Utilization and cost trends of topical mechlorethamine for cutaneous T-cell lymphoma in the United States: A Medicare part d analysis

Abstract Background: Valchlor (mechlorethamine gel) is a topical chemotherapy used to treat cutaneous T-cell lymphoma (CTCL). Despite its well-established role in CTCL treatment, limited data exist on its real-world use and cost trends across different provider types and geographic regions. Methods: We examined Centers for Medicare and Medicaid Services Medicare Part D prescriber-level data from 2018-2023 to identify trends in Valchlor prescribing. We analyzed total claims, total drug costs, and average cost per claim. Comparisons were made among provider specialties (e.g., dermatology vs. hematology-oncology vs. physician assistant) and across U.S. states. Statistical tests, including t-tests and ANOVA, were used to evaluate differences in cost per claim among subgroups. Results: In 2023, only 44 individual prescribers met the Medicare Part D public reporting threshold by submitting >10 Valchlor claims. In 2023, the top five states with the highest number of Valchlor prescriptions were New York (161 claims), California (104), Missouri (71), Ohio (62), and Connecticut (52). The top five prescribing cities were New York, NY (90 claims), Fairport, NY (59), New Haven, CT (52), Saint Louis, MO (46), and Chicago, IL (41). From 2018-2023, 3,945 Valchlor prescriptions were submitted to Medicare Part D. Dermatologists accounted for 3,113 (79% of total) claims, with an average cost per claim of ~$7,220. Physician assistants submitted 291 (7%) claims, averaging $6,097 per claim, while hematology-oncology specialists submitted 250 (6%) claims, with the highest average cost per claim at $9,346. Dermatologists, on average, wrote more Valchlor claims per prescriber than hematologist-oncologists (20.4 vs 12.1 claims per prescriber). Overall, the number of claims increased by 8.2%/year on average, and the cost per claim rose by 5.1% annually, indicating both growing utilization and rising cost. We further evaluated cost disparity by geographic distribution. States with the highest average cost per claim included Michigan ($17,193) and New Jersey ($13,740), while Indiana ($3,955) and Oregon ($4,184) had the lowest. A one-way ANOVA confirmed that these geographic differences were statistically significant (p < 0.001). These findings emphasize notable variation in Valchlor pricing and reimbursement across regions. There was no correlation between the cost per claim of Valchlor and the median household income of the state. There was also no relationship between the number of claims in a state and that state's average cost per claim. Almost all (99.4%) claims originated in a state where there is a treatment center recognized by the Cutaneous Lymphoma Foundation (CLF), and 64.87% originated in a city with a CLF-recognized treatment center. Conclusion: Valchlor remains a valuable therapy for CTCL; however, its rising cost and variable prescribing patterns warrant closer scrutiny, suggesting opportunities to improve prescribing practices and reduce overall costs. These data provide a foundation for further evaluation of real-world usage and can inform future value-based care strategies in CTCL management.