RALOXIFENE Generic Brand HICL GCN Exception/Other RALOXIFENE EVISTA Is the request for the prevention (risk reduction) of breast cancer?

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1 Generic Brand HICL GCN Exception/Other RALOXIFENE EVISTA GUIDELINES FOR USE 1. Is the request for the prevention (risk reduction) of breast cancer? If yes, continue to #2. If no, approve by HICL for 12 months (standard copay rates still applies). APPROVAL TEXT: According to our Pharmacy & Therapeutics Committee approved prior authorization guidelines for RALOXIFENE, in order to qualify for $0 copay, approval requires the diagnosis of breast cancer prevention in women who are at increased risk.. 2. Is the patient female? If yes, continue to #3. If no, do not approve. DENIAL TEXT: According to our Pharmacy & Therapeutics Committee approved prior authorization guidelines for RALOXIFENE, in order to qualify for $0 copay, approval requires the diagnosis of breast cancer prevention in women who are at increased risk.). 3. Is the patient considered to be at increased risk for breast cancer (e.g. an estimated 5-year breast cancer risk of 3% or greater)? If yes, approve by HICL for 5 years for $0 co-pay. If no, do not approve. DENIAL TEXT: According to our Pharmacy & Therapeutics Committee approved prior authorization guidelines for RALOXIFENE, in order to qualify for $0 copay, approval requires the diagnosis of breast cancer prevention in women who are at increased risk.

2 RATIONALE To be compliant with the Affordable Care Act and cover at no cost preventative medicine for breast cancer in women who are at increased risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. (B recommendation) The USPSTF recommends against the routine use of medications, such as tamoxifen or raloxifene, for risk reduction of primary breast cancer in women who are not at increased risk for breast cancer. (D recommendation) Breast cancer is the most common nonskin cancer in women. An estimated 232,340 new cases will be diagnosed in 2013, and 39,620 women will die of the disease (1). In the United States, mortality rates are highest among African American women. Screening for breast cancer may allow for early detection but does not prevent the development of the disease. CLINICAL CONSIDERATIONS The National Cancer Institute has developed a Breast Cancer Risk Assessment Tool (available at that is based on the Gail model and estimates the 5-year incidence of invasive breast cancer in women on the basis of characteristics entered into a risk calculator. This tool helps identify women who may be at increased risk for the disease. Other risk assessment models have been developed by the Breast Cancer Surveillance Consortium (BCSC), Rosner and Colditz, Chlebowski, Tyrer and Cuzick, and others (5-7). Examples of risk factors elicited by risk assessment tools include patient age, race or ethnicity, age at menarche, age at first live childbirth, personal history of DCIS or LCIS, number of firstdegree relatives with breast cancer, personal history of breast biopsy, body mass index, menopause status or age, breast density, estrogen and progestin use, smoking, alcohol use, physical activity, and diet. These models are not recommended for use in women with a personal history of breast cancer, a history of radiation treatment to the chest, or a possible family history of mutations in the BRCA1 or BRCA2 genes. Only a small fraction of women are at increased risk for breast cancer. Most who are at increased risk will not develop the disease, and most cases will arise in women who are not identified as being at increased risk. Risk assessment should be repeated when there is a significant change in breast cancer risk factors.

3 CLINICAL CONSIDERATIONS (CONTINUED) There is no single cutoff for defining increased risk. Most clinical trials defined increased risk as a 5-year risk for invasive breast cancer of 1.66% or greater, as determined by the BCPT (Breast Cancer Prevention Trial). At this cutoff, however, many women would not have a net benefit from risk-reducing medications. Freedman and colleagues (8) developed risk tables that incorporate the BCPT estimate of a woman's breast cancer risk as well as her age, race or ethnicity, and presence of uterus. On the basis of the Freedman risk benefit tables for women aged 50 years or older (Figures 1 to 4), the USPSTF concludes that many women with an estimated 5-year breast cancer risk of 3% or greater are likely to have more benefit than harm from using tamoxifen or raloxifene, although the balance depends on age, race or ethnicity, the medication used, and whether the patient has a uterus (8). SUPPORTING CLINICAL DATA To understand the effectiveness of risk-reducing medications for breast cancer, the USPSTF reviewed 7 large randomized, controlled trials of breast cancer outcomes in women without preexisting breast cancer. Other relevant study outcomes included death, fractures, thromboembolic events, cardiovascular disease events, uterine abnormalities, cataracts, and other adverse effects. STAR (Study of Tamoxifen and Raloxifene) was a head-to-head comparison of tamoxifen versus raloxifene with more than 9800 patients in each study group. Four studies compared tamoxifen with placebo: NSABP-1 (National Surgical Adjuvant Breast and Bowel Project), IBIS-I, the Royal Marsden Hospital trial and the Italian Tamoxifen Prevention Study. Two studies compared raloxifene with placebo: the Multiple Outcomes of Raloxifene Evaluation study, with long-term follow-up in the Continuing Outcomes Relevant to Evista study, and the Raloxifene Use for the Heart trial. These were all multicenter trials that were relevant to primary care. They enrolled between 2471 and 19,747 women, predominantly in North America, Europe, and the United Kingdom. All trials met criteria for fair or good quality as well as high applicability to the U.S. primary care population. For STAR, eligibility criteria included having a 5-year predicted breast cancer risk of 1.66% or greater; median follow-up was 81 months. For the placebo-controlled trials involving tamoxifen, eligibility criteria and duration of follow-up varied. Eligibility criteria for NSABP-1 included having a 5-year predicted breast cancer risk of 1.66% or greater and median follow-up was about 7 years. Eligibility criteria for IBIS-I included having an estimated 10-year risk of 5% or greater; median follow-up was 96 months. For the Royal Marsden Hospital and Italian Tamoxifen Prevention trials, eligibility criteria did not include a prespecified breast cancer risk threshold, and median follow-up was 13 and 11 years, respectively. For placebo-controlled trials involving raloxifene (Multiple Outcomes of Raloxifene Evaluation and Continuing Outcomes Relevant to Evista), eligibility criteria did not include a prespecified breast cancer risk threshold; together, these trials provided 8 years of follow-up. In placebo-controlled trials, tamoxifen and raloxifene significantly reduced the risk for invasive breast cancer (tamoxifen RR, 0.70 [95% CI, 0.59 to 0.82] raloxifene RR, 0.44 [95% CI, 0.27 to 0.71]. In STAR, tamoxifen reduced breast cancer more than raloxifene (raloxifene RR, 1.24 [95% CI, 1.05 to 1.47]).

4 SUPPORTING CLINICAL DATA (CONTINUED) Both medications reduced breast cancer in all subgroups studied, although trial data for racial subgroups were not available. Tamoxifen reduced breast cancer outcomes in subgroups based on age, menopausal status, estrogen use, family history of breast cancer, and history of LCIS or atypical ductal hyperplasia. In NSABP-1, tamoxifen was most effective in preventing invasive breast cancer in high-risk groups, including women with LCIS, atypical ductal hyperplasia, the highest Gail risk scores, and the greatest number of relatives with breast cancer. Raloxifene reduced breast cancer outcomes in subgroups based on age, age at menarche, parity, age at first live childbirth, and body mass index. Effect estimates for raloxifene were limited by small sample size for subgroups based on prior estrogen use, family history of breast cancer, and prior hysterectomy or oophorectomy. Specific risk factors may be more useful than risk calculators in certain clinical settings. Both medications reduced breast cancer risk in postmenopausal women. Tamoxifen also reduced the incidence of invasive breast cancer in premenopausal women who were at increased risk for the disease. Risk reduction with tamoxifen was greatest in women with 3 or more first-degree relatives with breast cancer, LCIS, or atypical hyperplasia. Reduction of invasive breast cancer continued for at least 3 to 5 years after discontinuation of tamoxifen in the 2 trials providing post treatment follow-up data. Neither medication significantly reduced the risk for ER-negative breast cancer, noninvasive breast cancer, or all-cause mortality. In the placebo-controlled trials and STAR, raloxifene reduced vertebral fractures (RR, 0.61 [95% CI, 0.54 to 0.69]), whereas tamoxifen reduced nonvertebral fractures (RR, 0.66 [95% CI, 0.45 to 0.98]). Tamoxifen and raloxifene had similar effects on vertebral fractures in STAR. The USPSTF could not assess the effect of these medications on mortality attributed to breast cancer or other causes. The effects of tamoxifen and raloxifene on mortality were not statistically significant in the clinical trials, which did not have sufficient long-term follow-up for this outcome. Although there is convincing evidence that these medications can reduce the incidence of invasive breast cancer (predominantly ER-positive cancer), whether reductions in breast cancer incidence lead to a corresponding reduction in mortality is unclear. The USPSTF also considered meta-analysis summary calculations of the number of events reduced per 1000 women in placebo-controlled trials, assuming 5 years of treatment. Both medications reduced the incidence of invasive breast cancer, with 7 fewer events per 1000 women for tamoxifen (4 trials) and 9 fewer events per 1000 women for raloxifene (2 trials). When compared head-to-head in STAR, tamoxifen reduced breast cancer incidence by 5 more events per 1000 women than raloxifene. Compared with placebo, raloxifene reduced the incidence of vertebral fractures by 7 events per 1000 women (2 trials), whereas tamoxifen reduced the incidence of nonvertebral fractures by 3 events per 1000 women (1 trial). There were no significant differences in vertebral fractures when the drugs were compared head-tohead in STAR. FDA APPROVED INDICATIONS Tamoxifen and raloxifene are selective estrogen receptor modulators that have been shown in randomized, controlled trials to reduce the risk for estrogen receptor (ER) positive breast cancer. They have been approved by the U.S. Food and Drug Administration (FDA) for this indication.

5 Tamoxifen and raloxifene have multiple FDA approved indications, please see prescribing information for further information.

6 SAFETY The USPSTF found adequate evidence that tamoxifen and raloxifene increase risk for venous thromboembolic events (VTEs) by 4 to 7 events per 1000 women over 5 years and that tamoxifen increases risk more than raloxifene. The USPSTF found that potential harms from thromboembolic events are small to moderate, with increased potential for harms in older women. The USPSTF also found adequate evidence that tamoxifen but not raloxifene increases risk for endometrial cancer (4 more cases per 1000 women). Potential harms from tamoxifen-related endometrial cancer are small to moderate and depend on hysterectomy status and age. The potential risks for tamoxifen-related harms are higher in women older than 50 years and in women with a uterus. Tamoxifen may also increase the incidence of cataracts. Vasomotor symptoms (hot flashes) are a common adverse effect of both medications that is not typically classified as serious, but these symptoms may affect a patient's quality of life and willingness to use or adhere to these medications. Tamoxifen is not recommended for use in combination with hormone therapy or hormonal contraception or in women who are pregnant, those who may become pregnant, or breastfeeding mothers. DOSAGE Selective estrogen receptor modulators (tamoxifen and raloxifene) have been shown to reduce the incidence of invasive breast cancer in several randomized, controlled trials. Tamoxifen has been approved for this use in women aged 35 years or older, and raloxifene has been approved for this use in postmenopausal women. The usual daily doses for tamoxifen and raloxifene are 20 mg and 60 mg, respectively, for 5 years. REFERENCES Nolvadex [Prescribing Information]. Wilmington, DE: Astra Zeneca Pharmaceuticals.; September Evitsa [Prescribing Information]. Indianapolis, IN: Eli Lilly and Company; September The Center for Consumer Information & Insurance Oversight. FAQs/aca_implementation_faqs18.html [Accessed on 4/25/14]. Medications for Risk Reduction of Primary Breast Cancer in Women: U.S. Preventive Service Task Force Recommendation Statement. m [Accessed on 4/25/14]. Commercial HIEx X Created: 08/15 Effective: 02/01/16 Client Approval: 01/13/16 P&T Approval: 01/16