Expensive shots given to reduce the risk of infection in many cancer patients are overused at considerable cost, a report co-authored by a renowned Omaha physician says.
“People need to learn to use it correctly,” Dr. James Armitage, a professor at the University of Nebraska Medical Center, said of the medication this week in an interview. “If they don’t know how, they probably shouldn’t be practicing oncology.”
The New England Journal of Medicine published the report this week. The article spotlights a practice that has received increasing scrutiny from cancer experts. The practice involves using medicines designed to boost white blood cells that fight infections that may come with chemotherapy.
The two drugs in question are called filgrastim and pegfilgrastim. The most widely used brands of those drugs are Neupogen and Neulasta, both of which are manufactured by Amgen.
Dr. Charles Bennett, another author of the report, said the overuse of the drugs may cost the American health-care system billions of dollars a year. Bennett, a physician at the South Carolina College of Pharmacy, said that perhaps more than half of patients who get the drugs don’t need them.
The report itself was less emphatic, saying that “wide variation from guideline standards results in extensive use of these agents,” even when the risk of infection is low.
The drugs are expensive. Neulasta, which may accompany one round of chemo, costs more than $2,800 per injection, Bennett said. Some cancer patients undergo multiple rounds of chemo.
Blue Cross Blue Shield of Nebraska’s group and individual plans generally cover Neupogen and Neulasta, spokesman Andy Williams said.
For seven years now, American Society of Clinical Oncology guidelines have suggested patients with a 20 percent or greater chance of getting “febrile neutropenia,” a condition that can lead to serious infections, receive the injections. Patients receiving certain kinds or doses of chemo, and those undergoing chemo who are older than 65, have other health conditions or had previous treatment for cancer are appropriate candidates for the drugs, the guidelines say.
But Armitage, widely recognized for his expertise in treating lymphoma, said the drugs frequently are used for patients who aren’t at high risk.
“Everybody knows how the drug’s being used in practice, and it’s often given in situations that don’t meet the guidelines,” he said.
Amgen reported that Neupogen and Neulasta garnered $5.4 billion in global sales last year, up from $5.2 billion the year before. More than 75 percent of those revenues were generated in the United States.
The company said Wednesday through a written statement: “Amgen believes high-quality care for cancer patients is a priority.” It said the clinical oncology society’s guidelines confirm that a 20 percent risk of febrile neutropenia “is unacceptable for cancer patients receiving chemotherapy.”
Dr. Gamini Soori, an Omaha oncologist with Nebraska Cancer Specialists, said infections related to febrile neutropenia can be life-threatening. So when the drugs were approved in the early 1990s (filgrastim) and early 2000s (pegfilgrastim) to pump up an important kind of white blood cells, cancer doctors were delighted, he said.
Cancer patients and oncologists now had another weapon to boost resistance against the infections besides “praying to the good Lord that their blood counts would come up,” Soori said.
But with use, data mounted about who benefits from the drugs, and the national oncology organization issued its guidelines in 2006.
Soori said those in his oncology group follow the guidelines but it simply takes time for everyone to get up to speed. “It’s no different than wearing seat belts,” Soori said. “I think it’s a learning curve and an adapting curve.”
Dr. Tom Smith, an oncologist at the Johns Hopkins Kimmel Cancer Center in Baltimore, said there shouldn’t be a learning curve. Smith didn’t find Bennett’s cost assertions to be exaggerated.
He referred to a 2012 study at a cancer center that found that about half of patients receiving pegfilgrastim didn’t meet the guidelines for treatment with that drug. That center, Smith said, provided no financial incentive for administering pegfilgrastim.
Smith said he was aware of a West Coast clinic that made more than $1,000 for each Neulasta shot. That, he said, is a strong incentive for using it.
Smith and others said lowering chemo doses or using antibiotics in some cases are alternatives to using the expensive drugs.
Last year, Smith helped write a report for the American Society of Clinical Oncology that identifies five ways to improve care and reduce costs. No. 5 on that list: Halt overuse of the white cell-stimulating drugs.
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