Helping Employers Understand Their Role in Managing Oncology Benefits, Costs

When the pandemic put cancer screenings to a halt in the spring of 2020, many experts feared delayed diagnoses—and higher cancer costs—would follow. And by 2022, employer surveys confirmed that cancer had replaced musculoskeletal conditions as the top driver of benefit costs.¹

With that in mind, the Greater Philadelphia Business Coalition on Health (GPBCH) brought members together April 4 for a daylong Oncology Management Summit to learn about trends in payment models and tools for everything from colorectal screening to empowering patients.

Goldfarb

Employers have many reasons to be engaged in this issue, said Neil Goldfarb, president and CEO of GPBCH. “Cancer prevalence for many cancers has been increasing,” he said. “Colorectal cancer is occurring more frequently in younger populations.”

Although there is good news in cancer—more people survive cancer and return to work—there is also challenging news, in that cancer costs are rising. “There are many things happening in the oncology space—new, wonderful technologies that come with a price tag,” Goldfarb said. “And so, we need to think about how…we manage these resources most effectively and efficiently.”

Natasha Coleman, MPH, the American Cancer Society’s (ACS) northeast region vice president for community impact, followed with some well-known statistics on who gets cancer: 1 of 2 men and 1 of 3 women will develop the disease in their lifetime. Thanks to better screening, declining smoking rates, and a revolution in therapeutics, cancer deaths have declined steadily since 1991.

The most recent annual ACS update on 2023 cancer statistics² highlights how prevention can work: effects of the use of the human papillomavirus vaccine over the past decade are taking hold, and rates of cervical cancer have declined 65% for women aged 20 to 24. But breakdowns of lung cancer by racial and ethnic group show disparities that continue to track disparities in smoking rates. That is an area where employers can make a difference, Coleman said.

“Start to think about what policies you have in place to support your employees who want to quit smoking,” she said. Having nonsmoking policies in the workplace matters, as lung cancer remains the leading cause of cancer death.

Colorectal cancer merits mention, Coleman said, because it is “the most preventable cancer.” The recent change in the US Preventive Services Task Force recommendation to start screening at age 45—along with new, less intrusive screening options—mean that this cancer can be caught early among younger people, with particular implications for people of color. Twenty percent of those with a diagnosis of colorectal cancer are younger than 55 years, and diagnoses in this younger age group doubled from 11% in 1995 to 20% in 2019.

ACS’ big challenge today is getting the US population back to the screening levels seen prior to the pandemic. There are many challenges, Coleman said: People lost access to insurance coverage, and there is increased mistrust in the health system. “It really threw us off our cancer screening schedule,” she said.

Employers can help here, too. Do company wellness initiatives remind employees to receive a colorectal screening? Are women encouraged to get mammograms?

ACS is working on legislative initiatives to ensure that if patients follow up their colorectal screening by getting polyps removed, this procedure is treated as diagnostic. “Patients should not receive a bill,” she said. “Those are some things that we support.”

Tools for Employers and Patients

Speakers from the National Comprehensive Cancer Network (NCCN) explained the role of the 32 institutions in developing clinical guidelines that represent the gold standard of treatment for 97% of cancer types. James McCanney, JD, director of business development, explained that payers use NCCN guidelines in making reimbursement decisions, including the Medicare administrative contractors. In addition, NCCN guidelines form the foundation for multiple commercial clinical pathway tools or pathways developed by academic or community oncology networks.

McCanney pointed to evidence published in JCO Oncology Practice that showed how adherence to the NCCN guidelines not only ensured that patients received high-quality care, but helped reduce chemotherapy costs.³

Although the NCCN may be best known for its clinical guidelines, McCanney explained that the network has also developed other free content, including an interactive tool for employers that was first developed with the Business Group on Health.⁴ “We worked with a number of employer thought leaders on this toolkit to promote access to high-quality cancer care and benefit design,” he said. “We really tried to work with the employers to understand pain points, areas of need, and how to assess them with resource limitations that exist.”

The result was 6 “guiding principles,” which offer strategies to include in employer benefit designs as well as tactics that employers can take to ensure that their employees know what cancer benefits are in the plans.

Patrick Delaney, executive director of the NCCN Foundation, presented information on the network’s patient-friendly resources—material to help patients understand their cancer diagnoses and treatment options in consumer-friendly language and patient-friendly formats. All materials are available in digital formats that are free to download, and some are available in printed format as funding permits.

Patient sites are not updated as often as clinical sites, but sites for the most common cancers, such as lung and colorectal, are updated more frequently, Delaney said. In addition, NCCN creates patient-focused material for supportive care on topics such as anemia, survivorship, and chimeric antigen receptor T-cell adverse effects. Resources are translated into 18 languages, he noted.

In addition, NCCN creates consumer-oriented webinars, which became more popular during the pandemic. Although NCCN is not directly patient facing, it does work with patient advocacy groups to develop materials.

“We have started working with employers,” Delaney said, and the organization seeks partnerships to customize materials. “We are always looking for feedback.”

Screening and Biomarkers

Changing the recommendation to screen for colorectal cancer at younger ages does not mean that most Americans comply with it, according to Victoria Raymond, senior director for medical affairs with Guardant Health, maker of the Shield blood test that screens for this cancer. In fact, Raymond said, ACS data show that 52% of individuals aged 45 to 64 years—those who are still in the workforce—have never been tested or are not up-to-date with guidelines.⁵

This should alarm employers, she said, because 90% of individuals with colorectal cancers that are caught early on can be cured at a relatively low cost. On the other hand, 14% survive when cancer is caught at stage III or later, and when it costs 3 times as much to treat.⁶

Availability of a stool-based test completed at home has not increased screening rates to the CDC goal of 80%, Raymond said. Some users are uncomfortable handling the stool and unsure of the steps involved; rates of stool-based tests and colonoscopy combined reached 69.7% in 2020.⁷ “These options work; we know that many people are completing them,” she said. “But there are lots of people who are not doing screening as well.”

Guardant’s Shield is a blood-based test that detects the presence of colorectal cancer through circulating tumor DNA; it has been validated in a study to have 83% sensitivity and 90% specificity.⁸ A different study examining patient preferences for colorectal cancer screening found that 37% wanted a colonoscopy. Of those remaining, 83% chose the blood test, 15% chose the fecal test, and 3% refused screening completely.⁹

Robert Baird, RN, MSA, president of the National Cancer Treatment Alliance, outlined what employers should know about biomarker testing—not only to ensure that the right treatment reaches the right patient, but also to help employers avoid paying for treatments that will not work.

Oncology spending has doubled in the past decade to $240 billion and will continue to grow, he noted. “It’s really starting to get the attention of self-insured employers—it’s really hitting their radar screens like never before,” Baird said. “A lot of that spending is attributed to new therapies coming out. [They’re] very effective therapies, but they can be very expensive. And it’s becoming a greater part of the employer health care budget—greater than 12% in some of the [study data] we’ve seen.”

Baird walked the audience through the ways tests are used—diagnosis, guiding treatment, monitoring treatment response, monitoring recurrence—as well as the types of tests, which can include testing for a single gene, a select gene panel, or comprehensive genomic profiling (CGP). The latter has become more common, as it can eliminate the need to collect additional tissue if new driver mutations and treatments are discovered later.

Despite the advances and utility of testing, Baird said, many national insurers arbitrarily limit the number of genes or biomarkers that can be tested at 50; some require patients to have progressed on a line of therapy before testing can begin. Using lung cancer as an example, given the advances in use of biomarker testing in this common cancer, Baird cited findings from a study that showed only 8% of patients received all biomarker testing recommended in NCCN guidelines.¹⁰

Employer involvement in plan design is critical to ensuring coverage for biomarker testing, he stated. CGP might cost $3000, which is a fraction of the cost of a targeted therapy, and thus worth the investment to ensure patients are receiving the right care, Baird said. “You get a better understanding of the entire view of that patient—different genes, different things you may not have seen,” which could help avoid unnecessary toxicities or emergency department costs down the line. CGP could also be the first step to a patient’s participation in a clinical trial, he added, which can benefit both patient and employer by reducing some costs.

Kristy Pellicano, biomarker testing specialist for Genentech, said she has seen many of the same challenges that Baird addressed. Providers are very worried that tests will not be covered; when they cannot access the right tests, it could mean the patient cannot get access to the right therapy. “It wasn’t just one provider,” she said. “We all know coverage is complicated. It’s nuanced.”

Pellicano described a roundtable her company hosted that included multiple payer stakeholders and NCCN. At the meeting, a provider and payer debated the need for prior authorization for testing, and it turned out the providers were very unfamiliar with the prior authorization process for tests. As Baird had done, Pellicano used lung cancer as an example of a case where getting the right test can make all the difference in whether a patient receives the appropriate treatment.

Forming partnerships with entities such as the National Cancer Treatment Alliance to educate providers, legislators, and Medicaid is essential, she said. “My hope [is] that this has helped get you a little bit closer to the questions that have to be asked.”

References

1. Miller S. Cancer now top driver of employer health care costs, survey shows. SHRM. August 31, 2022. Accessed May 18, 2023. https://bit.ly/3Iq0Fa3

2. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023;73(1):17-48. doi:10.3322/caac.21763

3. Newcomer LN, Weininger R, Carlson RW. Transforming prior authorization to decision support. J Oncol Pract. 2017;13(1):e57-e61. doi:10.1200/JOP.2016.015198

4. Employer toolkit. NCCN. Accessed May 18, 2023. https://www.nccn.org/business-policy/business/employer-resources/employer-toolkit

5. Colorectal cancer: facts and figures, 2020-2022. American Cancer Society. Accessed May 19, 2023. https://bit.ly/3oeDpF1

6. Cancer stat facts: colorectal cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Accessed May 19, 2023. https://bit.ly/3oeKl54

7. Use of colorectal cancer screening tests. CDC. Updated March 22, 2023. Accessed May 19, 2023. https://bit.ly/3og7d4i

8. Guardant Health announces positive results from pivotal ECLIPSE study evaluating a blood test for the detection of colorectal cancer. News release. Guardant Health. December 15, 2022. Accessed May 18, 2023. https://bit.ly/3pYEykw

9. Adler A, Geiger S, Keil A, et al. Improving compliance to colorectal cancer screening using blood and stool based tests in patients refusing screening colonoscopy in Germany. BMC Gastroenterol. 2014;14:183. doi:10.1186/1471-230X-14-183

10. Guttierrez ME, Choi K, Lanman RB, et al. Genomic profiling of advanced non–small cell lung cancer in community settings: gaps and opportunities. Clin Lung Cancer. 2017;18(6):651-659. doi:10.1016/j.cllc.2017.04.004