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Cost-Effectiveness of New and Emerging Treatment Options for the Treatment of Metastatic Colorectal Cancer

Jennifer Zadlo, PharmD, BCOP
With the ever-evolving development of new therapies for the treatment of mCRC, patient care considerations must remain in the forefront of therapy. Along with increased effectiveness of new agents, so also increased are the costs of these new and emerging agents. Currently, more than 40,000 new patients are treated for mCRC annually in the United States. New therapies must be evaluated not only for their clinical efficacy, but also for the convenience of administration, how their use affects patient and caregiver schedules and lifestyles, along with the potential AEs associated with therapy, as noted earlier.21

Many patients with cancer of any type want more detailed information about their diagnosis, treatment options, and prognosis, and they want to be active participants in decision making about their therapy.31 However, data have demonstrated that as many as one-third of patients with cancer have misunderstood the information they receive.31,32 For example, if patients misunderstand their prognosis, polarized decisions about treatment options can be made that can impede optimal management. One study of patients with advanced malignant disease found that most overestimated their life expectancy post-diagnosis and 59% were overly optimistic overall about their prognosis. Patients who thought they were going to live for at least 6 months were more likely to be in favor of receiving life-extending therapy over best supportive care compared with those who believed there was at least a 10% chance that they would not survive until that 6-month mark. Essentially, patient understanding of their chance for survival can seriously impact therapy choices.31,33

Shared decision making (SDM) is a process that enables clinicians and their patients to participate jointly in making health decisions.34,35 In this process, the patients and clinicians discuss treatment options and their benefits and risks, and consider a patient’s values, preferences, and circumstances surrounding their management. SDM allows scientific evidence and patient preferences to be incorporated together into a collaborative discussion that will increase patient knowledge, risk perception surrounding therapy choices, and patient-clinician communication overall. Conflict surrounding both the use of clinical testing and treatment choice can then be reduced.34 SDM is now a critical aspect of cancer treatment and management. The key factors for effective SDM include35:
  • Determination of the situations in which SDM is critical
  • Acknowledgment of the decision to the patient
  • Description of the treatment options, including risks, benefits, and uncertainty associated with each potential choice
  • Elicitation of patient preferences and values
  • Agreement on a plan for the next steps in the decision-making process


It must be emphasized that SDM is not a 1-step process. Truly incorporating SDM into clinical decision making requires multiple steps and visits. The typical components of SDM surrounding therapy over the course of a series of office visits would include36:
  • Choice talk: The clinician offers (and justifies) the different choices for therapy but checks for the patient’s reaction and defers closure on a decision
  • Option talk: The clinician lists the options for therapy in more detail, including their risks and benefits to generate a dialogue with the patient and offers decision aids (DAs), summarizing the various options and checking for patient misconceptions about them
  • Decision talk: The clinician and patient focus on eliciting a patient preference and moving to a therapy decision, also offering a review of the process leading to that decision to arrive at closure


DAs can have the potential to assist clinicians and patients to navigate complex management choices in mCRC. One study by Leighl et al used an oncologist-designed take-home booklet and accompanying audio DA to assist patients with mCRC who were considering first-line chemotherapy. A total of 107 of 207 patients received this DA, and they demonstrated a greater increase in understanding of their treatment options and their risks and benefits along with prognosis compared with a control group who did not receive the DA. The investigators concluded that use of a DA such as this can improve informed consent surrounding therapy for mCRC.31

More recently, Fu et al conducted a survey of patients with advanced CRC who were undergoing or who had completed one chemotherapy regimen. Patients were initially asked to rate the importance of 15 therapy-related AEs that may arise from chemotherapy or biological therapy as they related to treatment decision making. Patients then identified the top 5 AEs that would most impact them and elucidated their preferences for treatment in hypothetical mCRC treatment case studies. Results demonstrated that patients clearly identified serious AEs, including stroke, myocardial infarction, and GI perforation, as key drivers in their therapy decision making. However, they also showed a lower willingness to tolerate symptom-related events related to therapy, including pain, fatigue, and depression. Patients’ willingness to tolerate these therapy-associated AEs substantially highlights a need for improved clinician–patient communication surrounding the risks and benefits of the various therapies available for mCRC to truly achieve collaborative and optimal decisions for individualized therapy and management plans.37

Conclusions

While the continuous development of new therapies for mCRC has revolutionized treatment of the disease, they have arrived with an increasing cost burden on the healthcare system. Patterns of treatment choice, medical care usage, and cost differences depend on therapies chosen, as well as patient and health system characteristics that impact overall patient management and healthcare usage. Overall, it is difficult to generalize an actual value of any particular cancer therapy. However, estimates can be attempted by measuring clinical benefits and risks of treatment in addition to cost. It is most important to focus on shared decision management between clinician and patient in selecting therapy options that offer clinical benefit, while avoiding unmanageable cost burden for the patient. Such shared-decision processes benefit patient confidence in care, overall management, and ultimately, patient outcomes.

Author affiliation: Clinical Pharmacy Specialist, Gastrointestinal Medical Oncology, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX.
Funding source: This activity is supported by an educational grant from Taiho Oncology, Inc.
Author disclosure: Dr Zadlo has no relevant financial relationships with commercial interests to disclose.
Authorship information: Concept and design, drafting of the manuscript, and critical revision of the manuscript for important intellectual content.
Address correspondence to: JLZadlo@mdanderson.org.
 
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