Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Sep 9.
Published in final edited form as: JCO Oncol Pract. 2025 Sep 5;22(7):1312–1321. doi: 10.1200/OP-24-00995

Changes in Cost of Guideline-Concordant Cancer Treatment: Observations and Implications

Judy J Wang 1, Sonia Persaud 2, Sara Tabatabai 3, Nirjhar Chakraborty 4, Pranam Dey 5, Niti U Trivedi 6, Aaron Philip Mitchell 7
PMCID: PMC12416744  NIHMSID: NIHMS2102822  PMID: 40911806

Abstract

PURPOSE:

Cost of cancer care in the U.S. is substantial. Prior studies have explored pricing comparisons at the level of individual cancer drugs but not that of clinical indications. This study evaluates cost patterns for providing the best guideline-concordant therapy for solid tumor treatment indications.

METHODS:

We identified all NCCN guideline-concordant treatment indications for the 17 most common solid tumor malignancies in 2017 and 2021. Best available treatments were determined for each indication using NCCN Evidence Block scores. We grouped treatments by 1) those administered on an ongoing basis (priced per month) and 2) those administered for a pre-specified duration (priced per course of therapy). Costs were calculated using Medicare reimbursement rates and analyzed across both timepoints.

RESULTS:

Across all indications, median cost of the best-available cancer treatment changed from $10,784 (IQR = [$691,$16,489]) in 2017 to $17,936 (IQR = [$2,640;$19,209]) in 2021 for regimens administered on an ongoing basis, and from $10,501 (IQR = [$6,068;$51,365]) in 2017 to $9,038 (IQR = [$5,045;$79,386]) in 2021 for regimens administered for a set duration. Among the subset of indications newly present in 2021, median costs were higher at $21,524 (IQR=$[5,639; 22,369]) per month for ongoing regimens and $17,005 (IQR=[$6,178;$258,284]) per course for prespecified regimens. Among the subset of indications present in both 2017 and 2021, relative change in cost of the best-available treatment was −2% (IQR=[−39%, +9%]). Indications for which the best-available treatment had a new generic or biosimilar entrant (N=16), median cost decrease was substantially larger at −57% (IQR=[−78%, −44%]).

CONCLUSION:

This study observed an increase in absolute median cost of cancer therapy on a treatment indications level, largely driven by new biomarker-driven indications and therapies.

INTRODUCTION

The high cost of cancer care in the U.S. has been a long-standing concern. Cost of cancer treatment in the Medicare system alone was estimated to be $183 billion in 2015 and projected to reach $246 billion by 2030, representing a 34% increase1,2. Similar trends are seen globally3–5. On an individual level, greater attention has been directed towards understanding the impact of financial toxicity on patient outcomes and wellbeing, both during their cancer treatment and in survivorship6,7. Cancer patients have been found to be at higher risk of poor mental health, high accruing medical debt, and caregiver distress due to high costs of care7,8.

Numerous factors contribute to the rising cost of cancer care. Greater access to screening, an aging population, and more effective treatments have increased the incidence of cancer detection and duration of therapy9–11. With advancements in research and development of novel agents, the substantial cost of treatment regimens is another major culprit12–14. Existing studies have underscored the escalating costs of individual cancer medications, which have consistently outpaced the rate of inflation12,14. Between 2007 and 2013, there was an average inflation-adjusted annual increase of 5% in cost of oral anticancer drugs15. In another economic evaluation of 65 cancer drugs in the U.S. from 2009 to 2019, 74% had pricing increases that exceeded inflation16,17.

Nonetheless, we have a much more limited understanding of the cost landscape on a treatment indication level. Instead of looking at how the price of ipilimumab evolved, for example, it is more practical to ask how the cost of administering the best-available treatment for metastatic melanoma has changed over time. The latter may directly correlate with individual drug cost trends, but may also be influenced by the changing landscape of drug development, regulation, and commercialization. The entrance of more affordable generics and biosimilars to the market in recent years may further impact the treatment cost on an indication level, despite existing brand-named agents retaining higher price points18,19.

This study explores changes in cost of the best guideline-concordant therapy for individual cancer treatment indications over a recent four-year period. We assess treatment costs on the indication level to uncover trends not otherwise realized on the level of individual drugs.

METHODS

We abstracted all unique treatment indications for the 17 most common solid tumor malignancies in the NCCN Guidelines at two separate time points, July 1st 2017, and July 1st 2021. Examples of separate indications include: “Bladder: perioperative chemotherapy: Neoadjuvant” and “Bladder: perioperative chemotherapy: Adjuvant”20. We then analyzed these indications to determine the subset that were present in both 2017 and 2021 (‘matched’ indications), and which had been newly added between 2017 and 2021 (‘unmatched’ indications).

For every indication, all NCCN guideline-recommended treatment options were identified. Treatment options that involved radiation or stem cell therapy were excluded due to their significant difference in modality and subsequent challenge in cost comparison with other treatment types. We abstracted the following parameters for each regimen: full name, line of therapy, duration of therapy, and NCCN Evidence Block (EB) scores including Efficacy, Safety, Quality, Consistency. Cost of all regimens were calculated using Medicare reimbursement rates from Medicare Plan Finder unit retail price, as done previously20,21. Administration and supportive care costs were included, while ancillary and nonmedical costs were not included.

To determine the best treatment for each clinical indication, we ranked all treatment options within a given indication based on their EB scores, prioritizing (in order of clinical importance) Efficacy, Safety, Quality, then Consistency, as done previously22. In the minority of cases where more than one regimen received the highest ranked score, we chose the cheapest of such regimens for analysis. In doing so, we aimed to identify the most cost-effective option among the best available treatments at a given timepoint. For this study, we defined this highest-scoring, most cost-effective therapy as the “best-available regimen” for each clinical indication.

Data abstraction was performed in Microsoft Excel. Data cleaning was performed on a Python 3.9.12 platform with SciPy (version 1.13.0). Graphs were generated with Matplotlib (version 3.9.1).

Outcome variables

The primary outcome was the cost of best-available regimens, as defined above. We used two broad categories of treatment regimens to reflect different therapeutic approaches and resulting differences in cost accrual. Treatments administered on an ongoing basis (often, those for advanced/metastatic disease) were defined as “continuous therapy” and were priced as the cost per month of therapy. Treatments administered for a prespecified number of cycles (often, those for adjuvant or neoadjuvant treatment) were defined as “complete therapy” and were priced as the cost per full course of therapy. In addition to the exact cost of the anticancer drugs calculated in either of these two ways, we also included the cost of supportive care medications typically administered with the treatment, such as antiemetics. Data from both 2017 and 2021 were adjusted for inflation to 2024 USD (time of analysis)23. Median costs with interquartile ranges (IQR) were reported.

Data analysis

We first compared the cost of all indications in 2017 and 2021. One caveat to further analysis is that not all indications remained the same at both time points, with newer or further stratified indications appearing in the 2021 data set. In order to address this discrepancy, we separated all indications into “matched” indications (those that are present in both 2017 and 2021) and “unmatched” indications (those that either do not have an associated 2017 equivalent or vice versa). For unmatched indications, we focused on the subset of indications that were newly present in 2021 (as opposed to the smaller subset that were present in the 2017 Guidelines and subsequently removed). T-test was performed to determine whether average costs for all, matched, and unmatched indications were statistically different between the two timepoints.

For matched indications, we conducted subgroup analysis to further explore within-indication changes in cost from 2017 to 2021. We looked at changes in median cost based on notable characteristics:

  1. For same (best-available regimen in 2017 remained identical in 2021) vs different regimens (best-available regimen in 2017 was replaced by another, often newer option in 2021); while the former can help highlight the directionality of cost for the same anticancer drug over time, the latter would include cases wherein an older therapy was supplanted by a newer therapy which is likely to be more costly.

  2. For regimens with newly approved and available generic and/or biosimilar alternatives vs not; the process of identifying such drugs involved searching through all generic drug approvals from 2016 to 2021 in the FDA ANDA (Generic Drug Approvals) database24.

  3. Grouped within each of the 17 solid tumor cancer types.

RESULTS

Summary of clinical treatment indications

We identified 202 best-available solid tumor treatment indications in 2017 and 333 in 2021 (Table 1). 171 indications were present in both years and matched for further analysis. 31 unmatched indications existed only in 2017, while 162 unmatched indications were only present in 2021.

Table 1:

Summary of NCCN treatment indications included in this study, with details about the type of regimen, line of therapy, and associated cancer type(s). “Continuous” indications are those wherein treatment is administered on an ongoing basis, priced per month of therapy. “Complete” indications are those wherein treatment is administered for a limited number of cycles, priced per full course of therapy. “First-line” indicates initial systemic therapy, inclusive of adjuvant and neoadjuvant indications. Subsequent indicates all later lines of therapy, including maintenance regimens. NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer.

2017 2021
total matched unmatched total matched unmatched
Type of regimen Continuous 112 97 15 203 97 106
Complete 90 74 16 130 74 56
0
Line(s) of therapy First-line 66 58 8 190 112 78
Subsequent line(s) 136 113 23 143 59 84
Cancer type(s) Bladder 2 2 0 19 2 17
Brain 6 6 0 16 6 10
Breast 11 9 2 12 7 5
Colon 23 23 0 29 25 4
Kidney 10 10 0 10 9 1
Liver 4 4 0 17 7 10
NSCLC 21 20 1 38 21 17
Melanoma 16 15 1 20 15 5
Oral Cavity/Pharynx 4 3 1 15 3 12
Ovary 31 18 13 47 14 33
Pancreas 7 7 0 24 9 15
Prostate 20 13 7 16 12 4
Rectal 21 21 0 27 20 7
SCLC 5 4 1 7 4 3
Soft Tissue 4 4 0 8 4 4
Stomach 10 7 3 15 7 8
Uterus 7 5 2 13 6 7
TOTAL 202 171 31 333 171 162
Open in a new tab

Amongst the 171 matched indications, 97 (57%) were continuous regimens and 74 (43%) were complete regimens. 97 (57%) indications had identical best-available treatments in both years. 16 (9%) indications incorporated new generic and/or biosimilar agents as best-available treatment during the study period.

For the 162 unmatched 2021 indications, 106 (65%) were continuous regimens and 56 (35%) were complete regimens. Most common cancer types for this cohort were ovary (33/162, 20%), bladder (17/162, 10%), and non-small cell lung (17/162, 10%). Least common cancer types included kidney (1/162, 1%) and small cell lung (3/162, 2%).

Cost for standard-of-care on an indications level

For all indications with continuous best-available therapies, median cost was $10,784 per month (IQR = [$691;$16,489]) in 2017 and $17,936 per month (IQR = [$2,640;$19,209]) in 2021 (p<0.001) (Table 2, Figure 1a). Median cost for matched indications (those present at both time points) was $16,209 (IQR = [$2,194;$23,012]) in 2017 and $16,471 (IQR = [$1,347;$23,680]) in 2021 (p=0.28). Median cost of unmatched indications newly present in 2021 increased to $21,524 per month (IQR = $[5,639; 22,369]).

Table 2:

Median and IQR treatment costs for continuous and complete regimens in 2017 and 2021. Prices are shown for all indications (total), and in subsets of “matched” indications (those present in NCCN Guidelines in both 2017 and 2021, n = 171) and “unmatched” indications (those present in NCCN Guidelines in only 2021, n=162). “Continuous” indications are those wherein treatment is administered on an ongoing basis, priced per month of therapy. “Complete” indications are those wherein treatment is administered for a limited number of cycles, priced per full course of therapy. “First-line” indicates initial systemic therapy, inclusive of adjuvant and neoadjuvant indications. Subsequent indicates all later lines of therapy, including maintenance regimens. IQR, interquartile range.

2017 2021 p-value
median (IQ1; IQ3) IQR median (IQ1, IQ3) IQR
Continuous total 10,784 (691; 16,489) 15,798 17,936 (2,640; 19,209) 16,569 <0.001*
matched 16,209 (2,194, 23,012) 20,818 16,471 (1,347; 23,680) 22,333 0.28*
unmatched --- --- --- 21,524 (5,639; 22,369) 16,730 0.28**
Complete total 10,501 (6,068; 51,365) 45,297 9,038 (5,045; 79,386) 74,341 0.69*
matched 13,162 (7,527; 66,260) 58,733 7,735 (5,749; 61,859) 56,110 0.16*
unmatched --- --- --- 17,005 (6,178; 258,284) 252,106 0.002**
Open in a new tab
*

for t-test conducted between 2017 and 2021 subsets

**

for t-test conducted between matched and unmatched 2021 subsets

Figure 1:

Figure 1:

Figure 1:

Open in a new tab

Absolute median and IQR treatment costs in 2017 and 2021, stratified by all, matched, and unmatched indications.

For all indications with complete best-available therapies, median cost per full course was $10,501 (IQR = [$6,068;$51,365]) in 2017 and $9,038 (IQR = [$5,045;$79,386]) in 2021 (p=0.69) (Figure 1b). While median cost for matched indications decreased from $13,161 (IQR = [$7,527;$66,260]) in 2017 to $7,735 (IQR = [$5,749;$61,859]) in 2021 (p=0.16), cost was significantly higher at $17,005 (IQR = [$6,178;$258,284]) for unmatched 2021 indications (p=0.002). Across the 17 cancer types, treatment cost was higher in 2021 than 2017 for 12 (71%) cancer types for continuous therapies, and 10 (59%) cancer types for complete therapies.

Sub-analyses for matched indications (those present at both timepoints)

For indications present in both 2017 and 2021 (n=171), median relative change in cost was −2% (IQR = [−40%, +16%] (Figure 2). 92 indications (54%) had lower median costs in 2021 than in 2017. Complete therapies observed a larger decrease in cost at −29% (IQR = [−50%, +6%]) compared to continuous therapies at +2% (IQR = [−24%, +17%]). Among the subset wherein the best-available treatment remained the same (n=97), relative change in median cost was 0% (IQR = [−31%, +12%]). The remaining 74 indications with new best-available treatments saw a decrease in median cost by 12% (IQR = [−50%, +63%]). Indications with new generic and/or biosimilar entrants saw a significant decrease in cost at −57% (IQR = [−78%, −44%]).

Figure 2:

Figure 2:

Open in a new tab

Percentage change in treatment cost from 2017–2021 for matched subset (n=171). Subgroup analyses show treatment cost changes within indications grouped as follows: a) Gold: indications with continuous treatment priced per month vs complete treatment price per full course b) Green: indications where best-available regimen stayed the same vs replaced by another regimen in 2021 c) Blue: indications where best-available regimen included agent with generic/biosimilar alternatives vs not

Across all cancer types, the biggest decreases in median cost were observed for brain (−67%), stomach (−40%), and prostate (−39%) cancers (Figure 3). Biggest increases were seen for pancreas (18%) and liver (17%). On an individual indication level, “M1 castration-recurrent prostate cancer, without visceral metastases” had the biggest percentage relative decrease at −98%, while “glioblastoma recurrence therapy, diffuse or multiple” had the biggest increase at 3551% (Table 3).

Figure 3:

Figure 3:

Open in a new tab

Percentage change in treatment cost from 2017–2021 for matched subset, with indications grouped by cancer type (n=171).

Table 3:

Indications with the greatest relative pricing increases and decreases, among the subset of indications present in NCCN Guidelines in both 2017 and 2021 (“matched” indications, n=171). Costs are shown in 2024 dollars. % indicates relative price change.

Clinical Indication Type of treatment 2017 2021 Change in Cost
Regimen Cost Regimen Cost Dollars %
Indications with greatest relative increase in cost Brain_Glioblastoma_Recurrence therapy, diffuse or multiple continuous Temozolomide 667 Regorafenib 24,371 23,704 3,551
Lung_Squamous cell carcinoma_Maintenance therapy continuous Docetaxel 687 Pembrolizumab 17,936 17,249 2,511
Ovary_Platinum-resistant high-grade serous disease_Preferred agents continuous Gemcitabine 716 Paclitaxel (weekly) + bevacizumab 10,539 9,823 1,372
Prostate_Radical prostatectomy biochemical failure and radiation therapy recurrence, M0 continuous Agonist alone 291 LHRH antagonist (relugolix) 2,811 2,520 867
Ovary_Primary or Adjuvant Systemic therapy_Stage III-IV Low-Grade Serous Carcinoma continuous Letrozole 14 Exemestane 122 107 746
Small cell lung_First-line therapy for extensive stage SCLC complete Carboplatin + etoposide 6,068 Carboplatin + etoposide + atezolizumab 50,978 44,910 740
Soft tissue_Resectable GIST_Neoadjuvant treatment complete Imatinib 2,449 Imatinib 19,149 16,700 682
Colon_Advanced or metastatic disease_Subsequent therapy complete FOLFOX 1,700 Pembrolizumab 12,715 11,015 648
Rectal_Advanced or metastatic disease_Subsequent therapy continuous FOLFOX 1,700 Pembrolizumab 12,715 11,015 648
Lung_Adjuvant; chemotherapy regimens for patients with comorbidities or patients not able to tolerate cisplatin complete Paclitaxel 200 mg/m2 day 1, carboplatin AUC 6 day 1 5,056 Carboplatin + pemetrexed 32,984 27,927 552
Indications with greatest relative decrease in cost Prostate_M1 Castration-recurrent prostate cancer_No visceral metastases continuous Abiraterone + prednisone 12,293 Abiraterone 279 (12,014) −98
Prostate_Subsequent systemic therapy for M1 Castration-recurrent prostate cancer_No visceral metastases, prior docetaxel therapy continuous Abiraterone + prednisone 12,293 Abiraterone 279 (12,014) −98
Soft tissue_Resectable GIST_Adjuvant treatment complete Imatinib 31,924 Imatinib 1,469 (30,455) −95
Ovary_Platinum-sensitive high-grade serous disease, first recurrence continuous Carboplatin + paclitaxel + bevacizumab 15,524 Carboplatin + paclitaxel 1,157 (14,367) −93
Melanoma of the skin_Adjuvant therapy for recurrent melanoma_Nodal recurrence complete High-dose ipilimumab 2,093,681 Pembrolizumab 215,237 (1,878,444) −90
Ovary_Platinum-sensitive high-grade serous disease, first recurrence complete Paclitaxel, albumin-bound 37,865 Carboplatin + paclitaxel (Weekly) 8,388 (29,476) −78
Melanoma of the skin_Adjuvant therapy for primary melanoma_Stage III (clinically positive node[s]) complete High-dose ipilimumab 959,167 Pembrolizumab 215,237 (743,931) −78
Melanoma of the skin_Adjuvant therapy for primary melanoma_Stage III (sentinel node positive) complete High-dose ipilimumab 959,167 Pembrolizumab 215,237 (743,931) −78
Brain_Glioblastoma_Recurrence therapy, local resected continuous Temozolomide 667 Temozolomide 150 (518) −78
Brain_Glioblastoma_Adjuvant treatment, poor performance status (KPS < 60), any MGMT promoter methylation, <= 70 years complete Temozolomide 3,697 Temozolomide 830 (2,867) −78
Open in a new tab

DISCUSSION

From 2017 to 2021, we observed an increase in absolute median cost and IQR for high-EB scored, cost-effective treatments priced per month on a clinical indications level. While median cost for prespecified complete-course treatments decreased slightly, they similarly saw a wider range of costs with a greater maximum at the later timepoint. To our knowledge, this is the first study to examine cost changes over time from this standpoint.

In our subgroup analysis of matched and unmatched indications, Figure 1 suggests that cost increases have been concentrated within indications newly present in 2021. The majority of these new indications involve biomarker-specific targeted therapies or prior exposures to newer agents that were not previously part of standard-of-care. For example, in pancreatic cancer, the best-available regimen for all patients with “locally advanced, unresectable disease, poor performance status” in 2017 was gemcitabine infusion; four years later, those with NTRK gene fusion were instead recommended entrectinib25 (30 times the cost of standard gemcitabine) or larotrectinib26 (56 times the cost) per NCCN EB scores. This is one example of the types of new agents driving the wider range of costs for complete regimens in 2021.

With respect to the 171 indications present at both years, we see minimal changes in the cost of standard of care treatments over this four year period (−2%). This remained true whether the best-available regimen changed or did not change during this time. While more indications had the same best-available regimen, 44% of indications did adopt new standard-of-care over which is consistent with the relatively rapid adoption of new therapies in oncology especially after the 2000s27,28.

Our data supports the established assumption that new generic and/or biosimilar entrants is a significant driver of decreased cost. In our dataset, the availability of generic carmustine (generic approved in 2018 for brain cancer), abiraterone (generic approved in 2018 for prostate cancer), and imatinib (generic approved 2016 for GIST) accounted for – with implementation lag time in mind – the 57% decrease in cost seen in Figure 229,30. New biosimilar entrants can similarly lower the cost of a given treatment regimen, as the availability of trastuzumab biosimilars led to a decline in breast cancer treatment costs31–33. Horn et al. found that competition from multiple biosimilars appears to have even greater downward effects on prices.31 Despite these promising outcomes, the uptake of generic and biosimilars alike has been slow34,35. The potential for generics and biosimilars to lower costs may also be limited by the relatively small number of cancer sites with available generics or biosimilars; we observed that only 9% of indications had generic or biosimilar agents in their best-available treatments.

In both 2017 and 2021, we observed high degrees of variance in treatment costs, especially for indications wherein the best-available regimen changed during the study period. This is not unexpected, as cases where an old regimen is supplanted by a new one would naturally provide more leeway for that regimen to be more costly. We found that the biggest pricing increases occurred with the entry of new agents. For example, the replacement of temozolomide by regorafenib for recurrent glioblastoma led to an over 3500% increase in treatment cost, as the total jumped from just under $670 to over $24,000 per month. The advent and inclusion of pembrolizumab into standard-of-care also led to large upticks in cost for lung and colorectal cancers (Table 3). Despite ongoing advocacy, there remains a relative paucity of pricing regulations, which exacerbates these unpredictable fluctuations of drug prices. The Inflation Reduction Act (IRA) of 2022, although capping pricing increases for existing cancer drugs36, did not address the high and ever-increasing launch prices of new drugs. Between 2008 and 2021, mean launch prices increased exponentially by 20.4% each year, and 13.0% per year after adjusting for drug characteristics37. Our study highlights the importance of measuring cost within a treatment indication or disease process, as doing so highlight the impact of factors such as high launch prices that are not otherwise as visible when looking at individual drugs but remain significant contributors to overall cost of care.

The price of cancer drugs does not consistently reflect clinical benefit. A cross-sectional study conducted in USA and Europe reported no significant correlation between drug prices and clinical outcomes such as overall survival and progression-free survival38, the results of which were similarly replicated in other countries like Japan and Italy39,40. Mitchell et al, also using NCCN Evidence Blocks, found inconsistent associations between treatment costs and other measures of clinical value like efficacy and quality of evidence21. Other studies additionally refuted R&D cost or drug development innovation as causes for high margins41,42. These further highlight the lack of transparency in drug pricing and the need for more robust strategies to ensure that costs reflect therapeutic benefits.

Challenges and limitations

Our study focused on the four-year time period from 2017 to 2021, and results may not hold for other time periods. Our findings may over-represent the impact of newly approved and accepted prescription drugs for certain cancer types but not others, as we are only able to capture changes within a limited time period. We were unable to extend the study to earlier time periods because the NCCN Evidence Blocks, essential for determining the highest-recommended treatments for each indication, was not originated for many cancer types until 201743. Despite this limitation, the period between 2017 and 2021 does encompass some of the largest pricing shifts for cancer drugs approved by the FDA and hence was chosen as the most appropriate time range to represent market changes at large.

Our calculations for “complete” therapy—treatments administered for a prespecified number of cycles and priced per entire course—does assume “intention to treat” and hence does not account for treatment discontinuation from adverse effects, progression of disease, or loss to follow up. To the extent that discontinuations occur for real-world patients, our cost measurements might overestimate the true cost of treatment delivery.

Overall, our finding that cancer cost did not change significantly within indications should not be taken to imply that overall costs did not change for patients or the healthcare system as a whole. This study does not attempt to approximate the real world cost of cancer care. For one, we do not take into consideration the prevalence of each cancer type and indication, and it is possible that the indications for which costs increased include a larger number of patients. Stage migration—when staging and diagnostic processes evolve over time and hence alter the standard of care for patients with the same extent of disease—is not reflected in our data. We identified best-available treatments according to NCCN’s EB scoring system, which might not always be those most used by clinicians. To the extent that clinicians might use lower-scoring but more-costly treatments, our results might not hold. Common factors that influence clinicians’ selection of treatment therapy include their experience with existing agents, patients’ comorbidities and preferences44–46, and the delay that often exists between guideline inclusion and clinical adoption47. Lastly, ancillary costs of treatment administration were not included. Some clinical indications may necessitate additional diagnostic testing, such as advanced imaging or genomic sequencing, which would further increase overall costs. For this reason, in some indications our calculated costs may be lower than the true cost of treatment delivery.

CONCLUSION

This study observed an overall increase in absolute median cost of best guideline-concordant therapies from 2017 to 2021. Within indications that were present in both years, we saw minimal relative changes in cost. Although introduction of newly approved drugs can cause large price increases for some indications, the financial cost of the best-available treatment decreased for other indications due to slower-than-inflation price increases and new generic entrants. This study appreciated several existing issues on drug pricing, including higher costs of new regimens and delayed uptake of generic and biosimilar agents into guideline recommendations, which all contribute to high levels of overall cost variability. Our findings continue to highlight the complex landscape of cancer care costs and calls for further research and policy changes.

CONTEXT SUMMARY.

Key objective:

How has the cost of the best guideline-concordant treatments for individual solid tumor cancer treatment indications changed over time?

Knowledge generated:

Median cost of best-available treatment increased by 66% for regimens administered on an ongoing basis and decreased by 14% for those administered for a pre-fixed duration from 2017 to 2021. Within treatment indications, change in cost during this 4 year period was −2%.

Relevance:

Exploring changes in cost on a treatment indications level highlights multiple complex factors that impact cost of care.

Funding sources:

National Cancer Institute (P30 CA008748, to Memorial Sloan Kettering Cancer Center)

Footnotes

Previously presented: ASCO 2024

Disclaimers: none

Contributor Information

Judy J Wang, New York Presbyterian/Weill Cornell Medicine, Department of Medicine.

Sonia Persaud, Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics.

Sara Tabatabai, NORC at the University of Chicago.

Nirjhar Chakraborty, Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics.

Pranam Dey, Brigham and Women’s Hospital.

Niti U Trivedi, Delfi Diagnostics.

Aaron Philip Mitchell, Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology.

REFERENCES

  • 1.Mariotto AB, Robin Yabroff K, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103(2):117–128. doi: 10.1093/JNCI/DJQ495 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Mariotto AB, Enewold L, Zhao J, Zeruto CA, Robin Yabroff K. Medical care costs associated with cancer survivorship in the United States. Cancer Epidemiology Biomarkers and Prevention. 2020;29(7):1304–1312. doi: 10.1158/1055-9965.EPI-19-1534/346908/P/MEDICAL-CARE-COSTS-ASSOCIATED-WITH-CANCER [DOI] [Google Scholar]
  • 3.Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: A population-based cost analysis. Lancet Oncol. 2013;14(12):1165–1174. doi: 10.1016/S1470-2045(13)70442-X [DOI] [PubMed] [Google Scholar]
  • 4.Garaszczuk R, Yong JHE, Sun Z, de Oliveira C. The Economic Burden of Cancer in Canada from a Societal Perspective. Curr Oncol. 2022;29(4):2735–2748. doi: 10.3390/CURRONCOL29040223 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Chen S, Cao Z, Prettner K, et al. Estimates and Projections of the Global Economic Cost of 29 Cancers in 204 Countries and Territories From 2020 to 2050. JAMA Oncol. 2023;9(4):465–472. doi: 10.1001/JAMAONCOL.2022.7826 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Smith GL, Lopez-Olivo MA, Advani PG, et al. Financial Burdens of Cancer Treatment: A Systematic Review of Risk Factors and Outcomes. J Natl Compr Canc Netw. 2019;17(10):1184–1192. doi: 10.6004/JNCCN.2019.7305 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Inguva S, Priyadarshini M, Shah R, Bhattacharya K. Financial toxicity and its impact on health outcomes and caregiver burden among adult cancer survivors in the USA. Future Oncol. 2022;18(13):1569–1581. doi: 10.2217/FON-2021-1282 [DOI] [PubMed] [Google Scholar]
  • 8.Benedict C, Fisher S, Schapira L, et al. Greater financial toxicity relates to greater distress and worse quality of life among breast and gynecologic cancer survivors. Psychooncology. 2022;31(1):9–20. doi: 10.1002/PON.5763 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Koh B, Tan DJH, Ng CH, et al. Patterns in Cancer Incidence Among People Younger Than 50 Years in the US, 2010 to 2019. JAMA Netw Open. 2023;6(8):E2328171. doi: 10.1001/JAMANETWORKOPEN.2023.28171 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Weir HK, Thompson TD, Stewart SL, White MC. Cancer Incidence Projections in the United States Between 2015 and 2050. Prev Chronic Dis. 2021;18:1–8. doi: 10.5888/PCD18.210006 [DOI] [Google Scholar]
  • 11.Fang CY, Frosch ZAK. Understanding and Addressing Cancer Care Costs in the United States. JAMA Netw Open. 2021;4(10):e2127964–e2127964. doi: 10.1001/JAMANETWORKOPEN.2021.27964 [DOI] [PubMed] [Google Scholar]
  • 12.Gordon N, Stemmer SM, Greenberg D, Goldstein DA. Trajectories of Injectable Cancer Drug Costs After Launch in the United States. J Clin Oncol. 2018;36(4):319–325. doi: 10.1200/JCO.2016.72.2124 [DOI] [PubMed] [Google Scholar]
  • 13.Hong SJ, Li EC, Matusiak LM, Schumock GT. Spending on Antineoplastic Agents in the United States, 2011 to 2016. J Oncol Pract. 2018;14(11). doi: 10.1200/JOP.18.00069 [DOI] [Google Scholar]
  • 14.Vokinger KN, Hwang TJ, Daniore P, et al. Analysis of Launch and Postapproval Cancer Drug Pricing, Clinical Benefit, and Policy Implications in the US and Europe. JAMA Oncol. 2021;7(9). doi: 10.1001/JAMAONCOL.2021.2026 [DOI] [Google Scholar]
  • 15.Bennette CS, Richards C, Sullivan SD, Ramsey SD. Steady Increase In Prices For Oral Anticancer Drugs After Market Launch Suggests A Lack Of Competitive Pressure. Health Aff (Millwood). 2016;35(5):805–812. doi: 10.1377/HLTHAFF.2015.1145 [DOI] [PubMed] [Google Scholar]
  • 16.Vokinger KN, Hwang TJ, Daniore P, et al. Analysis of Launch and Postapproval Cancer Drug Pricing, Clinical Benefit, and Policy Implications in the US and Europe. JAMA Oncol. 2021;7(9):e212026–e212026. doi: 10.1001/JAMAONCOL.2021.2026 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Gordon N, Stemmer SM, Greenberg D, Goldstein DA. Trajectories of Injectable Cancer Drug Costs After Launch in the United States. J Clin Oncol. 2018;36(4):319–325. doi: 10.1200/JCO.2016.72.2124 [DOI] [PubMed] [Google Scholar]
  • 18.Cortese BD, Dusetzina SB, Luckenbaugh AN, et al. Projected Savings for Generic Oncology Drugs Purchased via Mark Cuban Cost Plus Drug Company Versus in Medicare. J Clin Oncol. 2023;41(29):4664–4668. doi: 10.1200/JCO.23.00079 [DOI] [PubMed] [Google Scholar]
  • 19.Bachu RD, Abou-Dahech M, Balaji S, et al. Oncology biosimilars: New developments and future directions. Cancer Rep (Hoboken). 2022;5(11). doi: 10.1002/CNR2.1720 [DOI] [Google Scholar]
  • 20.Mitchell AP, Dey P, Ohn JA, Tabatabai SM, Curry MA, Bach PB. The Accuracy and Usefulness of the National Comprehensive Cancer Network Evidence Blocks Affordability Rating. Pharmacoeconomics. 2020;38(7):737–745. doi: 10.1007/S40273-020-00901-X [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Mitchell AP, Tabatabai SM, Dey P, Ohn JA, Curry MA, Bach PB. Association Between Clinical Value and Financial Cost of Cancer Treatments: A Cross-Sectional Analysis. J Natl Compr Canc Netw. 2020;18(10):1349–1353. doi: 10.6004/JNCCN.2020.7574 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Mitchell AP, Persaud S, Meza AM, et al. Quality of Treatment Selection for Medicare Beneficiaries With Cancer. Journal of Clinical Oncology. 2025;43(5):524–535. doi: 10.1200/JCO.24.00459 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.CPI Inflation Calculator. Accessed September 12, 2024. https://www.bls.gov/data/inflation_calculator.htm?os=io.&ref=app
  • 24.ANDA (Generic) Drug Approvals - Previous Years | FDA. Accessed March 28, 2025. https://www.fda.gov/drugs/first-generic-drug-approvals/anda-generic-drug-approvals-previous-years
  • 25.Doebele RC, Drilon A, Paz-Ares L, et al. Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1–2 trials. Lancet Oncol. 2020;21(2):271–282. doi: 10.1016/S1470-2045(19)30691-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Drilon A, Tan DSW, Lassen UN, et al. Efficacy and Safety of Larotrectinib in Patients With Tropomyosin Receptor Kinase Fusion-Positive Lung Cancers. JCO Precis Oncol. 2022;6(6). doi: 10.1200/PO.21.00418 [DOI] [Google Scholar]
  • 27.Carroll CE, Landrum MB, Wright AA, Keating NL. Adoption of Innovative Therapies Across Oncology Practices-Evidence From Immunotherapy. JAMA Oncol. 2023;9(3):324–333. doi: 10.1001/JAMAONCOL.2022.6296 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Scott EC, Baines AC, Gong Y, et al. Trends in the approval of cancer therapies by the FDA in the twenty-first century. Nat Rev Drug Discov. 2023;22(8):625–640. doi: 10.1038/S41573-023-00723-4 [DOI] [PubMed] [Google Scholar]
  • 29.Jenei K, Lythgoe MP, Prasad V. CostPlus and implications for generic imatinib. Lancet Regional Health - Americas. 2022;13:100317. doi: 10.1016/J.LANA.2022.100317 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.EMA Recommends Approval of Generic Carmustine. Accessed September 12, 2024. https://www.esmo.org/oncology-news/archive/ema-recommends-approval-of-generic-carmustine
  • 31.Horn DM, Alpert AE, Duggan MG, Garcia NA, Jacobson M. Biosimilar Competition and Payments in Medicare: The Case of Trastuzumab. JCO Oncol Pract. 2023;19(4):e476–e483. doi: 10.1200/OP.22.00639 [DOI] [PubMed] [Google Scholar]
  • 32.Lee SM, Jung JH, Suh D, et al. Budget Impact of Switching to Biosimilar Trastuzumab (CT-P6) for the Treatment of Breast Cancer and Gastric Cancer in 28 European Countries. BioDrugs. 2019;33(4):423–436. doi: 10.1007/S40259-019-00359-0 [DOI] [PubMed] [Google Scholar]
  • 33.Chai Q, Wen H, Lang Y, Zhang L, Song Y, Liu X. Budget Impact Analysis of the Introduction of a Trastuzumab Biosimilar for HER2-Positive Breast Cancer in China. Clin Drug Investig. 2022;42(11):937–947. doi: 10.1007/S40261-022-01197-9 [DOI] [Google Scholar]
  • 34.Mroczek DK, Hauner K, Greene GJ, et al. Obstacles to Biosimilar Acceptance and Uptake in Oncology: A Review. JAMA Oncol. 2024;10(7). doi: 10.1001/JAMAONCOL.2024.1447 [DOI] [Google Scholar]
  • 35.Peipert JD, Kaiser K, Kircher S, et al. Medical Oncologists’ Knowledge and Perspectives on the Use of Biosimilars in the United States. JCO Oncol Pract. 2023;19(3):e457–e464. doi: 10.1200/OP.22.00502 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Rep. Yarmuth JA [D K 3]. H.R.5376 – 117th Congress (2021–2022): Inflation Reduction Act of 2022. Published online 2022. Accessed September 12, 2024. https://www.congress.gov/bill/117th-congress/house-bill/5376
  • 37.Rome BN, Egilman AC, Kesselheim AS. Trends in Prescription Drug Launch Prices, 2008–2021. JAMA. 2022;327(21):2145–2147. doi: 10.1001/JAMA.2022.5542 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Vokinger KN, Hwang TJ, Grischott T, et al. Prices and clinical benefit of cancer drugs in the USA and Europe: a cost-benefit analysis. Lancet Oncol. 2020;21(5):664–670. doi: 10.1016/S1470-2045(20)30139-X [DOI] [PubMed] [Google Scholar]
  • 39.Trotta F, Mayer F, Barone-Adesi F, et al. Anticancer drug prices and clinical outcomes: a cross-sectional study in Italy. BMJ Open. 2019;9(12). doi: 10.1136/BMJOPEN-2019-033728 [DOI] [Google Scholar]
  • 40.Satoh E, Sasaki Y, Ohkuma R, et al. Lack of correlation between the costs of anticancer drugs and clinical benefits in Japan. Cancer Sci. 2018;109(12):3896–3901. doi: 10.1111/CAS.13831 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Yu NL, Helms Z, Bach PB. R&D Costs For Pharmaceutical Companies Do Not Explain Elevated US Drug Prices. Health Affairs Forefront. doi: 10.1377/FOREFRONT.20170307.059036 [DOI] [Google Scholar]
  • 42.Miljković MD, Tuia J, Olivier T, Haslam A, Prasad V. Cancer Drug Price and Novelty in Mechanism of Action. JAMA Netw Open. 2023;6(12):e2347006–e2347006. doi: 10.1001/JAMANETWORKOPEN.2023.47006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Carlson RW, Jonasch E. NCCN Evidence Blocks. J Natl Compr Canc Netw. 2016;14(5 Suppl):616–619. doi: 10.6004/JNCCN.2016.0177 [DOI] [PubMed] [Google Scholar]
  • 44.Rocque GB, Rasool A, Williams BR, et al. What Is Important When Making Treatment Decisions in Metastatic Breast Cancer? A Qualitative Analysis of Decision-Making in Patients and Oncologists. Oncologist. 2019;24(10):1313–1321. doi: 10.1634/THEONCOLOGIST.2018-0711 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Mohile SG, Magnuson A, Pandya C, et al. Community Oncologists’ Decision-Making for Treatment of Older Patients With Cancer. J Natl Compr Canc Netw. 2018;16(3):301–309. doi: 10.6004/JNCCN.2017.7047 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Grunfeld EA, Ramirez AJ, Maher EJ, et al. Chemotherapy for advanced breast cancer: what influences oncologists’ decision-making? Br J Cancer. 2001;84(9):1172–1178. doi: 10.1054/BJOC.2001.1733 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Khan S, Chambers D, Neta G. Revisiting time to translation: implementation of evidence-based practices (EBPs) in cancer control. Cancer Causes Control. 2021;32(3):221–230. doi: 10.1007/S10552-020-01376-Z [DOI] [PubMed] [Google Scholar]

RESOURCES