Market Outlook

Clinical pathways, which establish optimal treatment protocols for specific patient populations based on the best evidence, have become increasingly prevalent in the treatment of cancer as payers and oncology practices seek to standardize best care and control costs. Breast cancer is among the cancers considered top priority for pathways programs. This report examines the application of clinical pathways for metastatic HER2+, HR+/HER2-, and triple-negative breast cancer therapies and explores payer reimbursement policies for current and emerging drugs and their impact on oncologists’ prescribing. The report also investigates the potential for reimbursement and oncologists’ likely uptake of biosimilars of trastuzumab (Herceptin).

Questions Answered

  • Which drugs are oncologists permitted to prescribe according to MCOs’ and oncology practices’ clinical pathways programs for each of the three breast cancer subtypes in the first, second, and third and later lines of treatment?
  • Which third-party vendors and other stakeholders are influencing clinical pathways programs, and how are these programs structured by MCOs and oncology practices to encourage selection of on-pathway products?
  • Which breast cancer therapies are preferred on the formularies of the largest commercial plans of surveyed MCOs, and why are they preferred over competitors?
  • What clinical and market access factors most influence prescribers’ selection of breast cancer drugs currently on the market and those in development for HER2+, HR+/HER2-, and triple-negative subtypes?


United States

Primary research

Survey of 101 U.S. oncologists and 40 U.S. managed care organization (MCO) pharmacy and medical directors (PDs/MDs)

Key drugs covered

Current therapies: Afinitor, Avastin, Faslodex, Halaven, Herceptin, Ibrance, Kadcyla, Kisqali, Lynparza, Perjeta, Talzenna, Tykerb, Verzenio

Emerging therapies: alpelisib, margetuximab, tucatinib, Tecentriq

Content highlights

  • Reimbursement and contracting.
  • Access and prescribing.
  • Special topic: Breast cancer and clinical pathways opportunities and challenges for emerging therapies.


U.S. Access & Reimbursement provides in-depth insight on the impact of payer policy on prescribing behavior so that clients can build their market access strategy and optimize their brand positioning. This analysis of primary market research with physician specialists and U.S. payers helps clients stay up-to-date on restriction policies, gauge payer and prescriber attitudes toward specific therapies, identify opportunities where brands can capture patient share through market access, and maximize opportunities for emerging therapies by learning how previous brands gained favorable reimbursement or why they stumbled.

Table of contents

  • Detailed, Expanded Analysis: Special Focus on Breast Cancer: Use of Clinical Pathways (US)
    • Access & Reimbursement Breast Cancer US April 2019

Author(s): Chris Lewis

Chris Lewis serves as primary research manager, Access and Reimbursement, with responsibility for coordination, content review and content generation of the market access and reimbursement insights at DRG. Content is based on online surveys of managed care organizations and physicians and expert analysis of reimbursement and prescribing patterns of key therapies treating various disease states. Lewis was an analyst/senior analyst for the group’s HealthLeaders-InterStudy subsidiary for eight years, specializing in the managed care and pharmacy benefit management industries. Throughout her tenure, she has produced the Health Plan Analysis reports for California, New York, New Jersey, Connecticut, and Pennsylvania and authored DRG’s series of pharmacy benefit manager profiles. She has also conducted numerous webinars for the group. She is a seasoned journalist with a in communications from California State University, Sacramento.

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