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Cost Considerations in Non-Driver NSCLC Management

Insights From:Anders Mellemgaard, MD, Herlev University Hospital; Sanjay Popat, PhD, FRCP, The Royal Marsden Hospital;Martin Reck, MD, PhD, Hospital Grosshansdorf
Published: Monday, Dec 19, 2016


Transcript:

Martin Reck, MD, PhD:
Treatment has changed in patients with lung cancer, and treatment has currently particularly changed in the management of pretreated patients, of second-line patients. We have new treatment options, and sometimes we are obliged to also consider cost factors. It’s difficult to make a decision based on a cost factor. I think what is important for this decision is to figure out the patient with the highest chance for response to the adequate treatment. And for this, the PD-L1 status might be a supportive factor. On the other hand, PD-L1 negativity is not an exclusion factor for immunotherapy.

And the other thing is to look at additional clinical factors, like tumor dynamics, to make an adequate cost-conscious decision on the treatment combination that you are going to offer the patients. Furthermore, what you have to take into account is the general status of the patient, whether this is a patient in a good stage or whether we are talking about a patient in a reduced performance status where perhaps only immunotherapy is feasible.

Currently, the question whether there is a reimbursement of the PD-L1 assessment is under discussion. But I’m quite convinced that in the future, we will have a reimbursement for PD-L1 testing, and it’s an immune histochemical test. So, it’s not a very expensive test that we are requiring from our pathologists.

Sanjay Popat, PhD: There are several cost considerations to take into account when considering treatment options in the second-line setting. One does need to consider the cost of PD-L1 testing. And, indeed, this is something that needs to be talked about up front because these days, PD-L1 testing should be done at point of diagnosis. So, at the point at which the patient relapses, we should already have a good understanding of what the PD-L1 status is. There are some emerging data that are coming out which demonstrate that the PD-L1 status may change. And in some patients, one may want to re-biopsy if clinically feasible to retest the PD-L1 status, particularly if it was low at presentation. One needs to factor in the clinical decision-making process, the time taken for the testing, whilst the patient is in need of treatment.

One needs to consider the PD-L1 status because that may mean that the patient might be better off with immunotherapy. For example, if the PD-L1 status is high, say 10% or more, or potentially if the PD-L1 status is low, the patient may be better off with docetaxel. And in that setting, one needs to consider the best partner with that. When partnering docetaxel with oral therapy, that avoids chair time, it avoids intravenous time and preparation time in the pharmacy associated with that administration. So, therefore, there are some overall cost savings associated with the use of an oral angiokinase inhibitor rather than the intravenous one.

Anders Mellemgaard, MD: Obviously, with any treatment, there is a cost consideration also. We do know that cancer therapy is expensive, and the newer treatments that we’re getting are really expensive. I come from a country, Denmark, where the healthcare is provided by the state. So, it’s not an individual insurance issue whether a patient can have a particular treatment. But it is a community problem that treatments are getting more expensive.

So, there is regulation in different communities, and there is the issue about reimbursement. And the issue about reimbursement is not only about treatment, it’s also about testing. For example, if you have a biopsy and you want to send it off to a test for PD-L1, in some cases, that test is not reimbursed. Obviously, if you need that test, then that has an effect on whether to use these compounds or not. But I think it’s important that when the insurers are thinking about reimbursement, they think into the whole economic picture here that good treatment relies on good tissue of biopsies and good testing of the material that we have.

Transcript Edited for Clarity
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Transcript:

Martin Reck, MD, PhD:
Treatment has changed in patients with lung cancer, and treatment has currently particularly changed in the management of pretreated patients, of second-line patients. We have new treatment options, and sometimes we are obliged to also consider cost factors. It’s difficult to make a decision based on a cost factor. I think what is important for this decision is to figure out the patient with the highest chance for response to the adequate treatment. And for this, the PD-L1 status might be a supportive factor. On the other hand, PD-L1 negativity is not an exclusion factor for immunotherapy.

And the other thing is to look at additional clinical factors, like tumor dynamics, to make an adequate cost-conscious decision on the treatment combination that you are going to offer the patients. Furthermore, what you have to take into account is the general status of the patient, whether this is a patient in a good stage or whether we are talking about a patient in a reduced performance status where perhaps only immunotherapy is feasible.

Currently, the question whether there is a reimbursement of the PD-L1 assessment is under discussion. But I’m quite convinced that in the future, we will have a reimbursement for PD-L1 testing, and it’s an immune histochemical test. So, it’s not a very expensive test that we are requiring from our pathologists.

Sanjay Popat, PhD: There are several cost considerations to take into account when considering treatment options in the second-line setting. One does need to consider the cost of PD-L1 testing. And, indeed, this is something that needs to be talked about up front because these days, PD-L1 testing should be done at point of diagnosis. So, at the point at which the patient relapses, we should already have a good understanding of what the PD-L1 status is. There are some emerging data that are coming out which demonstrate that the PD-L1 status may change. And in some patients, one may want to re-biopsy if clinically feasible to retest the PD-L1 status, particularly if it was low at presentation. One needs to factor in the clinical decision-making process, the time taken for the testing, whilst the patient is in need of treatment.

One needs to consider the PD-L1 status because that may mean that the patient might be better off with immunotherapy. For example, if the PD-L1 status is high, say 10% or more, or potentially if the PD-L1 status is low, the patient may be better off with docetaxel. And in that setting, one needs to consider the best partner with that. When partnering docetaxel with oral therapy, that avoids chair time, it avoids intravenous time and preparation time in the pharmacy associated with that administration. So, therefore, there are some overall cost savings associated with the use of an oral angiokinase inhibitor rather than the intravenous one.

Anders Mellemgaard, MD: Obviously, with any treatment, there is a cost consideration also. We do know that cancer therapy is expensive, and the newer treatments that we’re getting are really expensive. I come from a country, Denmark, where the healthcare is provided by the state. So, it’s not an individual insurance issue whether a patient can have a particular treatment. But it is a community problem that treatments are getting more expensive.

So, there is regulation in different communities, and there is the issue about reimbursement. And the issue about reimbursement is not only about treatment, it’s also about testing. For example, if you have a biopsy and you want to send it off to a test for PD-L1, in some cases, that test is not reimbursed. Obviously, if you need that test, then that has an effect on whether to use these compounds or not. But I think it’s important that when the insurers are thinking about reimbursement, they think into the whole economic picture here that good treatment relies on good tissue of biopsies and good testing of the material that we have.

Transcript Edited for Clarity
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