Neuroblastoma is a tumor that develops from nerve tissue, most commonly in the adrenal glands, and affects mostly infants and young children. It is staged I-IV and categorized as low-risk, intermediate-risk and high risk.
– Children with low-risk disease can be treated with surgery, and a complete resection is usually achieved.
– Intermediate-risk disease treatment includes combined chemotherapy and surgical resection.
– For children with high-risk neuroblastoma, there have been substantial improvements with aggressive combination modalities. These generally include chemotherapy, surgical resection, high-dose chemotherapy with stem cell rescue, radiation therapy and biologic/immunologic therapy (e.g., Unituxin® (dinutuximab*)). These approaches have improved event-free survival, but unfortunately, many are at high risk for relapse of their disease.
Let me share a brief summary of two high-claim cases we have followed recently. In cases like these, it’s difficult to anticipate ongoing costs.
CLAIMANT # 1:
Imagine having a newborn just four months old diagnosed with stage IV neuroblastoma per exploratory laparotomy, liver biopsy and bone marrow biopsy. The chemo regimen required inpatient confinement, then another confinement for low blood counts. Two months later, after chemo was completed, they began stem cell harvesting in preparation for the planned autologous stem cell transplant. Scans showed residual tumor with incomplete response and the baby was admitted for excision of the residual tumor. High dose chemo and autologous stem cell transplant followed surgical recovery.
This young child unfortunately had suffered post stem cell transplant complications and required home TPN, but was eventually weaned off and able to undergo radiation to the liver and primary site. With reevaluation and family conference, the decision was made to proceed with immunotherapy treatment regime with Unituxin® (dinutuximab*). This required inpatient care for the infusion therapy and paid claims varied from $65,000 to $175,000 per admit. Post treatment complications required acute care, but by August, the medical team was able to report no recurrence or progression!
The outcome was the good news, thanks to the fact there was a global transplant policy that covered the autologous stem cell transplant.
The bad news was the claims incurred.
– In 2015, the seven months of treatment (excluding the stem cell transplant, which was covered by the global contract) billed charges were $763,196. The TPA paid $341,644 from ground up.
– In 2016, with six months of treatment, billed charges were $1.6 million and the TPA paid $750,000.
This seven-year-old was diagnosed with high-risk neuroblastoma in mid-summer 2015 and began treatment with induction chemo, requiring multiple hospital admits followed by surgical resection/adrenalectomy with lymph node dissection in late November. A tandem autologous stem cell transplant after recovery was also planned, with an Optum transplant contract placed with Boston Children’s Hospital.
The child was admitted in March 2016 for the first stem cell transplant (paid $280,000) and readmitted the next month for the second stem cell transplant (paid $203,000). Post-transplant chemo of five cycles began in July, requiring four to five days of inpatient care. She was hospitalized for 18 days in August (paid $140,000) with hypertension and thrombotic microangiopathy (clots in small blood vessels) and has been treated with the monoclonal antibody Soliris® (eculizumab). Other complications required inpatient care and intensive outpatient care, and the eculizumab treatments remain ongoing every two weeks ($35,000 to $40,000 per treatment).
– Claims in 2015 billed $825,000 and the TPA paid $425,000.
– Claims in 2016 billed $2,176,303 and the TPA paid $1.8 million. Claims will be ongoing in 2017.
Although treatment outcomes are dependent on tumor characteristics, age and extents of metastasis, it is interesting to note that infants less than one year of age have a better survival rate than older children.
*On March 10, 2015 the U.S. Food and Drug Administration (FDA) approved dinutuximab, which is a monoclonal antibody against GD2, for use in the treatment of high-risk neuroblastoma. It was approved as part of a multimodality regimen, including surgery, chemotherapy, and radiation therapy, for patients who have achieved at least a partial response to prior first-line multiagent. It is indicated in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA) for pediatric patients with high-risk neuroblastoma.