With approximately 3,000 new cases diagnosed each year, acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy in the United States. Although the majority of pediatric patients diagnosed with ALL will be alive 5 years after diagnosis, there is a profound financial toxicity of cancer therapies on the patients and families. The majority of pediatric ALL therapy is provided in the outpatient setting and ranges from 2 to 3.5 years. However, large-scale studies of real-life costs for the length of pediatric ALL treatment are not available from the United States.
In efforts to further improve outcomes, it is essential to take into account the current cost of childhood ALL treatment strategies. Therefore, Lucie M. Turcotte, MD, MPH, and colleagues utilized administrative claims data to investigate the real-world costs of care for U.S. pediatric patients from a large cohort of commercially insured patients in both inpatient and outpatient settings over the course of 3 years of therapy. The study was published in JCO Oncology Practice (2022; doi:10.1200/OP.22.00344).
For this study, the investigators analyzed commercial insurance data from OptumLabs Data Warehouse to identify patients with ALL diagnosed between 1993 and 2017 ages 1-30 years with 36 months of continuous commercial insurance coverage. Patients treated with hematopoietic cell transplantation were excluded from the analysis. Additionally, patients were stratified by age (1-9, 10-12, and >=13 as proxies for National Cancer Institute risk groups). Both inpatient and outpatient cost utilization and cumulative reimbursements were determined at 8 and 36 months from diagnosis to approximate cost for the initial intensive phase of therapy and then the full length of therapy, respectively. Costs were adjusted for inflation to December 2020 U.S. dollars. Regression models were constructed to assess associations with demographic and clinical characteristics as well as treatment era.
In total, 927 patients were included in one of the largest samples analyzed to date; the median age at baseline was 6 years (interquartile range, 3-12 years), and 43 percent of patients were female. A total of 643 were aged 1-9 years, 79 were aged 10-12 years, and 205 were aged >=13 years. Overall, 9.5 percent of patients were diagnosed between 1993 and 2002, and 67 percent were diagnosed between 2007 and 2017.
Cost of cancer care for 3 years for ALL treatment was 50-70 percent among individuals aged 10-30 years compared with patients aged 1-9 years. Additionally, the cost for those diagnosed in 2013-2017 was 70 percent higher compared with those diagnosed in 1993-2002, and was not different because of sex, race, or ethnicity.
The 36-month median inflation-adjusted cost of care was $394,000 USD (interquartile range, $256,000-$695,000 USD), and 64 percent of the total cost was incurred during the initial 8 months of therapy. When compared with patients aged 1-9 years (median cost: $338,000), the 36-month cost was 1.5-fold higher for patients who were 10-12 years of age (median cost: $515,000), and 1.7-fold higher for patients who were age >=13 years (median cost: $695,000).
At 36 months, patients aged >=10 years had a median of 52 (age 10-12 years) and 56 (age >=13 years) inpatient days compared with 33 for those aged 1-9 years, generating an additional 23-25 inpatient days for the older patients. Median inpatient costs at 36 months were $180,000 for the cohort overall, $148,000 for patients aged 1-9 years, $278,000 for those aged 10-12 years, and $310,000 for those age >=13 years. Median outpatient costs at 36 months were $187,000 for the cohort overall, $171,000 for patients aged 1-9 years, $221,000 for those aged 10-12 years, and $274,000 for those age >=13 years.
To discuss the variance in cancer care cost and for additional insights into the results, Oncology Times spoke with the paper's corresponding author, Lucie M. Turcotte, MD, PhD, a pediatric hematologist and oncologist and Assistant Professor of Pediatrics in the Division of Hematology/Oncology at the University of Minnesota.
Oncology Times: What motivated you to pursue this research study? What did you find most surprising about the findings of the study?
Turcotte: "Outcomes for pediatric ALL are generally good, particularly among standard-risk patients. As our research team looked at some of the new ALL treatment trials, we were struck by the addition of expensive new agents. It led us to question the current cost of treating ALL so we would have a baseline for future analyses."
Oncology Times: The study revealed that even after adjusting for inflation, the cost for those diagnosed in 2013-2017 was 70 percent higher compared with those diagnosed in 1993-2002. What are the potential factors that contributed to the overall increase in U.S. health care spending over time?
Turcotte: "We hypothesized that the increase mirrors the overall increase in U.S. health care spending over time and may be secondary to increases in drug and pharmacy costs, personnel costs, and potentially increasing facility fees. The cost increase did not result in the same magnitude of survival improvement."
Oncology Times: Based on the findings of this study, what are some potential considerations to help refine and reduce the financial toxicity when it comes to treatment strategies for pediatric patients with ALL?
Turcotte: "As pediatric ALL treatment evolves, we need to consider how changes may impact short- and long-term health outcomes and cost. It is possible that the addition of new therapies may carry increased cost in the short-term but may result in reduced morbidity in the long-term. Future cost-effectiveness analyses will be needed to help determine optimal treatment regimens."
Oncology Times: What are some limitations of the current study that you hope to address in future research?
Turcotte: "The use of claims data presents many challenges-it relies on accurate and complete coding, and it is not always possible to identify specific cancer characteristics, such as risk status and relapse, and inpatient claims do not permit detailed examination of individual drivers of cost. Upcoming analyses from our team will use a new dataset from Optum Labs that will include data from SEER-we hope this will allow for more comprehensive assessment of cancer diagnosis details and treatments and may allow us to better assess racial disparities in cancer care."
Dibash Kumar Das is a contributing writer.