Previous studies have shown a positive association between treatment satisfaction and persistence. There is a paucity of real-world data regarding persistence associated with the use of apremilast, conventional systemic therapies and biologics in the treatment of psoriasis. The objective of this study was to compare treatment persistence among psoriasis (PSO) patients initiating apremilast, conventional systemic therapies or subcutaneous biologic therapy in US claims data. This descriptive, observational, retrospective cohort study was conducted using MarketScan Commercial and Medicare Supplemental Databases (2013-2016). Adults with ≥2 diagnosis codes for psoriasis (ICD-9:696.1; ICD-10:40.0) who initiated apremilast, other oral therapy, or biologic therapy were selected. The first prescription date was defined as the index date and patients were required to be continuously enrolled for ≥12 months pre- and ≥12 months post-index. Persistence was measured as the time from initiation to discontinuation, defined as the end of days’ supply prior to at least a 60-day gap without medication. At 12 months post-index the percentage of patients persisting on drug was assessed. In total, 972 patients initiating apremilast, 2,934 patients initiating other oral therapy, and 2,303 initiating biologic therapy met the inclusion criteria and had similar baseline characteristics. Mean enrollment follow-up time post-index was 499 days for apremilast, 591 days for other oral therapy, and 590 for biologic therapy. At 12 months post-index, persistence to initiated drug was 37.3% for apremilast, 20.4% for other oral therapy (p<0.001 vs apremilast), and 38.2% for biologic therapy (p=0.600 vs apremilast). Further sub-analyses showed a statistically significant, higher persistence for patients on apremilast compared to etanercept, (apremilast: 37.3% vs etanercept: 31.9%, p=0.022), while the persistence rates for patients on apremilast and adalimumab were similar (adalimumab: 40.2% vs apremilast: 37.3%, p=0.123). Patient persistence on apremilast therapy is significantly higher compared to conventional systemic therapies and not significantly different compared to biologic therapies.

BACKGROUND:Since the early 2000s, treatment options for multiple myeloma have rapidly expanded, adding significant complexity to the management of this disease. To our knowledge, no systematic qualitative research on clinical decision-making in multiple myeloma has been published. We sought to characterize how physicians view and implement guidelines and incorporate novel approaches into patient care.METHODS:We designed a semi-structured qualitative interview guide informed by literature review and an expert advisory panel. We conducted 60-minute interviews with a diverse sample of oncology physicians in the southeast United States. We used a constant comparative method to code and analyze interview transcripts. The research team and advisory panel discussed and validated emergent themes.RESULTS:Participants were 13 oncologists representing 5 academic and 4 community practices. Academic physicians reported using formal risk-stratification schemas; community physicians typically did not. Physicians also described differences in eligibility criteria for transplantation; community physicians emphasized distance, social support, and psychosocial capacity in making decisions about transplantation referral; the academic physicians reported using more specific clinical criteria. All physicians reported using a maintenance strategy both for post-transplant and for transplant-ineligible patients; however, determining the timing of maintenance therapy initiation and the response were reported as challenging, as was recognition or definition of relapse, especially in terms of when treatment re-initiation is indicated.CONCLUSIONS:Practices reported by both academic and community physicians suggest opportunities for interventions to improve patient care and outcomes through optimal multiple myeloma management and therapy selection. Community physicians in particular might benefit from targeted education interventions about risk stratification, transplant eligibility, and novel therapies.

The Hatch-Waxman Act of 1984 facilitated the market entry of generic drugs while protecting innovator patent rights, encouraging continued biopharmaceutical investment in research and development (R&D). We evaluated the impact of generics on drug volume and expenditures in oncology. Trends in annual sales volume and expenditures of generic and brand-name therapeutic oncology prescription drugs were assessed from 2005-14 from the IMS MIDAS database of audited biopharmaceutical sales in the US. Volume was measured using standard units (SU), defined as the smallest dose of a product. Sub-analyses were conducted for breast (BC) and colorectal cancer (CRC). The cost-savings generated from generic entry from 2006-14 was estimated. For overall oncology, generics represented 69.1-85.6% of total drug volume. Among brand products with generic entry (N = 21), average sales were $383 million (M) in the year prior to and $39M in the year after generic entry (-90%). Generic entry of oncology drugs over the period 2006-14 resulted in total cost-savings of $20.4 billion (B), with an average cost-savings of $970M. For BC and CRC, generic spending and volume increased from 2005-14. Generic entry resulted in total cost-savings of $10.9B in BC (N = 7) and $7.4B in CRC (N=3). For BC and CRC, average brand sales decreased by 95% and 86% from the year prior to the year after generic entry, respectively. Generic utilization represents an increasing majority of total oncology volume. Significant cost savings were generated with the entry of steeply discounted generics. The lifecycle of a brand drug, from to patent loss, fuels the generic pipeline and supports the continued development of the next generation of innovative therapies, providing substantial value to patients, the healthcare system and society. Further savings may soon be realized with the generic entry of breakthrough products, such as imatinib and rituximab.

The clinical endpoints selected for oncology trials have to meet the needs of diverse stakeholders: patients, clinicians, regulators, and HTA agencies, each with a different perspective. PFS is becoming a more widely accepted measure of treatment efficacy, but there is tension between regulators and payors regarding its acceptability. This study investigated PFS as a valid and credible endpoint from the perspectives of relevant decision-makers. Published and gray literature (2005–2015) were searched for regulatory and HTA guidance on PFS as an endpoint. We identified examples of decisions by regulators and HTA agencies in which PFS was the primary endpoint, and compared the assessments. Guidance from regulatory and HTA agencies indicates the suitability of PFS as an endpoint depends on the cancer type and stage, seen in assessments of afatinib and erlotinib in non-small cell lung cancer and bevacizumab in ovarian cancer: FDA and EMA approvals were based on PFS data. However, the TC in France awarded ASMR IV for erlotinib and bevacizumab and ASMR V for afatinib. NICE in the UK approved afatinib and erlotinib based on additional interim OS data and a patient access scheme; bevacizumab was not approved because of uncertainty in translating PFS gain to OS. PFS is a valid and credible endpoint in many oncology trials. However, differences in stakeholder perspectives and evidentiary requirements may mean that products approved on the basis of PFS data face delays in HTA or protracted pricing negotiations, or are rejected for reimbursement. PFS as an endpoint allows shorter trials , efficiency is improved, and fewer patients are exposed to an investigational drug. The limitations associated with PFS as an endpoint are largely manageable. Thus, the value and relevance of PFS needs to be recognized consistently across HTA agencies, and approaches harmonized between HTA agencies and regulators.

Introduction: The Orphan Drug Act (ODA) of 1983 established incentives for the development of drugs that treat rare or orphan diseases. The ODA targets therapies for diseases affecting fewer than 200,000 patients in the US. As a consequence, orphan drug development was stimulated and therapies have been developed to treat a variety of previously underserved conditions including acute myeloid leukemia, chronic lymphocytic leukemia, multiple myeloma, myelodysplastic syndromes, Gaucher disease and Hunter syndrome. Between 1973 to 1983, prior to the ODA, less than 10 drugs for orphan conditions were available to patients, while in 2013 the FDA website listed more than 400 approved orphan drugs (this includes both new molecular entities and supplemental applications/indications). Due to the perceived high therapy costs and therefore potential impact on payer’s drug budgets, orphan drugs are facing increasing scrutiny from payers. The objective of this study was to estimate the total annual expenditures on orphan drugs in the US from 2007 to 2013, and to evaluate orphan drug expenditures as a percentage of total pharmaceutical expenditures.

LEN and BORT are both effective for the treatment of patients with RRMM, but there are no head-to-head clinical trial data available to facilitate an economic analysis. However, the common control group (DEX) in the respective pivotal trials facilitated the use of indirect methods. Therefore, an indirect cost-effectiveness analysis comparing LEN/DEX to BORT, both as alternatives to DEX alone, was conducted. While other economic analyses have considered the cost/quality-adjusted life-years associated with novel agents in the RRMM setting (Brown et al, Eur J Health Econ, 2012; Möller et al, J Med Econ, 2011; Hornberger et al, Eur J Haematol, 2010), this is the first economic analysis comparing novel medicines for RRMM in China. This analysis evaluates cost/progression-free survival (PFS), as this is the more relevant endpoint for clinical decision makers in China.

Breakthrough innovation in oncology is commonly considered to be a substantial increase in overall survival (OS) above specific thresholds. However, this growing emphasis on significant OS gain, undervalues new products and may not capture aspects of treatment that are important to patients, including quality of life, delayed progression or improvements in side-effect profiles. We argue that progressive innovation in clinical and non-clinical domains needs to be considered and valued in regulatory and health technology assessment (HTA) decisions.

The study aims to assess the perspectives of different healthcare stakeholders on the current incremental cost-effectiveness ratio (ICER) thresholds and understand if these are still considered appropriate for their intended purpose. An electronic quantitative survey was administered to 150 attendees of the 17th ISPOR European Congress in Amsterdam, Netherlands, in November 2013, using a random sampling method. The respondents included representatives from academia, industry, consulting firms, clinicians, and public/government agencies. Respondents identified the five most important attributes driving positive reimbursement as: cost-effectiveness, quality of life, clinical efficacy, budget impact, and therapeutic innovativeness. Almost all respondents (91.3%) believe ICER thresholds should be used to evaluate new health technologies (formally or informally). Approximately 75.9% believe that ICER thresholds should increase beyond the current value of £30,000/QALY. The average suggested threshold is £51,274/QALY, regardless of therapeutic area. For a disease with high clinical unmet need, respondents suggest an average threshold of £61,535/QALY. The majority of respondents believe ICER thresholds should be an integral part of HTA; however, many believe the current thresholds inadequately reflect the value of innovative therapies. Specifically, respondents expressed that the thresholds should be raised for innovative treatments in therapeutic areas lacking significant treatment alternatives, as well as novel treatments for rare diseases. Additionally, 69.0% of respondents believe that the current level of ICER thresholds limits the availability of truly innovative therapies; hence a new threshold that varies by therapeutic area and degree of clinical unmet need should be established. A majority of respondents support the use of health economic evaluation, but believe that current ICER thresholds are too low and do not accurately reflect the value of novel therapies. The average threshold suggested is £51,274/QALY. Respondents indicate that the current ICER thresholds limit patient access to truly innovative therapies.

In several countries, incremental cost-effectiveness ratio (ICER) “thresholds” aid in the healthcare decision-making process by helping prioritize the distribution of resources across interventions. The aim of the study was to assess the use of ICER thresholds in the P&R process, and understand the evolution of ICER thresholds over time. A targeted literature review was conducted using search terms to address the following research questions: (i) How have ICER thresholds changed over time to reflect advances in medical technology? (ii) What is the societal willingness to pay (WTP) per QALY? (iii) How do the ICER values of interventions treating different diseases compare? PubMed and Grey Literature were searched for relevant studies published in English between January 1970 and September 2014. This review summarizes evidence from 48 studies. Literature revealed that countries use explicit and implicit ICER thresholds during the P&R process. In the US and UK, thresholds were established in 1982 and 1999 respectively, and despite significant advances in medical technology, these have not been updated. Our review indicates that the estimated societal WTP in the US is between $109,000–$297,000/QALY, and it has been recommended that the ICER threshold be raised to at least $200,000/QALY. Additionally, our review shows that ICER values vary significantly for different therapeutic areas based on medication cost, unmet need, and severity. For example, the average ICER value for an intervention treating Non-Small Cell Lung Cancer ($100,442/QALY) is approximately four-fold that of Type 2 Diabetes ($22,663/QALY). Researchers cite that ICER thresholds are dynamic, and should change over time to account for innovation in technology, inflation and increased research and development costs. In addition to end-of-life care, efforts should be made to establish different thresholds for diseases with high unmet needs to facilitate patient access to novel therapies.

To estimate the value of survival gains in myelodysplastic syndromes (MDS) attributable to the introduction of azacitidine (2004), lenalidomide (2005), and decitabine (2006). Using multivariate Cox proportional hazards models we estimated the increase in survival associated with the introduction of new therapies for MDS patients diagnosed from 2001–2011 in the Surveillance, Epidemiology, and End Results program registries. The key variable in the hazard model was the post-2006 indicator, which captured the increase in survival associated with the introduction of the 3 therapies relative to years 2001–2003. Importantly, we included flexible specifications of time trends to capture secular changes in survival over the study period. We estimated the cost and utilization of the 3 therapies from 2006–2012 using the Optum Touchstone commercial claims database. For 38,085 MDS patients diagnosed in 2001 or later we estimated that the introduction of these 3 therapies was associated with a hazard ratio of 0.901 (p<0.10). Approximately 25% of MDS patients used at least 1 of the 3 treatments over this period, implying an increase in median survival from 33 to 57.5 months, conditional on treatment observed in the community. Using an existing economic model to value survival gains, we estimated that the annual value of survival gains associated with the new therapies—i.e., the amount patients would be willing to pay for the improved survival profile—equaled $208,000 per year. Based on this, we estimate the net present value of the therapies to all future patients at $101.5 billion. Net of treatment costs, 85% of the total value accrues to patients. This study measured the value of survival gains attributable to 3 novel therapies for MDS and found significant benefits. For current and future MDS patients, these therapies will generate $101.5B in value from survival gains, with 85% accruing to patients.

Patient adherence is important for successful treatment in chronic conditions, including inflammation and immunology (I&I) diseases, to improve patient outcomes. Programs and interventions that aim at improving medication adherence play an essential role in optimizing care. This review and meta-analysis assessed the effectiveness of different types of adherence programs in I&I. A global systematic literature search was conducted and studies were identified from PubMed, conference proceedings, and grey literature. Selection criteria included studies of patient programs in I&I diseases published in English language between January 2008 and September 2013 that reported % of adherent patients. A meta-analysis was performed using a random effects model. Weights, odds ratios, 95% CI, and forest plots were developed for behavioral, informational, and combination interventions. Of 29 studies screened, a total of 13 studies were eligible for inclusion in the meta-analysis. Seven studies were in patients with osteoporosis, 4 in ulcerative colitis, 1 in childhood-onset systemic lupus erythematosus, and 1 in rheumatoid arthritis / psoriasis. Overall, patient programs increased adherence (OR = 2.48,95% CI = 1.68 - 3.64, P < 0.00001) as compared to standard of care or no intervention. Combination interventions that used both informational and behavioral strategies were superior in increasing adherence (OR = 3.68,95% CI = 2.20 - 6.16, P < 0.00001) compared to interventions using solely a behavioral strategy (OR = 1.85,95% CI = 1.00 - 3.45, P = 0.05) or only an informational strategy (OR = 2.16,95% CI = 1.36 - 3.44, P = 0.001). Patient programs and interventions can significantly improve adherence in I&I diseases as compared to standard of care or no intervention. Programs employing a multimodal approach are more effective in improving adherence than either informational or behavioral strategies alone. This in turn may improve patient outcomes.

Background Abraxane® and Taxol® are both effective drugs for the treatment of advanced stage breast cancer. However, each agent possesses unique drug delivery characteristics with the former not requiring premedication and having a considerably shorter recommended infusion time (i.e. 30 min vs. 2–4 h). To measure the overall efficiency and cost-saving potential associated with Abraxane® relative to Taxol®, a time and motion study was undertaken in breast cancer patients treated in China. Methods Baseline patient data collection included age, disease stage, number and sites of metastatic disease, and performance status. Time and resource use data were then collected from breast patients being treated with Abraxane® ( n = 12) or Taxol® ( n = 15) in one of three cancer clinics located in Jiangsu, Shanghai, and Beijing. Resource use and time impact on clinical staff were quantified using unit cost estimates. This included costs for drug preparation, administration, materials and supplies, premedication, patient chair time, labor costs, and all acute adverse drug reactions. Outcomes were presented as a mean total time and cost for delivering a dose of Abraxane® or Taxol® and were compared using parametric and non-parametric statistical tests where appropriate. All costs were reported in US dollars (US$1 = 6.1 RMB, as of January 2014). Results Patients were comparable with respect to mean age, number of metastatic sites, and performance status. Approximately 9 of 12 (75%) patients received Abraxane® as on a weekly schedule (vs. every 3 weeks) compared to 6 of 15 (40%) with Taxol®. There were 5 (33.3%) acute adverse drug reactions with Taxol®, 3 of which required a physician visit and the initiation of supportive interventions. In contrast, there was only one minor event with Abraxane® (8.3%), which was easily managed with a temporary stoppage of the infusion. From the time and motion study, the mean total time for Abraxane® and Taxol® delivery (preparation, administration, premedication, total chair time, and adverse effects management) was 84 and 282 min respectively ( p < 0.001), with the associated costs being US$59 and US$254 respectively per dose ( p < 0.001). Conclusion To our knowledge, this is first such study in breast cancer patients to be undertaken in China. Abraxane® was associated with fewer acute adverse drug reactions and significant reductions in health care resources, physician/nurse time and overall drug delivery costs compared to Taxol®.

Patient compliance and persistence to pharmacotherapies is important, especially in chronic conditions in inflammation and immunology (I&I) therapeutic area, to improve patient outcomes. Programs/interventions that aim at improving medication compliance and persistence play an important role in optimizing care. Since there is a lack of relevant systematic reviews in I&I, the objective of this study is to provide a comprehensive understanding of the effectiveness of compliance and persistence programs in the I&I therapeutic area. A systematic literature search was conducted and studies were identified from PubMed, conference proceedings and grey literature. Selection criteria included studies published in English, German, Spanish, Italian and French languages between January 2008 and September 2013, that evaluated the impact of programs on medication compliance and/or persistence in I&I. Abstracts were screened by two researchers for inclusion, and discrepancy was resolved by a third researcher. Selected publications underwent full review and abstraction. A total of 3,637 abstracts were screened, of which 29 evaluated the effectiveness of compliance and persistence programs. Studies reviewed covered different countries: the US (n = 19); Italy and the UK (n = 2 each); Australia, Denmark, Malaysia, and Poland (n = 1 each); multicenter (n = 1) and unreported/no country mentioned (n = 1). The majority of patient programs were conducted in the osteoporosis disease area (n = 9), followed by inflammatory bowel disease (n = 4), and multiple sclerosis and ulcerative colitis (n = 3 each). The most effective interventions were one-on-one tailored counseling and web-based education/communications that improved medication compliance by 44% and 31%, respectively. Additionally, group-based motivational and problem-solving support resulted in improvement of 12% at 24 months. A well-developed compliance program can have a significant impact on improving patient compliance as well as persistence to therapies. This, in turn may improve patient outcomes.

Bortezomib is an effective therapy for patients with MM. The recommended dosage is 1.3 mg/m2 IV dosed on days 1, 4, 8 and 11 for eight, three week cycles. However, a recent randomized non inferiority trial demonstrated that the same dosage of bortezomib administered SC is equally effective, but with an improved safety profile. To measure the overall efficiency and cost savings of the SC route, a prospective time and motion study was undertaken in MM patients treated in a sample of U.S. community oncology clinics. Time and motion and resource use data were collected from MM patients being treated with bortezomib IV (n=20) or SC (n=20) in seven U.S. community oncology clinics. Resource use and time impact on clinical staff were quantified using unit cost estimates. This included costs for drug preparation, wastage, administration, materials and supplies, premedication, patient chair time and all labor costs. The mean total time for IV and SC delivery (preparation, administration and total chair time) was 76.3 and 39.8 minutes (p = 0.005), with the associated (i.e. drug preparation and administration) cost being $U.S.189 and $U.S.90.84 respectively. With the inclusion of costs for drug wastage (i.e. mean of 1.2 mg for both IV and SC bortezomib, which is 34% of a 3.5 gram vial and costs approximately $U.S.500) and premedication, the cost for drug delivery was $U.S.808 (95%CI: $U.S.603 to $U.S.1011) and $U.S.596 (95%CI: $U.S.334 to $U.S.856) per dose of IV and SC bortezomib. Over a full cycle of therapy (i.e. 4 doses), the total cost for drug delivery including wastage and drug acquisition would be substantial at $U.S.7,113 and $U.S.6,327 for IV and SC bortezomib respectively. SC bortezomib resulted in a significant savings in drug delivery resources. However, drug wastage remained an important factor, regardless of the route of administration.

Lenalidomide (LEN) and bortezomib (BORT) are both effective for the treatment of relapsed/refractory MM. The former is administered 25 mg/day orally on days 1-21 of repeated 28-day cycles. The latter as a 1.3 mg/m2 intravenous dose on days 1, 4, 8 and 11 for eight, three week cycles. Currently, there are no data from head to head randomized trials comparing LEN and BORT. In the absence of such data, an indirect comparison between LEN and BORT was performed in the relapsed/refractory MM setting. Such an analysis was feasible because comparable controls were used in the pivotal randomized trials and patients had similar baseline characteristics. Three pivotal randomized trials with LEN (n=2) and BORT (n=1) in the relapsed/refractory setting were identified. Patients within each trial had similar disease characteristics. Data in terms of response rate (RR), time to progression (TTP) and overall survival (OS) were extracted from the pivotal trials. An indirect statistical comparison between LEN and BORT was then performed on these endpoints using the method of Bucher et al. (1997), which partly maintains the benefits of randomization on the magnitude of benefit. The analysis identified significant differences in efficacy between these drugs. Patients treated with LEN were significantly more likely to achieve a disease response (OR=1.92; 95%CI: 1.15 - 3.20) and to have a prolongation in TTP (HR = 0.64; 95%CI: 0.44 - 0.91). The analysis also identified a trend for an OS benefit in patients receiving treatment with LEN over BORT (HR = 0.71; 95%CI: 0.46 - 1.11). Keeping in mind the caveats associated with cross trial comparisons, the analysis suggested increased effectiveness of LEN over BORT in MM patients with refractory/relapsed disease. These findings, along with its oral route of administration and established safety profile suggest that LEN should be the preferred agent for refractory/relapsed MM.

Background: In the U.K. Medical Research Council Myeloma IX trial (mmix), zoledronic acid 4 mg once every 3–4 weeks, compared with clodronate 1600 mg daily, reduced the incidence of skeletal related events (sres), increased progression-free survival (pfs), and prolonged overall survival (os) in 1970 patients with newly-diagnosed multiple myeloma. The incidence of confirmed osteonecrosis of the jaw was higher with zoledronic acid than with clodronate. The objective of the present study was to evaluate, based on the findings in mmix, the cost-effectiveness of zoledronic acid compared with clodronate in patients with newly-diagnosed multiple myeloma. Methods: An economic model was used to project pfs, mmix, the incidence of sres and adverse events, and expected lifetime health care costs for patients with newly diagnosed multiple myeloma who are alternatively assumed to receive zoledronic acid or clodronate. The incremental cost-effectiveness ratio (icer) of zoledronic acid compared with clodronate was calculated as the ratio of the difference in cost to the difference in quality-adjusted life years (qalys). Model inputs were based on results of mmix and published sources. Results were generated under different assumptions regarding the beneficial effects of zoledronic acid on os beyond 5 years after treatment initiation. Results: Assuming lifetime treatment effects of zoledronic acid, treatment with zoledronic acid (compared with clodronate) increased qalys by 0.27 at an additional cost of CA$13,407, yielding an icer of CA$49,829 per qaly gained. If the threshold icer is CA$100,000 per qaly, the estimated probability that zoledronic acid is cost-effective is 80%. Assuming that the benefits of zoledronic acid on pfs and os diminish over 5 years beginning at the end of year 5, the icer is CAN$63,027 per qaly gained. If the benefits of zoledronic acid on pfs and os are assumed to persist for 5 years only, the icer is CAN$76,948 per qaly gained. Conclusions: Compared with clodronate, zoledronic acid represents a cost-effective treatment alternative in patients with multiple myeloma.

For many years, the backbone of cancer treatment has been the use of cytotoxic agents. There has been an emergence of new drugs, however, that are more specific to the target. Some of these agents have resulted in a prolongation of survival and even clinical cures in some cancers. In order to compare and contrast the costs and benefits of these new drug therapies, a descriptive evaluation across seven major tumour types was undertaken. A literature search was conducted from 2000 to 2011 to identify randomized trials of novel therapies in breast, lung, colorectal, kidney, lymphoma, multiple myeloma and chronic myelogenous leukemia. Clinical outcomes in terms of progression free (PFS) and overall survival (OS) benefit were extracted. Economic data in terms of cost per month of therapy was obtained from a U.S. cancer clinic. Approximately 22 novel therapies were approved across the seven cancers. Four of the 22 (18%) were used with a curative intent while the remainder were used in the palliative setting (n=18). Ten of these 18 (56%) latter agents also demonstrated an OS benefit. The median month cost for novel therapies used with a curative intent and those with a survival benefit in the palliative setting were $5450 and $6450 respectively. In contrast, the median monthly cost for drugs that did not offer either of these benefits was $7900. Of the agents identified, imatinib, lenalidomide, rituximab and trastuzumab provided the greatest magnitude of benefit for both PFS and OS and would be considered major clinical advances. Approximately 64% of novel drugs approved over the past 11 years are used with a curative intent or provide a survival benefit in the palliative care setting. The monthly cost for agents not providing these benefits, however, was higher, indicating a disconnect between efficacy and cost.