Considering Real-World Outcomes in NSCLC

Bhuvana Sagar, MD: In lung cancer, we have immunotherapies that have been approved, and they’ve added, significantly, to the total cost of care. Chemotherapy, by itself, was running in the thousands of dollars. When you added supportive care, it added, significantly, to the cost. Targeted therapy added another layer of complexity, and so did VEGF (vascular endothelial growth factor) inhibitors.

Now, we’re in the era of immunotherapy drugs. Immunotherapy drugs have added significantly to the cost pressure, overall. And while they improve survival in a small subset of patients (maybe 20% or 25% of patients have long-term survival benefit) it would be ideal if we can identify those patients who benefit from the drug and not have to treat everybody. That would be the ideal situation (like with Herceptin [trastuzumab]). If you’re able to target patients who have HER2-positive cancers, and you benefit them, that’s great. But at this point, I don’t think we have been able to identify who clearly benefits. We know that patients who have greater than 50% PD-L1 (programmed death-ligand 1)—positive tumors benefit more than the patients who have less positive tumors. Beyond that, it has not been a clear influence on treatment decisions.

At this time, we are not making coverage determinations based on cost only. We are making coverage decisions based on clinical trial evidence and if there is benefit to doing the therapy. So, we don’t deny a drug just because it is expensive or cover a drug just because it is cheap (at this point). We would like to drive affordability, if there are 2 different drug regimens and they both offer similar survival benefit, ideally. There should be a reason as to why we are not choosing the more affordable regimen. But at this time, we do not make coverage decisions based on only cost.