Patient, Oncologist, and Payer Preferences for Adjuvant Endocrine Therapy and CDK4/6 Inhibitor Regimens in Early-Stage Breast Cancer: A Discrete Choice Experiment

Figures & data

Figure 1 Example DCE choice task.

Notes: Example of DCE choice task for oncologists. Wording differed between stakeholders; non-clinical language was used in the choice tasks completed by patients and payers.

Abbreviations: DCE, discrete-choice experiment; ECG, electrocardiogram; PO, orally; QD, daily.

Table 1 Attributes and Levels Included in the DCE

Attributes	Definition	Levels
5-year iDFS	Percent of patients are cancer free at 5 years	76%
		83%
		88%
		95%
Nausea (not assessed by payers)	Percent risk of nausea; percent risk of grade 3/4 nausea	64%; 5%
		29%; <1%
		12%; 0%
Diarrhea (not assessed by payers)	Percent risk of diarrhea; percent risk of grade 3/4 diarrhea	81%; 9%
		35%; 1%
		11%; 0%
ECG monitoring		Does not require routine ECG testing to assess heart function because there is no known risk of arrhythmia
		Requires ECG testing to assess heart function 3 times within the first 3 months of treatment to monitor the 6% risk of arrhythmia
Neutropenia	Percent risk of neutropenia; Percent risk febrile neutropenia	66%; 2%
		24%; <1%
		1%; 0%
Alopecia	Percent risk of hair loss (noticeably visible, partial or complete)	34%
		10%
Dosing schedule		One tab, PO., QD for 5 years Two medicines initiated at the same time: One tab, PO, QD for 5 years One pill, PO, QD for 21 consecutive days followed by 7 days off; 28-day cycle is repeated for 2 years
		Two medicines initiated at the same time: One tab, PO, QD for 5 years One pill, PO, QD for 21 consecutive days followed by 7 days off; 28-day cycle is repeated for 1 year
Annual treatment cost per patient (only assessed by payers)		$149,400
		$77,000
		$40,000
		$5,100
GI symptoms (only assessed by payers)	Percent risk of grade 3/4 GI symptoms, including diarrhea, nausea, and/or vomiting, requiring medical intervention and possibly hospitalization	13%
		<1%

Note: The lowest cost level (i.e., $5,100) for the payer DCE reflects the average yearly cost across all hormone monotherapies.

Abbreviations: DCE, discrete choice experiment; ECG, electrocardiogram; GI, gastrointestinal; iDFS, invasive disease-free survival; PO, orally; QD, daily.

Table 2 Sample Characteristics: Patients and Oncologists

Patients
Current age in years, mean (SD)	58.9 (10.1)
Length of time since diagnosis in years, mean (SD)	7.3 (7.1)
AJCC stage at diagnosis, n (%)
Stage II	220 (73.3)
Stage IIIA, IIIB, or IIIC	80 (26.7)
US region of residence, n (%)
Northeast	59 (19.7)
Midwest	86 (28.7)
South	101 (33.7)
West	54 (18.0)
Marital status, n (%)
Committed relationship/married	196 (65.3)
Education, n (%)
College degree or higher	137 (45.7)
Employment status, n (%)
Not employed/retired/other	155 (51.7)
Employed/on leave of absence	145 (48.3)
Community type, n (%)
Rural/small town, population <30,000	101 (33.7)
Major metro/urban/suburban/small city, population ≥30,000	199 (66.3)
Menopausal status, n (%)
Natural menopause	140 (46.7)
Perceived risk of recurrence, n (%)
Low/very low risk	160 (53.3)
Moderate risk	98 (32.7)
High/very high risk	42 (14.0)
Ever received/currently receiving, n (%)
Tamoxifen	157 (52.3)
Anastrozole	168 (56.0)
Letrozole	73 (24.3)
Treatment status, n (%)
Currently receiving treatment	169 (56.3)
Oncologists
Current age in years, mean (SD)	50.5 (10.0)
Years in practice, mean (SD)	16.0 (7.6)
Gender, n (%)
Male	151 (75.4)
Female	38 (19.0)
Other/prefer not to answer	11 (5.5)
Primary specialty, n (%)
Medical oncology	119 (59.5)
Hematology oncology	81 (40.5)
Patients with BC treated by physician in past 3 months, mean (SD)	104.63 (89.2)
Patients with HR+/HER2- eBC treated by physician in past 3 months, mean (SD)	52.03 (53.9)
Patients with eBC physician prescribed adjuvant treatment in past 3 months, mean (SD)	40.41 (46.0)
Percentage of time spent in direct patient care, mean (SD)	92.31 (6.7)
Patients with BC seen/treated in practice in past 3 months, n (%)
<100	64 (32.0)
≥100	136 (68.0)
Practice setting, n (%)
Community-based solo/group practice	104 (52.0)
Outpatient oncology center	36 (18.0)
Academic-based practice	39 (19.5)
NCCN cancer center/other	21 (10.5)
Practice community type, n (%)
Rural/small town, population <30,000	10 (5.0)
Major metro/urban/suburban/small city, population ≥30,000	190 (95.0)

Abbreviations: AJCC, American Joint Committee on Cancer; BC, breast cancer; eBC, early-stage breast cancer; HER2-, human epidermal receptor 2-negative; HR+, hormone receptor positive; NCCN, National Comprehensive Cancer Network; SD, standard deviation; US, United States.

Table 3 Sample Characteristics: Payers

Payers
Current age in years, mean (SD)	55.0 (8.6)
Gender, n (%)
Male	49 (81.7)
Female	10 (16.7)
Prefer not to answer	1 (1.7)
Current position, n (%)
Medical Director/Chief Medical Officer	14 (23.3)
Pharmacy Director or VP/Chief of Pharmacy	40 (66.7)
SVP/VP/Director of Pharmacy Services	3 (5.0)
Clinical Pharmacist	3 (5.0)
Years in current position, mean (SD)	17.9 (5.6)
US region, n (%)
Northeast	11 (18.3)
Midwest	20 (33.3)
South	15 (25.0)
West	14 (23.3)
Type of organization, n (%)
National/regional managed care organization	31 (51.7)
Integrated delivery network	12 (20.0)
Blues affiliate	2 (3.3)
Pharmacy benefits manager	4 (6.7)
Hospital	11 (18.3)
Type of plan benefits managed, n (%)
Pharmacy benefits only	23 (38.3)
Medical benefits only	1 (1.7)
Both pharmacy and medical benefits	36 (60.0)
Number of lives managed with pharmacy benefits, median (IQR)	1,172,290 (5,016,250)
Number of lives managed with medical benefits, median (IQR)	957,500 (4,825,000)
Number of members with eBC covered by plan, median (IQR)	1,000 (4,700)

Abbreviations: eBC, early-stage breast cancer; IQR, interquartile range; SD, standard deviation; SVP, senior vice president; US, United States; VP, vice president.

Figure 2 Preference weights for (A) patients, oncologists and (B) payers.

Notes: Preference weights with 95% CIs were estimated by hierarchical Bayesian logistic regression models with effects coding. *Two medicines initiated at the same time: One tab, PO, QD for 5 years, one pill, PO, QD for 21 consecutive days followed by 7 days off; 28-day cycle is repeated for 2 years. **Two medicines initiated at the same time: One tab, PO, QD for 5 years, one pill, PO, QD for 21 consecutive days followed by 7 days off; 28-day cycle is repeated for 1 year.

Abbreviations: CI, confidence interval, DCE, discrete-choice experiment; ECG, electrocardiogram; G, grade; GI, gastrointestinal; iDFS, invasive disease-free survival, PO, orally; QD, daily.

Figure 3 Improvement in iDFS required to accept a change from the most to the least favorable safety and dosing attribute-levels among patients and oncologists.

Note: Percentage-point increase shown is over the base level of 76% iDFS.

Abbreviations: ECG, electrocardiogram; iDFS, invasive disease-free survival.

Figure 4 Improvement in iDFS required to accept a change from the most to the least favorable safety and dosing attribute-levels among payers.

Note: Percentage-point increase shown is over the base level of 76% iDFS.

Abbreviations: ECG, electrocardiogram; G, grade; GI, gastrointestinal; iDFS, invasive disease-free survival.

Figure 5 Relative attribute importance for patients, oncologists and payers.

Note: Relative importance estimates are shown with 95% CIs.

Abbreviations: CI, confidence interval; DCE, discrete-choice experiment; ECG, electrocardiogram; G, grade; GI, gastrointestinal; iDFS, invasive disease-free survival.