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Original Contribution CARE DELIVERY

ReCAPs (Research
Spending on Antineoplastic Agents in the United States,
Contributions Abbreviated for 2011 to 2016
Print) provide a structured,
Samuel J. Hong, Edward C. Li, Linda M. Matusiak, and Glen T. Schumock
one-page summary of each
paper highlighting the main
findings and significance of QUESTION ASKED: What were the expen- to 2016 dollars. Top-selling injectable antineo-
the work. The full version of ditures for antineoplastic agents in the United plastic agents in the hospital and clinic channels
the article is available online at States between 2011 and 2016? were described.
jop.ascopubs.org.
SUMMARY ANSWER: Total antineoplastic WHAT WE FOUND: Our analysis found that
expenditures in the United States grew from antineoplastic expenditures in the United
University of Illinois at Chicago, Chicago, IL; $26.8 billion in 2011 to $42.1 billion in 2016. States have increased consistently since 2011.
Sandoz, Princeton, NJ; and IQVIA, Plymouth The largest annual growth in spending oc- Antineoplastic expenditures represented 7% of
Meeting, PA curred in 2015 (15.6% increase from 2014; Fig). total US drug expenditures in 2011 and rose to
Corresponding author: Glen T. Schumock, Clinics accounted for the largest portion of 9.4% in 2016.
PharmD, MBA, PhD, 833 S Wood Street, total antineoplastic expenditures ($21.1 billion
Suite 145 (MC 874) Chicago, IL 60612; in 2016), followed by mail-order pharmacies BIAS, CONFOUNDING FACTOR(S), REAL-
e-mail: schumock@uic.edu. LIFE IMPLICATIONS: These results serve as a
($11.1 billion in 2016) and non-federal hos-
Disclosures provided by the authors are pitals ($6.1 billion in 2016). The highest- baseline measure of actual transaction costs
available with this article at expenditure antineoplastic agents in hospi- associated with antineoplastics by health care
jop.ascopubs.org. sector in the United States. This analysis may
tals and clinics from 2011 to 2016 were rit-
uximab, bevacizumab, and trastuzumab. be useful in informing decisions among
DOI: https://doi.org/10.1200/JOP.
health care policy makers and health care
18.00069; published online ahead of WHAT WE DID: IQVIA (formerly QuintilesIMS) providers and for monitoring the impact of
print at jop.ascopubs.org on National Sales Perspective data for the period efforts to contain costs. However, a limi-
September 18, 2018. of January 1, 2011 to December 31, 2016 were tation is that the data set analyzed captures
analyzed for actual expenditures. These were wholesaler purchases and is not reflective
totaled by health care sector and calendar of what is paid by patients or insurance
year, then adjusted for medical-cost inflation companies.

100 $45,000,000
Antineoplastic Agent

90 $40,000,000
Expenditures (%)

80 $35,000,000
US Dollars

70 $30,000,000
60
$25,000,000
50
$20,000,000
40
30 $15,000,000
20 $10,000,000
10 $5,000,000
0 $0
2011 2012 2013 2014 2015 2016
Clinics Mail order Nonfederal hospitals
Retail Long-term care Staff model
Home health Federal facilities Other
Total

Fig. Distribution of expenditures for antineoplastic agents by setting, 2011 to 2016.

Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 11 / November 2018 n jop.ascopubs.org 685
Original Contribution CARE DELIVERY

Spending on Antineoplastic Agents


in the United States, 2011 to 2016
Samuel J. Hong, Edward C. Li, Linda M. Matusiak, and Glen T. Schumock

University of Illinois at Chicago, Chicago, IL;


Sandoz, Princeton, NJ; and Plymouth
Abstract
Meeting, PA Purpose
Recent cancer drug approvals are lauded as being more effective with relatively fewer
ASSOCIATED CONTENT adverse effects, but these treatments come with a great cost to the US health care system.
Appendix available online There is little information on recent trends in actual antineoplastic expenditures
representative of the whole US health care system or by sector. Therefore, the objective of
this study was to describe antineoplastic expenditures in the United States by year and
sector.

Methods
This was a retrospective, cross-sectional study of IQVIA (formerly QuintilesIMS) National
Sales Perspective data for the period of January 1, 2011, to December 31, 2016. Actual
expenditures were totaled by health care sector and calendar year, then adjusted for
medical-cost inflation to 2016 dollars. Growth was calculated as the percentage increase
from the previous year.

Results
Total expenditures of antineoplastic agents across all channels grew from $26.8 billion in
2011 to $42.1 billion in 2016. Antineoplastic spending increased 12.2% in 2016 (compared
with the previous year), followed by 15.6% in 2015, 13.4% in 2014, 6.3% in 2013, and 0.4%
in 2012. Throughout the study period, 96.5% of total antineoplastic expenditures occurred
within clinics, mail-order pharmacies, nonfederal hospitals, and retail pharmacies.

Conclusion
Antineoplastic expenditures are expected to increase because of continuing development
and approval of costly targeted cancer therapies. Cost containment and utilization
management strategies must be balanced so as not to restrict access or disrupt innovation.
Future policies should focus on ensuring safe and appropriate use of antineoplastics while
balancing long-term drug costs.

INTRODUCTION new cancer therapies.3-8 In addition, the


The United States has made noteworthy oncology drug pipeline grew by 45% over
progress in the care of patients with cancer, the last decade, and there are 631 unique
as evidenced by the significant declines molecules in late-phase development.9,10
in cancer-related mortality for the most Cancer research is likely to continue or
common cancers.1 These meaningful and even accelerate with the recent enactment
durable improvements in cancer outcomes of the 21st Century Cures Act. This leg-
have been in part attributed to the devel- islation increases funding for medical re-
DOI: https://doi.org/10.1200/JOP. opment of new drugs and technologies.2 search and includes the Beau Biden Cancer
18.00069; published online ahead of
print at jop.ascopubs.org on
Between 2011 and 2016, the US Food and Moonshot Initiative, which is likely to
September 18, 2018. Drug Administration (FDA) approved 52 serve as a catalyst for the approval of new

Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 11 / November 2018 n jop.ascopubs.org e683
Hong et al

cancer therapies.11-13 In addition, many new treatments have METHODS


received expanded indications after the initial approval. For We conducted an analysis of trends in expenditures for an-
example, the FDA has approved pembrolizumab for micro- tineoplastic drugs for the period January 1, 2011 to December
satellite instability–high or mismatch repair–deficient tumors, 31, 2016. Data for this analysis were obtained from the IQVIA
marking the first time the FDA approved a cancer treatment (previously QuintilesIMS and IMS Health) National Sales
on the basis of a common biomarker instead of the location of Perspectives (NSP) database. The NSP is a statistically valid
the tumor origin.14 audit that projects 100% of the purchases in every major class of
However, these new cancer therapies come with significant trade and distribution channel for prescription pharmaceu-
financial consequences. Since the year 2000, there has been an ticals, nonprescription products, and select self-administered
upward trajectory in the monthly costs of cancer therapies, and diagnostic products in the United States, measuring both unit
from 2011 to 2016, oncology was ranked the highest thera- volume and invoice dollars. It is derived from annual trans-
peutic area in specialty drug spending.9,15,16 According to an actions from pharmaceutical manufacturers to wholesaler
analysis in 2015, antineoplastic drug prices have increased distribution centers for sales to nonfederal hospitals, clinics,
faster than those for other therapeutic areas, and the median retail pharmacies, mail-service pharmacies, home health
price per year of therapy for new drugs approved between 2009 facilities, long-term care outlets, and other entities. These
and 2013 was $115,981.17 With an increasingly robust on- transactions account for 340B discounts, which are factored
cology pipeline and improving survival rate, the overall cost of into the total expenditures.
cancer care in 2021 is estimated to exceed $147 billion.10,18,19 Antineoplastic agents were categorized as either biologics
In July 2017, the FDA approved tisagenlecleucel-T for chil- or drugs on the basis of their approval pathways, either through
dren and young adults with relapsed or refractory B-cell acute the 505(b) New Drug Application or the 351(a) Biologics
lymphoblastic leukemia. This was the first gene therapy in the License Application. We evaluated overall antineoplastic ex-
United States, and it will cost patients $475,000 as a one-time penditures within various health care sectors, which were
treatment.20,21 Such high prices and spending on cancer aggregated into retail pharmacies, mail-order pharmacies,
therapies come with significant financial toxicity, both to clinics, nonfederal hospitals, long-term care, staff-model
individual patients and to society.22,23 Stakeholders and so- health maintenance organizations (HMOs), home health
ciety at large experience great financial pressure as the cost of care, federal facilities, and other. Definitions for each health
treating cancer reaches unprecedented levels.24,25 This care sector are provided in Table 1. We subsequently evaluated
prompted a position statement from ASCO that recom- trends in expenditures of specific products within the clinic
mended that the affordability of cancer drugs be addressed, and nonfederal hospital expenditures and limited our analysis
and it provided a number of key strategies to reduce anti- to include only injectable products, because these are the
neoplastic expenditures.26 To assess the effectiveness of the primary agents dispensed within clinics and hospitals.
ASCO strategies and other programs to control antineoplastic Actual expenditures were totaled by health care sector and
costs, it is important to identify and describe the actual and calendar year and then adjusted for US medical-cost inflation
current trends in antineoplastic expenditures in the United (part of the overall consumer price index) to 2016 dollars.
States, both as a whole and within specific distribution Growth was calculated as the percentage increase from the
channels. Moreover, although it is true that price increases previous year. According to the categories listed above, ex-
have occurred in other drug classes, it is not clear how the rate penditures over time per sector were examined graphically.
of growth in expenditures over time has differed between Descriptive statistical analysis was used to characterize the
traditional antineoplastic drugs and biologics. Therefore, the data.
purpose of this study was to describe antineoplastic expen-
ditures by year and health care sector in the United States. RESULTS
We also sought to identify major contributors to changes Total expenditure of antineoplastic agents across all channels
in injectable antineoplastic expenditures specifically within the United States grew from $26.8 billion in 2011 to $42.1
within the clinics and hospitals, because these channels billion in 2016, as listed in Table 1. Spending on antineoplastic
contribute to more than two thirds of total antineoplastic agents increased 12.2% in 2016 compared with the previous
expenditures.27 year. The largest growth in the time period observed occurred in

e684 Volume 14 / Issue 11 / November 2018 n Journal of Oncology Practice Copyright © 2018 by American Society of Clinical Oncology
US Spending on Antineoplastic Agents

Table 1. Antineoplastic Expenditure and Growth by Sector and Year, 2011 to 2016
2011
Sector* Expenditures 2012 Expenditures 2013 Expenditures 2014 Expenditures 2015 Expenditures 2016 Expenditures

Retail pharmacies 2,593,159 2,363,105 (28.87) 2,609,239 (10.42) 2,712,556 (3.96) 2,799,326 (3.20) 2,626,549 (26.17)

Mail-order 3,880,194 4,852,463 (25.06) 6,059,738 (24.88) 7,806,352 (28.82) 9,603,840 (23.03) 11,183,871 (16.45)
pharmacies

Clinics 14,630,679 14,134,003 (23.39) 14,161,244 (0.19) 15,533,449 (9.69) 17,888,932 (15.16) 21,064,577 (17.75)

Nonfederal 4,579,014 4,713,451 (2.94) 4,806,286 (1.97) 5,339,981 (11.10) 6,070,457 (13.68) 6,079,079 (0.14)
hospitals

Long-term care 249,048 249,330 (0.11) 269,595 (8.13) 236,085 (212.43) 215,470 (28.73) 184,454 (214.39)

Staff-model HMO 177,097 218,824 (23.56) 314,721 (43.82) 399,951 (27.08) 498,272 (24.58) 565,017 (13.40)

Home health care 157,461 158,012 (0.35) 180,528 (14.25) 192,244 (6.49) 217,056 (12.91) 204,654 (25.71)

Federal facilities 516,061 198,639 (261.51) 189,490 (24.61) 197,844 (4.41) 165,705 (216.25) 152,271 (28.11)

Other 56,483 48,975 (213.29) 41,131 (216.02) 43,024 (4.60) 58,464 (35.89) 49,242 (215.77)

Total 26,839,196 26,936,800 (0.36) 28,631,971 (6.29) 32,461,486 (13.37) 37,517,522 (15.58) 42,109,714 (12.24)

NOTE. Data presented as thousands of US dollars (% growth from previous year).


Abbreviation: HMO, health maintenance organization.
*Retail pharmacies include stand-alone chain and independent stores as well as mass merchandisers and food and convenience stores with a licensed
pharmacy. Mail-order pharmacies include specialty pharmacies and licensed mail service pharmacies, including both private-sector and federal facilities. Clinics
include physician offices and outpatient clinics, including general, family medicine, and specialty clinics covering oncology, nephrology, dialysis, family planning,
orthopedics, and urgent care centers. Nonfederal hospitals include all non–federally owned facilities licensed as hospitals, including inpatient treatment and
rehabilitation facilities, in addition to general and specialty acute care institutions. Long-term care includes nursing homes and residential care facilities. Staff-
model HMO includes closed-panel HMO pharmacies and hospitals, union clinics and pharmacies, and workers’ compensation clinics. Home health care includes
licensed home health organizations and visiting nurse entities. Federal facilities include Public Health Service and other federal hospitals and US ships at sea
(Veterans Health Administration facilities are normally included in the federal facility sector, but data on expenditures were not available after December 31,
2013). Other covers a variety of otherwise unclassified government accounts, as well as entities such as jails, prisons, and veterinary hospitals and clinics.

2015 (15.6% increase compared with 2014). The smallest growth Clinics accounted for the largest portion of total antineoplastic
in spending was seen in 2012 (0.4% compared with 2011). expenditures (ranging from $14.1 to $21.1 billion and 47.7% to
Annual expenditures of antineoplastic agents from 2011 to 54.5% of total antineoplastic expenditures), followed by mail-
2016 across each of the various sectors are also listed in Table 1. order pharmacies (ranging from $3.9 to $11.2 billion and 14.5%
Although staff-model HMOs saw the largest increase in anti- to 25.6% of total antineoplastic expenditures), nonfederal
neoplastic expenditures from 2011 to 2016, with an average hospitals (ranging from $4.6 to $6.1 billion and 16.2% to 17.5%
increase of 26.5% compared with the previous year, expendi- of total antineoplastic expenditures), and retail pharmacies
tures within the HMO sector are considerably lower than the (ranging from $2.4 to $2.6 billion and 7.5% to 9.7% of total
other channels and make up only 1% of the total expenditures of antineoplastic expenditures). The remaining sectors (long-term
antineoplastic agents. Mail-order pharmacies experienced the care, home health care, and other) accounted for , 2% of total
second largest growth in antineoplastic expenditures, with an annual antineoplastic drug expenditures.
average annual increase of 23.7% compared with the previous Significant fluctuations in distribution of total antineo-
year, while representing more than 20% of the total expendi- plastic drug expenditures were seen in clinics, mail-order
tures of antineoplastic agents. All the sectors saw a net increase pharmacies, staff-model HMOs, and federal facilities. Clinics
in antineoplastic expenditures over the study period except for saw a consistent decline in the proportion of total antineo-
federal facilities (217.2%) and long-term care (25.5%). plastic drug antineoplastic drug expenditures (54.5% in 2011%
The distribution of annual antineoplastic drug expenditures to 50.1% in 2016), although the dollar amount of expenditures
across each of the varioushealth caresectors isshownin Figure 1. increased ($14.1 billion in 2011 to $21.1 billion in 2016).

Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 11 / November 2018 n jop.ascopubs.org e685
Hong et al

100 $45,000,000
Antineoplastic Agent 90 $40,000,000
Expenditures (%) 80 $35,000,000

US Dollars
70 $30,000,000
60
$25,000,000
50
$20,000,000
40
30 $15,000,000
20 $10,000,000
10 $5,000,000
0 $0
2011 2012 2013 2014 2015 2016
Clinics Mail order Nonfederal hospitals
Retail Long-term care Staff model
Home health Federal facilities Other
Total

Fig 1. Distribution of expenditures for antineoplastic agents by setting, 2011 to 2016.

Throughout the 2011 to 2016 period, more than two thirds of the recession had resolved) were even more significant, with an
antineoplastic drug expenditures remained within clinics and average annual increase of 13.7% compared with the previous
nonfederal hospitals. year. Since 2011, total drug expenditures (including anti-
A visual comparison of expenditures of the top-selling neoplastics and all other drugs) across the United States in-
agents considered to be traditional antineoplastic drugs, older creased from $328.4 billion (in 2011) to $448.2 billion (in
antineoplastic biologics, and newer antineoplastic biologics in 2016). Antineoplastic expenditures represented 7% of total US
hospitals and clinics is shown in Figure 2. The three anti- drug expenditures in 2011 and increased to 9.4% in 2016.8,28 As
neoplastic agents that saw the largest decrease in expenditures reported by Express Scripts, the steep increase in 2016 an-
from 2011 to 2016 in hospitals and clinics were traditional tineoplastic drug spending can be attributed to increases in
cytotoxic drugs that became generic during the study period: unit costs (11.9%) and use (9.6%).29,30
oxaliplatin ($1.6 billion in 2011 to $50 million in 2016, a 97% The reasons for growth in cancer drug expenditures include
decrease), docetaxel ($1.0 billion in 2011 to $0.1 billion in technology advancements, increasing prices, changing patient
2016, an 89% decrease), and gemcitabine ($0.4 billion in 2011 demographics, and changes in duration of therapy. Technology
to $36.8 million in 2016, a 92% decrease). The three anti- advancements contribute toward the surge of new cancer therapies
neoplastic drugs that maintained the largest expenditures being approved, whereby most are targeted small molecules or
from 2011 to 2016 in hospitals and clinics were older biologics: targeted biologics, rather than traditional cytotoxic chemotherapy.
rituximab (average annual expenditure of $3.5 billion), bev- Accordingly,thesenovelagentsaremoreexpensivethantraditional
acizumab (average annual expenditure of $2.9 billion), and cytotoxictherapiesonaprice-per-monthorprice-per-coursebasis.
trastuzumab (average annual expenditure of $2.2 billion; The aging population and advances in early detection have in-
Appendix Table A1, online only). The three antineoplastic creased the incidence of cancer and subsequent use of antineo-
drugs that saw the largest growth in expenditures from the first plastic therapy. Furthermore, modern treatments have led to
full year on the market to 2016 in hospitals and clinics were improvements in overall survival, resulting in longer treatment
newer biologics: nivolumab ($0.8 billion in 2015 to $2.6 billion durations, thereby increasing drug expenditures.2,9,10,31,32
in 2016, a 238% increase), pertuzumab ($0.2 billion in 2013 to Many of the newer cancer treatments are oral. In fact, we
$0.9 billion in 2016, an 80% increase), and pembrolizumab found a consistent increase in antineoplastic spending (23.7%
($0.4 billion in 2015 to $0.7 billion in 2016, an 84% increase). average annual increase) in specialty and mail-order phar-
macies from 2011 to 2016. A major driver is the growing shift
DISCUSSION from injectable to oral anticancer drugs.2,9,10,33 These newer
Our findings are that antineoplastic expenditures in the United and more expensive oral antineoplastic agents come with
States have increased consistently from $26.8 billion in 2011 many advantages but still exhibit poor adherence in a large
(when the great recession was nearing its end) to $42.1 billion in proportion of patients.34-36 The use of specialty pharmacy
2016 and that more recent increases (from 2014 to 2016, after drug programs has shown promise in improving adherence,

e686 Volume 14 / Issue 11 / November 2018 n Journal of Oncology Practice Copyright © 2018 by American Society of Clinical Oncology
US Spending on Antineoplastic Agents

$4,000,000 Docetaxel $4,000,000


Oxaliplatin
$3,500,000 Gemcitabine $3,500,000

$3,000,000 $3,000,000
US Dollars

US Dollars
$2,500,000 $2,500,000

$2,000,000 $2,000,000

$1,500,000 $1,500,000

$1,000,000 $1,000,000
Rituximab
$500,000 $500,000 Bevacizumab
Trastuzumab
$0 $0
2011 2012 2013 2014 2015 2016 2011 2012 2013 2014 2015 2016

Year Year

$4,000,000 Pertuzumab
Nivolumab
$3,500,000 Pembrolizumab

$3,000,000
US Dollars

$2,500,000

$2,000,000

$1,500,000

$1,000,000

$500,000

$0
2011 2012 2013 2014 2015 2016

Year

Fig 2. Comparison of spending on traditional drugs, older biologics, and newer biologics, 2011 to 2016.

and, thus, payers are shifting use from high-cost outpatient Biosimilars can help to moderate the expenditures of costly,
settings to lower-cost community oncology settings. Although older biologics and may offset the increase in expenditures for
this may further increase drug expenditures, total health care the newer generation of immuno-oncology drugs. For our study
use and costs may decrease.37,38 period of 2011 to 2016, there were no biosimilars approved for
In addition to oral anticancer treatments, there has been the active treatment of cancer in the United States. Although
high growth in the development of biologics. Targeted bi- there are a significant number of barriers to entry for biosimilars
ologics made up 21% of the late-phase oncology pipeline in in the United States, there is still great potential for reducing
2006 and 43% in 2016. The strong clinical profile of the newer biologic expenditures, as seen in Europe; they are priced ap-
immuno-oncology agents has led to their rapid uptake and proximately 30% less than their reference products.39,40 If this
expanded use across multiple cancer types.10 We found that 30% discount is applied to the 2016 top three antineoplastic
older biologics (rituximab, bevacizumab, and trastuzumab) biologics in US clinics and hospitals (rituximab, bevacizumab,
accounted for the highest antineoplastic expenditures in and nivolumab), our health care system would save $2.8 billion.
hospitals and clinics and remained that way from 2011 to Another cost-control strategy that has recently been the center
2016, whereas newer biologics (nivolumab, pertuzumab and of discussion is the promotion of value-based coverage decisions
pembrolizumab) saw exponential increases in expenditures. and/or value-based pricing. Groups such as ASCO, National
These trends in expenditures indicate the growing and Comprehensive Cancer Network, Memorial Sloan Kettering
urgent need for expenditure and price-reduction strategies. Cancer Center, and Institute for Clinical and Economic Review

Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 11 / November 2018 n jop.ascopubs.org e687
Hong et al

developed frameworks to help patients, manufacturers, providers, results depending on when it is accessed (for this analysis, it was
and payers assess the value of treatments.41-44 However, there are accessed on February 1, 2017). Another limitation is that ex-
many inherent complexities in assessing the value of treatments, pendituredataarelackingfromtheVeteransAffairssystemstarting
including, but not limited to, an absence of any distinct theoretical in the calendar year of 2014. The absence of this information affects
basis to measure value and any empirical analyses regarding how expenditures reported in federal facilities, as listed in Table 1 and,
stakeholders should make decisions on the basis of these value to a lesser extent, total expenditures across all sectors. A recent
metrics. Given the limitations listed above, stakeholders are being report to Congress for fiscal year 2017 of the TRICARE program
cautious in strictly promoting value-based policies.45 (which includes the Veterans Affairs) indicates that spending on
Without shifting toward a value-based approach, insurance oncological agents increased by 41% from 2014 to 2016.54 Last,
companies and payers have limited options to exert downward there is potential for misclassification of expenditures by sector if
pressure on drug expenditures. Historical strategies used by the class of trade on record of the purchasing pharmacy was
private payers and pharmacy benefits managers revolve around incorrectly documented. Although this is likely minimal, it could
utilization management, including formulary tiers and manda- lead to inaccuracies in the results by sector.
tory prior authorizations.46 However, for the first time, CVS In conclusion, antineoplastic expenditures are expected to
Health excluded brand-name cancer drugs, including those for increase because of continuing development and approval of
imatinib and enzalutamide, from its formulary.47 This strategy is costly cancer therapies and an aging population. Payers should
controversial, because they may restrict access to life-saving or carefully consider the implications of cost containment and
extending treatments.48 Another proposed strategy is to allow the utilization management strategies so as not to restrict access to
largest payer for oncology drugs, the Centers for Medicare and life-saving treatments or disrupt innovation in oncology re-
Medicaid Services, to negotiate drug prices—a practice that is search. Policies should focus on ensuring safe and appropriate
currently not allowed by law.49-51 The Centers for Medicare and use of antineoplastics while balancing long-term costs associ-
Medicaid Services Innovation Center is currently developing the ated with cancer.
Oncology Care Model, which seeks to provide higher quality care Acknowledgment
at a lower cost. Programs participating in the Oncology Care Presented at the 2017 American Society of Clinical Oncology Annual Meeting,
Chicago, IL, June 2-6, 2017. At the time of manuscript acceptance, Edward Li
Model are incentivized to implement evidence-based clinical was Professor at the University of New England College of Pharmacy in Portland,
pathways to promote the use of the most cost-effective drug ME. He is currently an employee of Sandoz. The views expressed are those of the
therapies. As recognized by a recent ASCO Policy Statement, authors and do not necessarily reflect the position or policy of IQVIA, Sandoz, or
any of its affiliated or subsidiary entities.
clinical pathways are also increasingly used by large payers to
reduce variation and control drug costs.52 Authors’ Disclosures of Potential Conflicts of Interest
Disclosures provided by the authors are available with this article at
Regardless of the future approaches taken, the information jop.ascopubs.org.
presented in our study serves as a baseline measure of actual
transaction costs associated with antineoplastics by the health Author Contributions
Conception and design: Samuel J. Hong, Edward C. Li, Glen T. Schumock
care sector in the United States. Results of this analysis may be Administrative support: Glen T. Schumock
useful in informing decisions among health care policy makers Provision of study material or patients: Linda M. Matusiak
Collection and assembly of data: Samuel J. Hong, Edward C. Li, Glen T.
and health care providers and for monitoring the impact of Schumock
efforts to contain costs. Although other studies that examine Data analysis and interpretation: All authors
antineoplastic expenditures exist, they are either projection Manuscript writing: All authors
Final approval of manuscript: All authors
based or focus on subpopulations or subgroups of antineo- Accountable for all aspects of the work: All authors
plastic agents.31,53 With increasing antineoplastic expenditures Corresponding author: Glen T. Schumock, PharmD, MBA, PhD, 833 S Wood
and use of specialty and mail-order pharmacies, future analyses Street, Suite 145 (MC 874) Chicago, IL 60612; e-mail: schumock@uic.edu.
should focus on expenditures within these channels.
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Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 11 / November 2018 n jop.ascopubs.org e689
Hong et al

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Spending on Antineoplastic Agents in the United States, 2011 to 2016

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are
self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more
information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jop/site/ifc/journal-policies.html.

Samuel J. Hong Linda M. Matusiak


Consulting or Advisory Role: Astellas Pharma No relationship to disclose
Edward C. Li Glen T. Schumock
Honoraria: Eli Lilly, Pfizer, Apobiologix, Mylan, Taiho Pharmaceutical Consulting or Advisory Role: Eisai
Consulting or Advisory Role: New Century Health (Inst)
Speakers’ Bureau: Pfizer

e690 Volume 14 / Issue 11 / November 2018 n Journal of Oncology Practice Copyright © 2018 by American Society of Clinical Oncology
US Spending on Antineoplastic Agents

Appendix

Table A1. Top 25 Injectable Drugs and Biologics by Expenditure in Clinics and Hospitals in 2015 and 2016 and Percent
Change from 2015
Antineoplastic Agent 2016 Expenditures (USD) 2015 Expenditures (USD) Change From 2015 (%)

Rituximab 3,737,773 3,599,984 4

Bevacizumab 2,965,858 3,114,968 25

Nivolumab 2,586,533 765,001 238

Trastuzumab 2,586,045 2,524,395 2

Pemetrexed 1,098,756 1,213,387 29

Pertuzumab 932,273 854,664 9

Ipilimumab 809,170 648,434 25

Pembrolizumab 718,428 391,075 84

Nanoparticle albumin-bound paclitaxel 634,600 703,665 210

Bortezomib 612,701 699,264 212

Carfilzomib 610,901 574,776 6

Cetuximab 583,889 632,953 28

Leuprolide 536,878 538,101 0

Fulvestrant 432,761 372,195 16

Cyclophosphamide 365,808 444,246 218

Ado-trastuzumab emtansine 329,375 323,748 2

Ramucirumab 269,446 282,442 25

Bendamustine 241,027 739,772 267

Panitumumab 231,530 214,529 8

Azacitidine 204,274 249,232 218

Doxorubicin liposomal 194,953 210,905 28

Decitabine 177,129 204,531 213

Cabazitaxel 161,609 141,198 14

Eribulin 157,914 154,015 3

Melphalan 132,190 130,369 1

Abbreviation: USD, US dollars.

Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 11 / November 2018 n jop.ascopubs.org e691
Used with permission. Copyright © American Society of Clinical Oncology 2018. All rights
reserved.