These results provide evidence that history of several chronic comorbidities increases risk of FN, which should be considered when managing patients during chemotherapy.

Novel oral targeted drugs are increasingly used for cancer therapy, but their extreme cost, often exceeding $10,000 per month, poses a significant barrier for patients and insurers alike, leading to the potential breakdown of traditional cost-sharing strategies. Insured patients' routine use of charity assistance to supplement their coverage would indicate a major deficiency in the current health care policies. By using data from a specialty pharmacy affiliated with an academic center (1,557 prescriptions dispensed between January 2014 and March 2017), we examined sources of payment for novel oral anticancer agents, distinguishing contributions from health insurance, patients, and from charitable assistance organizations. Thirty-six percent of 211 patients received charity assistance, including 47% of patients who were 65 years old or older. Charity sources covered 4% of total drug costs and 64% of out-of-pocket expenditures. The proportion of patients receiving financial assistance ranged from 7% when the upfront out-of-pocket requirement was less than $100 to 67% when it exceeded $1,000. When patients' out-of-pocket requirement exceeded $1,000, the median direct cash contribution paradoxically fell to $0 because of extensive use of charity support. Receipt of upfront charity assistance was associated with a longer time to filling the first prescription (median 9 v 7 days; P = .011) and with longer overall duration of therapy (median, 261 v 134 days; P = .014). These findings indicate that high out-of-pocket burden for expensive novel oral anticancer drugs leads to widespread use of charity support in the United States and that a significant financial barrier disparately affects older Medicare beneficiaries.

Introduction Guidelines recommend pegfilgrastim for primary prophylaxis of febrile neutropenia after highly myelosuppressive chemotherapy. While deviations from guidelines could result in overuse and increased costs, underuse is also a concern and could compromise quality of care. Our objectives were to evaluate guideline adherence and quantify the extent to which physician heterogeneity may influence pegfilgrastim use. Methods We randomly sampled 550 patients from a retrospective cohort of those who received infusions at an academic cancer center between 1 September 2013 and 1 September 2014. Electronic medical and drug dispensing records provided information on patient characteristics, chemotherapy characteristics, prescribing physician, and pegfilgrastim administration. Results We included 154 patients treated by 25 physicians. About half of patients were male and mean age was 61.3 years. Forty (26.1%) patients had no febrile neutropenia risk factors, 62 (40.5%) had one, and 51 (33.3%) had two or more. Thirty patients (19.5%) received pegfilgrastim, of which 12 (40%) received palliative chemotherapy. Nine (60%) of 15 patients on a regimen with a febrile neutropenia risk  ≥ 20% received pegfilgrastim. Pegfilgrastim use significantly varied by cancer type (p < 0.01), chemotherapy regimen (p < 0.001), and regimen febrile neutropenia risk (p < 0.001). Multivariable analysis reaffirmed the association between chemotherapy regimen febrile neutropenia risk ≥ 20% and pegfilgrastim use (odds ratio (OR) = 10.1, 95% confidence interval (CI): 1.6-62.7) and suggested that 31% (95% CI: 8%-71%) of the variation in use was attributable to physician characteristics. Conclusion Pegfilgrastim was potentially overused for palliative chemotherapy and underused for chemotherapy regimens with febrile neutropenia risk ≥ 20%. Successful interventions to modify prescribing practices likely require an understanding of the relationship between specific physician characteristics and pegfilgrastim use.