Multiple Myeloma: Factors for Payers to Consider
Multiple Myleoma (MM) is a malignant cancer caused by the abnormal accumulation of the plasma cells derived from B cells in the bone marrow, leading to eventual marrow failure and skeletal destruction through bone metastases.1 The American Cancer Society estimates that 30,300 new cases of MM will be diagnosed in 2016 and will result in about 12,650 MM-related deaths this year.2 Primarily, MM is a disease of the elderly, as the median age at myeloma diagnosis ranges from 63 to 70 years.3
Despite the introduction of several therapeutic agents in the past decade that have led to improved response rates and increased survival, myeloma remains incurable; a majority of patients will eventually relapse or become refractory to treatment. As suggested by the mean age of diagnosis, the strongest risk factor for developing MM is advanced age. Other risk factors for the development of MM may include bone pain, anemia-related fatigue, hypercalcemia, weight loss, renal insufficiency, and paresthesia.3
Treatment
The initial diagnosis is based on laboratory results, including blood chemistries and protein electrophoresis. The recommended initial diagnostic workup should also include a complete history and physical examination, as well as baseline serum, urine, bone, and marrow analysis.1,4 The initiation of pharmacotherapy is dependent on the degree of disease progression as evidenced by laboratory and clinical data. Currently, the International Staging System (ISS) is used to stage the disease according to levels of serum ß2 microglobulin and serum albumin.1,2 The goals of treatment are to reduce symptoms, to slow disease progressions, and to provide prolonged remissions. It is recommended that treatment for MM be individualized based on the extent of the disease and rate of disease progression.5 A majority of individuals require myeloma-specific therapies that may include combination drug therapy, high-dose chemotherapy with stem-cell transplantation, radiation therapy, and/or new emerging drug therapies in development, as outlined in the National Comprehensive Cancer Network guidelines.5,6
Economic Burden
The management of cancer remains an important issue for US payers. According to the National Cancer Institute,7 the cost of cancer continues to increase and is expected to reach $174 billion by 2020. The cost of MM accounts for approximately 9% to 10% of total cancer care costs; this is highly disproportionate to the incidence and prevalence of MM versus other tumor types.4 The cost of novel MM therapies will continue to be an important factor in formulary status and poses challenges both in ensuring patient access to treatment and for providers and payers.8 Additionally, myeloma-related complications are a major contributor of total costs. Schulman and Kohles9 assessed the US economic burden of metastatic bone disease and found that metastatic bone disease in patients with MM has been estimated to account for $57,720 per patient in excess direct annual costs. In another analysis, Barlev and colleagues10 looked at inpatient treatment of myeloma-related complications and estimated that payer costs were $31,016 for surgery to the bone, $23,347 for pathologic fracture, and $43,691 for spinal cord compression.
The treatment landscape for MM will continue to evolve as more therapies in the pipeline gain approval. Therefore, payers will need to consider not only the economic factors but also quality of life, treatment-related toxicities, and pharmacoeconomic analyses to determine the most cost-effective therapies. A progressive partnership between patients, caregivers, and payers will help ensure access to agents that will produce the most optimal outcome for both the patient and the health plan.—Eileen Koutnik-Fotopoulos
