At the 2023 ASCO Quality Care Symposium, Puneeth Indurlal, MD, MS, The US Oncology Network (The Network), McKesson, The Woodlands, Texas, and colleagues presented their findings on the impact of different dosing approaches of lenalidomide on the total cost of care (TCOC) for patients in The Network.

Lenalidomide is an oral medication used to treat multiple myeloma and other hematologic cancers. It is available in capsules of multiple strengths, including 2.5mg, 5mg, 10mg, 15mg, 20mg, and 25 mg. When the Oncology Care Model (OCM) was in effect, lenalidomide had the highest total Part D spending among cancer drugs, with a mean cost of $735 per pill over 6 years for each strength. For the standard treatment dosing, a patient takes one dose strength once a day for 21 days on a 28-day cycle, 14 days on a 21-day cycle, or 28 days on a 28-day cycle. However, depending on patient toxicities, the doses and schedules can be adjusted.

Dr Indurlal and colleagues investigated how different dosing approaches—including multiple number of pills taken daily, frequency of pill intake per day, and the combination of multiple smaller strengths of pills as total strength—and the cost of the medication impacted the TCOC from July 2016 to June 2022 (the period that OCM was in effect). The researchers used Medicare prescription data for lenalidomide from 15 practices in The Network who participated in the OCM. They grouped the dispenses based on how many pills were taken per day, which was calculated by using the count of pills dispensed and the days’ supply. 

The results showed that of 52,793 total dispenses, 85.5% were for one pill daily doses, 10% (5,281) were for fewer than one pill daily doses, and 4.5% (2,377) were for alternative dosing approaches. The group that used alternative dosing approaches had a higher mean total cost of $28,300 per dispense compared to the cost per dispense for one pill daily doses, which was $15,600. In addition, a higher percentage of episodes of care with alternative dosing approaches had TCOC that was more than the OCM benchmark compared to the episodes with one pill daily dosing (95% vs 52%, respectively). The alternative dosing approach that had the highest mean total cost was when total strengths of the medication was dispensed as a combination of multiple smaller strengths.

The authors indicate that alternative dosing approaches, particularly the dispensing of more than one pill per day, can lead to “significantly” higher total cost of treatment and “unfavorable” value-based care outcomes. These dosing approaches may also impact similar oral medications that have high per pill costs. Dr Indurlal and colleagues emphasize the use of appropriate dosing strategies for optimizing pill counts of oral medications, which can “lead to cost savings for patients and the health system at large.”

Indurlal P, Garey JS, Mendenhall M, Waterhouse DM, Thomas HI, Wilfong LS. The impact of dosing approaches for lenalidomide on total cost of care in episodic value-based care models at a community oncology network. Presented at: the 2023 ASCO Quality Care Symposium; October 27-28, 2023; Boston, MA, and virtual; Abstract 16.