Panelists:Raoul S. Concepcion, MD, FACS, Urology Associates; Michael D. Fabrizio, MD, FACS, Eastern Virginia Medical School; Jorge A. Garcia, MD, FACP, Taussig Cancer Institute; Judd W. Moul, MD, FACS, Duke University Medical Center; Charles J. Ryan, MD, UCSF Helen Diller Family Comprehensive Cancer Center
Michael Fabrizio, MD, FACS: There is one thing I think we should mention, it’s kind of the elephant in the room. There’s always someone in the room or multiple urologists in the room who start talking about cost of therapy. And it’s not just Provenge, which is, on average, $31,000 an infusion for 3 infusions. It’s all the other drugs we’ve mentioned today. There are oftentimes somebody saying, well, why are we spending so much on this disease. And I think it’s imperative for us to tell the urologists, they should probably not get involved in those conversations. They need to look at the evidence of what we’re doing for the patients. We have no control over those costs. Those costs shouldn’t be in the discussion with patient care, in my opinion, but I think it’s an important thing to bring up.
Judd W. Moul, MD, FACS: It’s certainly not fair to make Provenge the whipping boy for cost because, as you say, that’s not the only expensive one. They’re all in the same ball park.
Jorge A. Garcia, MD, FACP: I think the challenge with that point is the fact that any other agent has actually shown response. We like to see reductions in PSA or reductions in tumor size and so forth. But, if you look, for instance, at a patient who has asymptomatic metastatic castration resistant prostate cancer (CRPC), that patient today is a candidate for IMPACT, that patient is a candidate for COUGAR 302, that patient is a candidate for PREVAIL, that patient is a candidate for chemotherapy, and in the absence of symptoms, let’s assume not radium-223.
So my challenge when I’m making those choices is whether I should use sipuleucel-T?. Because if I were to say, okay, I’m going to put you on sipuleucel-T, or abiraterone, or enzalutamide, who would win in that decision? So that’s why with the absence of PSA declines, when you get sipuleucel-T, smart people have thought about, well, how are we going to circumvent that. And there are enough data right now to suggest that even if you actually use an oral compound, abiraterone or enzalutamide, you’re not actually abrogating the benefits of sip-T in that context.
Charles J. Ryan, MD: I would address the cost issue in the following way: I don’t worry so much about the dollar cost. I worry a lot about the economy of these therapies. In other words, what I mean by that is, all these therapies we’re talking about, we’re talking about data that were generated in studies designed to get the drug approved by the FDA. So that’s kind of a different goal from what we have every day in the clinic, which is optimally managing a patient. And what Judd brought out, which is really interesting, is if you give sipuleucel-T in that sweet spot, it’s very cost effective. If you’re giving it not in that sweet spot in the situation where it’s not going to benefit a patient, you’re wasting money. And so, I think, the key thing is to not focus on the cost of the therapies that we’re giving but the cost of giving them in the smartest way at the right time.
Judd W. Moul, MD, FACS: Just to follow up on the quartile data, if you look at the third and fourth quartiles, basically PSAs above 75 or 150, the hazard ratio was essentially null. So I agree 100%, it should be given when it has the most chance of working.
Charles J. Ryan, MD: There’s a tendency for people to think we have many therapy options, and all of my patients are going to get every dish on the menu, so to speak. And that’s not the right way to do things. I mean, if we’ve already given a patient docetaxel and they’ve progressed, this isn’t the time to bring in the sipuleucel. You missed that window, and you move on.
Raoul S. Concepcion, MD, FACS: And clearly I think we would all agree that this is where there was this huge unmet need to have prognostic and predictive biomarkers to help us guide these decisions.
Transcript Edited for Clarity