Original Research
Gynecology
Patient cost sharing during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment in ovarian cancer

https://doi.org/10.1016/j.ajog.2021.01.029Get rights and content

Background

More patients with ovarian cancer are being treated with poly(adenosine diphosphate-ribose) polymerase inhibitors because regulatory agencies have granted these drugs new approvals for a variety of treatment indications. However, poly(adenosine diphosphate-ribose) polymerase inhibitors are expensive. When administered as a maintenance therapy, these drugs may be administered for months or years. How much of this cost patients experience as out-of-pocket spending is unknown.

Objective

This study aimed to estimate the out-of-pocket spending that patients experience during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment and to characterize which healthcare services account for that spending.

Study Design

A retrospective cohort study was performed with a sample of patients with ovarian cancer treated between 2014 and 2017 with olaparib, niraparib, or rucaparib. Patients were identified using MarketScan, a health insurance claims database. All insurance claims during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment were collected. The primary outcome variable was the patients’ out-of-pocket spending (copayment, coinsurance, and deductibles) during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment for the medication itself. Other outcomes of interest included out-of-pocket spending for other healthcare services, the types and frequency of other healthcare services used, health plan spending, the estimated proportion of patients’ household income used each month for healthcare, and patients’ out-of-pocket spending immediately before poly(adenosine diphosphate-ribose) polymerase inhibitor treatment.

Results

We identified 503 patients with ovarian cancer with a median age of 55 years (interquartile range, 50–62 years); 83% of those had out-of-pocket spendings during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment. The median treatment duration was 124 days (interquartile range, 66–240 days). The mean out-of-pocket spending for poly(adenosine diphosphate-ribose) polymerase inhibitors was $305 (standard deviation, $2275) per month. On average, this accounted for 44.8% (standard deviation, 34.8%) of the patients’ overall monthly out-of-pocket spending. The mean out-of-pocket spending for other healthcare services was $165 (standard deviation, $769) per month. Health plans spent, on average, $12,661 (standard deviation, $15,668) per month for poly(adenosine diphosphate-ribose) polymerase inhibitors and $7108 (standard deviation, $15,254) per month for all other healthcare services. The cost sharing for office visits, laboratory tests, and imaging studies represented the majority of non–poly(adenosine diphosphate-ribose) polymerase inhibitor treatment out-of-pocket spending. The average amount patients paid for all healthcare services per month during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment was $470 (standard deviation, $2407), which was estimated to be 8.7% of the patients’ monthly household income. The mean out-of-pocket spending in the 12 months before poly(adenosine diphosphate-ribose) polymerase inhibitor treatment was $3110 (standard deviation, $6987).

Conclusion

Patients can face high out-of-pocket costs for poly(adenosine diphosphate-ribose) polymerase inhibitors, although the sum of cost sharing for other healthcare services used during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment is often higher. The spending on healthcare costs consumes a large proportion of these patients’ household income. Patients with ovarian cancer experience high out-of-pocket costs for healthcare, both before and during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment.

Introduction

Since 2014, the poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors olaparib, rucaparib, and niraparib together have been granted 9 indications for use in patients with ovarian cancer. The clinical trials supporting these regulatory approvals show the drugs’ substantial clinical benefit, particularly among patients with a BRCA-mutated or homologous recombination (HR)-deficient tumor.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 However, these new therapies are expensive. A PARP inhibitor’s “sticker price” can be as high as $16,999 for a month of treatment.11 Previous analyses found the drugs’ cost to be an obstacle to PARP inhibitors being considered as a cost-effective treatment for ovarian cancer.12, 13, 14, 15

AJOG at a Glance

The clinical use of poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitor therapy in the management of ovarian cancer is expanding. Like other new anticancer drugs, PARP inhibitors are costly, but how much of that cost patients experience as out-of-pocket spending is unclear.

In this observational cohort study using insurance claims, the copayments for PARP inhibitor therapy were, on average, $305 per month. Cost sharing for these medications accounted for 45% of an average patient’s total out-of-pocket spending during each month of PARP inhibitor treatment.

Previous research found that the median amount that patients spend out-of-pocket is approximately $3000 during frontline treatment for ovarian cancer. This investigation found that high levels of cost sharing often persist during therapy with subsequent lines of treatment.

The cost sharing experienced by patients for treatment with PARP inhibitors is unknown. Whatever this amount, it is in addition to the other out-of-pocket expenses for healthcare that is incurred during cancer treatment. With more patients receiving PARP inhibitor treatment and maintenance strategies potentially lasting for years,1,9,10 the patients’ risk for experiencing financial hardship owing to the cumulative cost of treatment is high. In other cancer types, treatment-related financial burdens have been associated with diminished quality of life and coping strategies including nonadherence to medication, delayed or missed clinic visits, refusal of recommended testing, and reduced spending on non–health care necessities.16,17 In patients with gynecologic cancers, psychological distress related to the costs of cancer care is common, as is the use of coping strategies.18,19 Our goal with this study was to evaluate the spending that patients and their insurers incurred during treatment with PARP inhibitors.

Section snippets

Materials and Methods

We performed an observational, retrospective cohort study using the Truven Health MarketScan Commercial Claims and Encounters database (IBM Corporation, Armonk, NY). The MarketScan database comprises paid and adjudicated health insurance claims and includes deidentified information from a nationwide sample of commercially insured individuals (additional information about MarketScan is available in the Supplemental Appendix). We included all individuals with ovarian cancer who had at least 1

Results

From the MarketScan database, we identified 503 patients with ovarian cancer with a median age of 55 years (interquartile range [IQR], 50–62 years) who had started treatment with a PARP inhibitor during the study period (Table 1). The patients’ median duration of treatment with a PARP inhibitor was 124 days (IQR, 66–240 days). A total of 3326 patient-months of PARP inhibitor treatment was observed. Consistent with its date of approval, the majority of patients (292/503; 58.1%) were treated with

Principal findings

Among a sample of patients with ovarian cancer who were commercially insured and receiving PARP inhibitor treatment, we found that the patients’ mean out-of-pocket spending for these agents was $305 each month. On average, the cost sharing for these drugs accounted for just less than half of the patients’ total monthly healthcare spending. Cost sharing for office visits, other prescription medications, and imaging studies accounted for the majority of non-PARP out-of-pocket costs. We estimated

Acknowledgments

For editing during the preparation of this manuscript, the authors acknowledge and are grateful to Tamara K. Locke from Scientific Publications, Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas. Ms Locke has agreed to this acknowledgment.

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      Moreover, maintenance PARP inhibitor therapy was approved prior to the publication of sufficient data to support its overall survival benefit, quality of life benefit, and cost effectiveness for patients (Berchuck et al., 2017). Despite the convenience of oral administration, PARP inhibitors carry adverse effects of low blood cell counts, nausea, fatigue, a 1% risk of myelodysplastic syndrome or acute myeloid leukemia (Morice et al., 2021), and financial toxicity, with out-of-pocket co-pays averaging $305 per month, and sometimes exceeding $1,000 monthly (O’Cearbhaill, 2018; LaFargue et al., 2019; Harrison et al., 2021). Following a succession of highly successful and publicized randomized trials (Coleman et al., 2019; González-Martín et al., 2019; Ray-Coquard et al., 2019), patients with ovarian cancer are very eager to learn about and try these medications.

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    C.C.S. and L.A.M. report receiving research funding from AstraZeneca for unrelated research. The remaining authors report no conflict of interest.

    This research was supported, in part, by grant number 5T32CA101642 from the National Cancer Institute (which supports the training of R.F.H. and principal investigator K.H.L.); grant number K07CA201013 from the National Cancer Institute (which supports L.A.M.); grant number RP160674 from Cancer Prevention and Research Institute of Texas and Komen grant number SAC150061 from Susan G. Komen (which support S.H.G.); and Cancer Center Support Grant P30CA016672 from the National Cancer Institute.

    This study was accepted for presentation as an oral presentation at the 2020 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer, Toronto, Ontario, Canada, scheduled for March 28–31, 2020. This meeting was canceled because of the coronavirus disease 2019 pandemic.

    Cite this article as: Harrison RF, Fu S, Sun CC, et al. Patient cost sharing during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment in ovarian cancer. Am J Obstet Gynecol 2021;225:68.e1-11.

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