What Does the U.S. Buy and What Does
What
Does the U S Buy and What Does
It Get From Its Cancer Chemotherapy Purchases Compared to European Nations?
Purchases Compared to European Nations?
Sean Nicholson (Cornell and NBER)
Claudio Lucarelli (Cornell)
Claudio Lucarelli
David Asch (Univ. of Pennsylvania)
June 26, 2010
Average Chemotherapy Spending Per Metastatic
Colorectal Cancer Patient 2nd Quarter of 2008
Colorectal Cancer Patient, 2
Quarter of 2008
Dollars
50000
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
US
France
Germany
Italy
Spain
United Kingdom
Average Chemotherapy Spending Per Metastatic
Lung Cancer Patient 2nd Quarter of 2008
Lung Cancer Patient, 2
Quarter of 2008
Dollars
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
US
France
Germany
Italy
Spain
United Kingdom
Average Chemotherapy Spending Per Adjuvant Breast Cancer Patient 2nd Quarter of 2008
Breast Cancer Patient, 2
Quarter of 2008
Dollars
16000
14000
12000
10000
8000
6000
4000
2000
0
US
France
Germany
Italy
Spain
United Kingdom
Research Questions
1) Why does the U.S. spend more than the EU on chemotherapy treatment for colorectal, non‐small cell lung cancer (NSCLC), ,
g
(
),
and breast cancer?
a) Higher prices for the same chemotherapy regimens?
b) More expensive (and effective?) mix of regimens in U.S.?
More expensive (and effective?) mix of regimens in U S ?
2) Do U.S. patients have better expected health outcomes as a
result of a different treatment mix? Is the extra spending
l f diff
i ?
h
di
worth it?
3) What would U.S. spending and outcomes be if U.S. adopted
the EU treatment mix? What would EU spending and outcomes be if they adopted the US treatment mix?
outcomes be if they adopted the US treatment mix?
Data
1) Drug Prices from IMS
1)
Drug Prices from IMS
 Converted to dollars using 2008 exchange rates
2) Regimen (combination of drugs) Market Shares
) g
(
g)
 IntrinsiQ: market share by regimen by quarter for Stage 4 (colorectal
and NSCLC) and Stages 1‐3 only (breast cancer)
 Synovate: similar information for 5 European countries
3) Regimen‐Specific Dose Per Drug Per Patient
 National Comprehensive Cancer Network: recommended quantity of each drug used in each regimen for a representative patient. Assume f
hd
di
h
i
f
i
i
chemo is administered as recommended.
4) Expected Survival and Quality Adjusted Life Years (QALYs)
4)
Expected Survival and Quality Adjusted Life Years (QALYs)
 Survival rates, time to progression of cancer, tumor response rates, and side effects from randomized clinical trials. NOT from actual
practice (where differences in patient severity would be an issue)
practice (where differences in patient severity would be an issue)
Spending Decomposition
 Calculate what U.S. would spend per patient on chemotherapy
if used U S regimen mix but paid average EU price (across
if used U.S. regimen mix but paid average EU price (across
five countries) for each regimen.
 Difference between actual U.S. spending and above
calculation is the “price effect” – spending difference due
p
to different prices.
 Difference between 1st calculation and actual EU spending
per patient is the “treatment
per patient is the treatment mix
mix” or or “market
market share
share” effect – spending difference due to different use of regimens. Spending Per Patient, 2nd Quarter of 2008
Metastatic Colorectal Cancer
$50,000
$45,000
$43,598
$40,000
Spending (($)
$35,000
$19,008
$30,000
$25,000
$20,000
$15,000
$10,551
$14,038
$10,000
$5,000
$0
Actual US spending per Spending difference due Spending difference due Average EU spending per patient
to different regimen to different regimen mix
patient
prices
Market share of nine colon cancer regimens in six countries
(regimen indicated by expected QALYs)
100%
1.01
1.01
1 01
1.01
1.01
1.01
1.01
0.94
1.01
1.01
0.88
1.01
80%
0.94
0 94
0.94
0.94
1.01
M
Market Share 0.94
0.85
60%
0.88
0.94
0.88
0.88
0.68
0.88
Oxaliplatin‐Capecitabine
40%
0.85
0.88
0.85
0.68
20%
0.85
0.68
0.68
0.68
0.85
0.85
0.68
C
Capecitabine
i bi
0.68
0.54
0.54
0%
0.54
0.54
0.54
0 53
0.53
0.53
US
France
0.54
0 53
0.53
Germany
Country
Irinotecan‐Capecitabine
Irinotecan‐5 Fluorouracil
0.68
0.68
0.68
Bevacizumab‐Oxaliplatin‐
Capecitabine
Bevacizumab‐Oxaliplatin‐5 Fluorouracil
Bevacizumab
Irinotecan 5
Bevacizumab‐Irinotecan‐5 Fluorouracil
Oxaliplatin‐5 Fluorouracil
0.53
0.53
0.53
Italy
Spain
UK
5 Fluorouracil
Percent Spending Difference Due to Price and Market Share Effects
Colon Cancer
$40,000
$35,000
37 2%
37.2%
$
$30,000
45.7%
43.7%
43.1%
34.4%
35.7%
34.7%
41.3%
32.8%
34.9%
$s 2008
$25,000
35.7%
Market share effect
Price effect
$20,000
$15,000
$15 000
62.8%
$10,000
54.3%
56.3%
56.9%
65.6%
64.3%
58.7%
65.3%
67.2%
65.1%
64.3%
$5,000
$0
2005:4 2006:1 2006:2 2006:3 2006:4 2007:1 2007:2 2007:3 2007:4 2008:1 2008:2
Year : Quarter
Spending Per Patient, 2nd Quarter of 2008
Metastatic Non‐Small Cell Lung Cancer
$18,000
$16,356
$306
$16,000
$14,000
$8,280
Spending ($
$)
$12,000
$10 000
$10,000
$8,000
$7,770
$6,000
$6 000
$4,000
$2,000
$0
Actual US spending per Actual
US spending per Spending difference due Spending difference due Spending difference due Spending difference due Average EU spending per Average EU spending per
patient
to different regimen to different regimen mix
patient
prices
Market Share of nine lung cancer regimens in six countries
(regimen indicated expected QALYs)
100%
0.60
0.50
0.60
0.50
0.60
0.50
0.60
0.60
0.50
0 50
0.46
0.46
0.46
0.50
0.42
0.44
0.42
0.46
0.42
0.46
Market Sharre
80%
0.50
0.42
0.42
60%
0.41
0.46
0.41
0.41
Bevacizumab‐Paclitaxel‐
Carboplatin
Docetaxel‐
Cisplatin/Carboplatin
Paclitaxel‐
Cisplatin/Carboplatin
Gemcitabine‐Paclitaxel
Vinorelbine‐Cisplatin
40%
0.44
0.42
0.41
20%
0.41
0.41
Gemcitabine‐
Cisplatin/Carboplatin
Vinorelbine
0.37
0.37
0.37
0.37
Etoposide‐
Cisplatin/Carboplatin
Cisplatin
0.37
0.37
0%
0.32
0.31
US
0.32
France
0.32
0.31
0.31 0.32
0.32
Germany
Country
Italy
0.32
Spain
UK
Percent Spending Difference Due to Price and Market Share Effects
Lung Cancer
$12,000
$10,000
$s 2008
$8,000
$6 000
$6,000
88.9%
$4,000
79 9%
79.9%
80 5%
80.5%
81.6%
74.8%
74 8%
95.5%
94.3%
95.5%
98.4%
5.7%
4.5%
1.6%
96.4%
80 4%
80.4%
$2,000
$0
20.1%
‐$2 000
‐$2,000
19.5%
18.4%
25.2%
19.6%
11.1%
4.5%
3.6%
2005:4 2006:1 2006:2 2006:3 2006:4 2007:1 2007:2 2007:3 2007:4 2008:1 2008:2
Year : Quarter
Market share effect
Price effect
Spending Per Patient, 2nd Quarter of 2008 Adjuvant Breast Cancer
$16,000
$14,717
$14,000
$1,315
$1,312
Spending ($
$)
$12,000
$10,000
$8,239
$8,000
$6,000
$5,163
$4,000
$2,000
$0
Actual US spending per Spending difference due Spending difference due Average EU spending per patient
to different regimen to difference regimen patient
prices
mix
Market share of ten adjuvant breast cancer regimens in six countries
(regimen indicated by expected QALYs)
100%
12.2
11.8
11 8
12.2
11.8
11.8
11.6
80%
11.8
11 8
11.8
11.6
10.6
10
6
10.4
10.6
Market Sharre
10.6
60%
11 8
11.8
12.2
10.6
11.6
10.4
10.2
10.2
10.4
10.4
9.7 10.2
9.7
9.7
9.7
10 4
10.4
11.6
10.2
40%
9.6
9.6
9.7
9.6
9.6
20%
9.6
10.2
Trastuzumab‐Docetaxel‐
Carboplatin
Docetaxel‐Epirubicin‐
Cyclophosphamide‐5 l
l
Fluorouracil
Docetaxel‐Doxorubicin‐
Cyclophosphamide
8.7
8.7
8.7
France
Doxorubicin‐Cyclophosphamide
Epirubicin‐Cyclophosphamide‐5 Fluorouracil
8.7
9.7
US
Docetaxel‐Cyclophosphamide
Doxorubicin‐Cyclophosphamide‐
5 Fluorouracil
5 Fluorouracil
10.4
0%
11.8
10.6
Paclitaxel‐Doxorubicin‐
Cyclophosphamide
10.6
9.6
Trastuzumab‐Paclitaxel‐
Doxorubicin‐Cyclophosphamide
11.8
11.8
11.8
11.6
10.2
12.2
11.8
11.8
11.6
11 6
8.7
Germany
Country
Italy
Spain
UK
Methotrexate‐
C l h h id 5
Cyclophosphamide‐5 Fluorouracil
Percent Spending Difference Due to Price and Market Share Effects
Breast Cancer
$10,000
$8,000
$6,000
$s 2008
86.2%
89.9%
$4,000
74.5%
77.7%
83.3%
87.1%
87.6%
90.4%
97.3%
98.2%
Market share effect
93.1%
Price effect
Price effect
$2,000
$0
25.5%
‐$2,000
22.3%
16.7%
12.9%
12.4%
9.6%
2.7%
1.8%
6.9%
10.1%
13.8%
2005:4 2006:1 2006:2 2006:3 2006:4 2007:1 2007:2 2007:3 2007:4 2008:1 2008:2
Year : Quarter
Incremental Spending Per Incremental E
Expected QALY (ICER)
t d QALY (ICER)

For each type of cancer we define a benchmark regimen, yp
g
,
usually the oldest and least expensive:
 colorectal: fluorouracil + leucovorin
 NSCLC: cisplatin
NSCLC: cisplatin
 breast: methotrexate + cyclophosphamide + fluorouracil
ICER = (average per patient spending on all non‐benchmark regimens –
average per patient spending for benchmark regimen)
(average QALY for all non‐benchmark regimens –
average QALY of benchmark regimen)
Incremental Spending Per Incremental Expected QALY: 1st‐Line Metastatic Colon Cancer Regimens $200,000
$180,000
$160,000
$140 000
$140,000
($ss 2008)
$120,000
U.S.
France
$100,000
G
Germany
$80,000
Italy
Spain
$60,000
UK
$40,000
$20,000
US
Percent change
2002:1-2008:2
2002:1
2008:2
-35.3%
US
France
G
Germany
Italy
Spain
UK
Percent change
2005:4-2008:2
-10.1%
8.6%
00 %
0.01%
10.3%
-2.5%
-13.9%
$0
2002:1
2003:1
2004:1
2005:1
2006:1
2007:1
2008:1
Year : Quarter
Incremental Spending Per Incremental Expected QALY: 1st‐Line Metastatic Lung Cancer Regimens $140,000
$120,000
($ss 2008)
$100 000
$100,000
U.S.
$80,000
France
G
Germany
$60,000
Italy
Spain
$40,000
UK
$20,000
$0
2002:1
2003:1
2004:1
2005:1
2006:1
2007:1
2008:1
US
Year : Quarter
US
France
Germany
Italy
Spain
UK
Percent change
2002:1-2008:2
2002:1
2008:2
-32.6%
Percent change
2005:4-2008:2
13.4%
-20.5%
-29.6%
-13.4%
-10.8%
-7.9%
Incremental Spending Per Expected QALY: Adjuvant Breast Cancer Regimens $7,000
$6,000
($s 2008) $5 000
$5,000
U.S.
$4,000
France
Germany
$3,000
Italy
Spain
$2,000
UK
$1,000
$0
US
2002:1
2003:1
2004:1
2005:1
Year : Quarter
2006:1
2007:1
2008:1
Percent change
2002:1-2008:2
60.13%
Percent change
2005:4-2008:2
US
33.31%
France
2.10%
Germany
G
-0.83%
0 83%
Italy
-11.40%
Spain
23.35%
UK
-10.42%
Additional Spending on Breast Cancer Appears to Be W th It US S
Worth It; US Spending on Colorectal Cancer Harder to Justify
di
C l
t lC
H d t J tif
Cancer type
Metastatic colorectal
Incremental Dollar Saved
Per QALY Lost if the US
Used the EU Chemo Mix
d h
h
Incremental Dollar Cost
Per QALY Gained if EU
Used the US Chemo Mix
d h
h
$257,423
$184,438
Metastatic NSCLC
$72,384
$171,945
Adjuvant breast
Adjuvant breast $8 271
$8,271
$9 868
$9,868
Conclusions
 Prices for NSCLC and breast cancer chemo regimens similar
between U S and EU (lower in U S for generics; higher for
between U.S. and EU (lower in U.S. for generics; higher for
branded drugs). Similar to Danzon and Furukawa (2008).
 Prices much higher in U.S. for colorectal cancer.
p
g
y
g
 Cancer patients in US generally receive regimens that would be more expensive, even at EU prices.
 Greater use of expensive regimens in U.S. appears to be Greater use of expensive regimens in U S appears to be
worth it for breast cancer; less so for colorectal cancer.