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Supplements Managed Care Considerations in Chemotherapy-Induced Nausea and Vomiting
Overview of Chemotherapy-Induced Nausea and Vomiting and Evidence-Based Therapies
Nelly Adel, PharmD, BCOP, BCPS
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Chemotherapy-Induced Nausea and Vomiting: Roles of Pharmacists and Formulary Decision Makers
Stacey W. McCullough, PharmD
Managed Care Considerations in Chemotherapy-Induced Nausea and Vomiting

Chemotherapy-Induced Nausea and Vomiting: Roles of Pharmacists and Formulary Decision Makers

Stacey W. McCullough, PharmD
Healthcare Usage
Dehydration, anorexia, and electrolyte imbalance often accompany CINV and can lead to rehospitalization, the need for hydration therapy, and reduced treatment compliance.15,19,24 In a retrospective, claims-based study of 1059 patients with solid tumors receiving therapy with anthracycline plus cyclophosphamide, cisplatin, or carboplatin, incidences of total CINV events and CINV-related emergency department (ED) visits were lower in the group receiving an NK1 receptor antagonist (44% and 9%, respectively) than in the group not receiving an NK1 receptor antagonist (50% and 15%, respectively).10 Patients in the NK1 receptor antagonist group also had a lower number of CINV-related office visits (40% vs 44%, respectively) and lower proportions of overall ED visits and hospitalizations. For patients receiving HEC or MEC, the treatment inclusion of an NK1 receptor antagonist, according to current NCCN guidelines for CINV, may reduce healthcare resource usage, including CINV-related office, hospital, and ED visits.10

Cost Considerations for CINV
The study of 178 patients with cancer previously mentioned found that those who reported severe nausea had higher average costs due to healthcare usage ($802.40 per patient) than patients who reported moderate ($32.30) or mild nausea ($6.70).7 Average total direct medical costs for patients receiving HEC were $819.16, compared with $674.05 for patients receiving MEC (P = .11). Total average direct medical costs for patients were $732.14, based on treatments prescribed and physician-reported healthcare usage. On average, the total cost for CINV was $778.58 per patient from the day of administration through the 5 days following the first cycle of chemotherapy, with higher costs for patients with more severe CINV.7

Another cost evaluation study showed that CINV affected up to 24% of patients on HEC and up to 32% on MEC, with nearly double the overall healthcare costs for patients with CINV.9 A retrospective cohort analysis assessed the cost of CINV in 5912 adult patients diagnosed with breast, lung, or colon cancer who were newly treated with single-day HEC or MEC and received a short- or long-acting prophylactic 5-HT3 receptor antagonist.9 The mean total healthcare cost in the first cycle for patients with CINV was $18,836 compared with $9582 for patients without CINV (P <.001).9 Similar results were seen in another retrospective analysis of medical claims of 2018 individuals with cancer treated with HEC or MEC.11 This study found that despite the use of a 5-HT3 receptor antagonist, 28% of patients had uncontrolled CINV, with an estimated increase of $1300 in monthly medical costs associated with uncontrolled CINV. The indirect costs per patient per month were $433 higher for those in the uncontrolled CINV group.11 Data have also shown that CINV-related hospitalizations and office visits were common in the first month after chemotherapy in patients treated with HEC or MEC.8

Indirect Costs of CINV
A cross-sectional survey using a dual sampling frame of 5532 patients with cancer found that 48% experienced treatment-related nausea/vomiting and that patients spent 4.5 hours, on average, per visit to treat AEs.25 Approximately 43% of the patients were employed, and of these, 78% were actively working. Of the employed patients, 46% reported working due to financial need, and 29% said, given a reduction in time spent at the doctor’s office, they would spend the surplus time working for pay.25 Across all demographic subgroups, the employed patients missed an average of 18 workdays annually due to treatment-related AEs (TRAEs). Doctor visits due to TRAEs forced 28% of patients to work part time when they wanted to work full time. Supportive care strategies that may effectively reduce AEs such as CINV may help improve patient productivity at work and reduce the overall time burden for treatment.25

Cost of Compliance
The most important impact of CINV could be its potential to lead to noncompliance with treatment, resulting in delays in chemotherapy administration, dose reduction, or interruption of therapy, thereby potentially impacting treatment efficacy.5,26,27 A survey of more than 2000 clinicians determined that CINV was associated with delayed or discontinued chemotherapy in approximately 30% of patients.28 One retrospective claims analysis of adults who initiated treatment consisting of single-day intravenous HEC or MEC regimens found that a treatment that more effectively reduced the occurrence of CINV in these patients also resulted in better adherence and fewer treatment delays than less efficacious antiemetic therapies.27

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