy may also contribute greatly to the cost of care. It is important for clinicians and payers to be aware of the recommended guidelines pertaining to the use of these products to prevent variability in utilization, which will inevitably result in additional costs that may not have been considered previously.6

Thromboembolism, on the other hand, is readily preventable with low-cost therapy. The cost of thromboprophylaxis with agents such as aspirin, warfarin, or low-molecular-weight heparin is very reasonable when compared with the high cost of treating deep vein thrombosis or pulmonary embolism once they occur. In addition, the incidence of VTE can often be reduced with lower doses of dexamethasone.7

In addition to side effect management, a key ingredient in providing value-based care for patients diagnosed with cancer is that of palliative care. This approach is aimed at improving the quality of life of patients and their families through prevention and relief of suffering by means of early identification, impeccable assessment, and tolerable treatment.8 For many patients diagnosed with cancer, the primary focus is on the various therapeutic options and the management of associated toxicities, while a discussion and plan involving palliative care is often overlooked. Palliative measures are most effective when implemented early in the course of treatment, and should be considered for every patient. Formulating a palliative care plan, in addition to being aware of the potential side effects of therapy and providing appropriate preventive and management strategies, are all critical to the overall success of treating MM.

References

  1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 1.2011, NCCN Web site. www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf. Accessed August 2011.
  2. Kumar SK, Rajkumar SV, Dispenzieri A, et al. Improved survival in multiple myeloma and the impact of novel therapies. Blood.2008;111:2516-2520.
  3. Murray L, ed. 2011 Red Book (Micromedex 2.0 Online). Montvale, NJ: Thompson PDR; 2011. Accessed May 25, 2011.
  4. Seattle Genetics Sets Adcetris Price. BioCentury via BioPortfolio. www.bioportfolio.com/news/article/777951/Seattle-Genetics-Sets-Adcetris- Price.html. Accessed August 27, 2011.
  5. Eva von Schaper E, Kresge N. Novartis’ Gilenya spurs rivals to increase price. Bloomberg News. http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/03/23/BUE71IH0L5.DTL. Accessed August 26, 2011.
  6. Wright JD, Neugut AI, Wilde ET, et al. Physician characteristics and variability of erythropoiesis-stimulating agent use among Medicare patients with cancer. J Clin Oncol. 2011;29(suppl). Abstract 6020.
  7. Rajkumar SV, Jacobus S, Callander NS, et al. Lenalidomide plus high-dose dexamethasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial. Lancet Oncol. 2010;11:29-37.
  8. World Health Organization. WHO Definition of Palliative Care. www. who.int/cancer/palliative/definition/en/. Accessed August 23, 2011.
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Last modified: May 20, 2015
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