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Biosimilar Use in the Treatment of NSCLC

Panelists: Adam M. Brufsky, MD, PhD, M University of Pittsburgh; Kashyap Patel, MD, Carolina Blood and Cancer Care; Lee Schwartzberg, MD, FACP, West Cancer Center
Published: Wednesday, Mar 25, 2020



Transcript: 

Adam M. Brufsky, MD, PhD: Let’s move on with a specific example. I think that in your practice, we have the biosimilar bevacizumab now. How did you end up adopting the biosimilar bevacizumab in your practical practice for metastatic lung cancer, for example?

Kashyap Patel, MD: Again, I really want to share my expertise as well as my opinion on the role the biosimilar can play in addressing Medicare Part B drug price. We are an oncology care model [OCM] practice, and one of the foundations of OCM is to maintain the quality of care or improve it, improve patient experience, reduce the cost of care. I cannot not offer a patient what they deserve even if it’s expensive. But when I have a choice, for example, in stage IV lung cancer, we have a large population of stage IV non–small cell lung cancer that we treat at our clinic being in South Carolina, in the tobacco belt.

So, bevacizumab has played a significant role because we’re able to reduce the cost, ASP [average sales price], and what we project is that by 2021 December, my total drug spending will go down by about 15% to 17%. And it’s based on the fact that the history of biosimilars has shown in the last 2 years, that within 2 years the ASP drops about 30% to 35%. Fifty percent of my total drug budget is in biologics. So, when I extrapolate 35% savings in the biologics, my total drug budget would go down by 15%, which is almost $1 million-plus savings to us. And we feel that we can be part of playing the role of a steward or trustee of the society by helping to spend less without compromising the care.

At the same time, what we don’t realize is a lot of patients who are living paycheck to paycheck with Medicare only, even a 30% reduction in that out-of-pocket cost could save them $100 a month. It may not sound like a whole lot to me and you sitting here, but when you look at a typical traditional elder-age patient who lives either in South Carolina, Mississippi, Georgia, in that part of the country, who has to drive 30 miles 1 way, a saving of $100 would be about 8% of their paycheck from Medicare. That’s a huge saving for them as an out-of-pocket cost.

Adam M. Brufsky, MD, PhD: I totally agree with you. I think that the issue is this is a big deal, not only for the patients but actually for the practices as well. One thing that we, and I’ll get into this when we talk about trastuzumab in our practice, the question I have is you probably have some 340B drug pricing programs. Do you have 340B hospitals or not in your practice?

Kashyap Patel, MD: We are not. We are independent.

Adam M. Brufsky, MD, PhD: You’re not, okay. We’ll talk about that because that’s a big question because the whole 340B system is totally different.

Kashyap Patel, MD: It is different.

Adam M. Brufsky, MD, PhD: It’s kind of what you get, you get the lowest ASP that you can. It’s a really interesting dilemma. We’ll get more into that when I talk about that, but that’s a little bit different scenario. But you still have to deal with multiple insurers. And multiple payers, some of which may already have preferred a particular biosimilar. How do you handle that, or how did you handle that with the bevacizumab? Also aren’t there 2 or 3 that are available now or just 1 biosimilar?

Kashyap Patel, MD: I think right now there’s only 1.

Adam M. Brufsky, MD, PhD: Just 1, okay.

Kashyap Patel, MD: I think there are 2 more approved, but they’ll be coming later on.

Adam M. Brufsky, MD, PhD: Right. But right now, you have 1. I think it’s Mvandi?

Kashyap Patel, MD: Mvasi.

Adam M. Brufsky, MD, PhD: Mvasi. I don’t use bevacizumab. We’re not allowed to in breast [cancer] anymore, so I can’t use it. But anyway, so there’s Mvasi. You decided to do it. So there really is not a decision between any 1 or 2.

Kashyap Patel, MD: Not right now.

Adam M. Brufsky, MD, PhD: It’s between that and the originator bevacizumab.

Kashyap Patel, MD: Right, exactly. You’re right on the spot because we went through that issue in the other part of biosimilars. We had 3 biosimilars in the filgrastim space, and we had coverage issues. So, I wrote a very long letter to our state Medicaid and said, “Listen, we have been asked to reduce the cost of care. Biosimilars offer us a fundamental paradigm shift in addressing that, using a new class of drug without compromising care. But if the state government does not work with us, how can you expect us to provide this sort of care?” And they were kind enough, they listened to us, and they started approving biosimilars in Medicaid as well, which was a very pleasant surprise. It all comes back to education. We had the same challenge with our commercial insurance, so I made 3 trips personally to the state commercial insurance’s chief medical officer. I made a presentation and showed them that what’s at stake is not a few dollars of savings. It’s billions of dollars that we will save.

Adam M. Brufsky, MD, PhD: So they said even though you would promise them at least a 30% reduction in the ASP, they were still like, “No, we don’t want to do this?” Really? They had to be convinced. I’m shocked.

Kashyap Patel, MD: I’m telling you. I don’t want to bring this….

Adam M. Brufsky, MD, PhD: Not to diss any politicians listening to this, but I am kind of shocked they don’t want to save money.

Kashyap Patel, MD: Well, there are so many middlemen between them.

Adam M. Brufsky, MD, PhD: Right, good point.

Kashyap Patel, MD: And so, the middleman will advise commercial insurance that, “Oh, this is going to be best because we make more discount at the back end.”

Adam M. Brufsky, MD, PhD: Right, got it.

Kashyap Patel, MD: It comes as rebates as well.

Adam M. Brufsky, MD, PhD: I understand that. And so, do people need education about these drugs? Did they think they were different? How did you say, listen, other than this is cheaper, how did you make the point to them that yes, this is kind of the same? You said, “We think this is the same, but it’s cheaper?” How did you make that argument to them?

Kashyap Patel, MD: Actually, I took a lot of training in the biosimilar space, and then I started a solo battle at my clinic and then started talking at the COA [Community Oncology Alliance]. At 2 organizations, I steered the formation of a biosimilars committee. It was almost like I was self-propelling myself to do that. At the end of the day, when you start doing something very vigorously, they say, “Well, you become the chairman.” I didn’t know what I was asking for but, now I’m dealing with that.

Adam M. Brufsky, MD, PhD: Do you have any points? You were able to do this. You were self-motivated. You learned on your own. Do you have any points for somebody who wants to get involved in this at their level or their part of the country? How would you do it?

Kashyap Patel, MD: Absolutely. I think in my experience, it’s the education of the payers, when you look at the payer battle. Education of physicians about the process of approval of biosimilars, education of physicians there. Europe has been using it since 2006. They have used over 700 million unique doses and still have not seen any adverse outcome.

Adam M. Brufsky, MD, PhD: People don’t understand that. That’s a very big point to make, yes.

Kashyap Patel, MD: Yes. They are safe, they’re effective, they’re less expensive, and they reduce the cost of care by anywhere between 36% to 50% in Europe, almost 35% in the United States for those that are in the market so far. I think education will definitely help us bridge that gap that we are facing right now.


Transcript Edited for Clarity

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Transcript: 

Adam M. Brufsky, MD, PhD: Let’s move on with a specific example. I think that in your practice, we have the biosimilar bevacizumab now. How did you end up adopting the biosimilar bevacizumab in your practical practice for metastatic lung cancer, for example?

Kashyap Patel, MD: Again, I really want to share my expertise as well as my opinion on the role the biosimilar can play in addressing Medicare Part B drug price. We are an oncology care model [OCM] practice, and one of the foundations of OCM is to maintain the quality of care or improve it, improve patient experience, reduce the cost of care. I cannot not offer a patient what they deserve even if it’s expensive. But when I have a choice, for example, in stage IV lung cancer, we have a large population of stage IV non–small cell lung cancer that we treat at our clinic being in South Carolina, in the tobacco belt.

So, bevacizumab has played a significant role because we’re able to reduce the cost, ASP [average sales price], and what we project is that by 2021 December, my total drug spending will go down by about 15% to 17%. And it’s based on the fact that the history of biosimilars has shown in the last 2 years, that within 2 years the ASP drops about 30% to 35%. Fifty percent of my total drug budget is in biologics. So, when I extrapolate 35% savings in the biologics, my total drug budget would go down by 15%, which is almost $1 million-plus savings to us. And we feel that we can be part of playing the role of a steward or trustee of the society by helping to spend less without compromising the care.

At the same time, what we don’t realize is a lot of patients who are living paycheck to paycheck with Medicare only, even a 30% reduction in that out-of-pocket cost could save them $100 a month. It may not sound like a whole lot to me and you sitting here, but when you look at a typical traditional elder-age patient who lives either in South Carolina, Mississippi, Georgia, in that part of the country, who has to drive 30 miles 1 way, a saving of $100 would be about 8% of their paycheck from Medicare. That’s a huge saving for them as an out-of-pocket cost.

Adam M. Brufsky, MD, PhD: I totally agree with you. I think that the issue is this is a big deal, not only for the patients but actually for the practices as well. One thing that we, and I’ll get into this when we talk about trastuzumab in our practice, the question I have is you probably have some 340B drug pricing programs. Do you have 340B hospitals or not in your practice?

Kashyap Patel, MD: We are not. We are independent.

Adam M. Brufsky, MD, PhD: You’re not, okay. We’ll talk about that because that’s a big question because the whole 340B system is totally different.

Kashyap Patel, MD: It is different.

Adam M. Brufsky, MD, PhD: It’s kind of what you get, you get the lowest ASP that you can. It’s a really interesting dilemma. We’ll get more into that when I talk about that, but that’s a little bit different scenario. But you still have to deal with multiple insurers. And multiple payers, some of which may already have preferred a particular biosimilar. How do you handle that, or how did you handle that with the bevacizumab? Also aren’t there 2 or 3 that are available now or just 1 biosimilar?

Kashyap Patel, MD: I think right now there’s only 1.

Adam M. Brufsky, MD, PhD: Just 1, okay.

Kashyap Patel, MD: I think there are 2 more approved, but they’ll be coming later on.

Adam M. Brufsky, MD, PhD: Right. But right now, you have 1. I think it’s Mvandi?

Kashyap Patel, MD: Mvasi.

Adam M. Brufsky, MD, PhD: Mvasi. I don’t use bevacizumab. We’re not allowed to in breast [cancer] anymore, so I can’t use it. But anyway, so there’s Mvasi. You decided to do it. So there really is not a decision between any 1 or 2.

Kashyap Patel, MD: Not right now.

Adam M. Brufsky, MD, PhD: It’s between that and the originator bevacizumab.

Kashyap Patel, MD: Right, exactly. You’re right on the spot because we went through that issue in the other part of biosimilars. We had 3 biosimilars in the filgrastim space, and we had coverage issues. So, I wrote a very long letter to our state Medicaid and said, “Listen, we have been asked to reduce the cost of care. Biosimilars offer us a fundamental paradigm shift in addressing that, using a new class of drug without compromising care. But if the state government does not work with us, how can you expect us to provide this sort of care?” And they were kind enough, they listened to us, and they started approving biosimilars in Medicaid as well, which was a very pleasant surprise. It all comes back to education. We had the same challenge with our commercial insurance, so I made 3 trips personally to the state commercial insurance’s chief medical officer. I made a presentation and showed them that what’s at stake is not a few dollars of savings. It’s billions of dollars that we will save.

Adam M. Brufsky, MD, PhD: So they said even though you would promise them at least a 30% reduction in the ASP, they were still like, “No, we don’t want to do this?” Really? They had to be convinced. I’m shocked.

Kashyap Patel, MD: I’m telling you. I don’t want to bring this….

Adam M. Brufsky, MD, PhD: Not to diss any politicians listening to this, but I am kind of shocked they don’t want to save money.

Kashyap Patel, MD: Well, there are so many middlemen between them.

Adam M. Brufsky, MD, PhD: Right, good point.

Kashyap Patel, MD: And so, the middleman will advise commercial insurance that, “Oh, this is going to be best because we make more discount at the back end.”

Adam M. Brufsky, MD, PhD: Right, got it.

Kashyap Patel, MD: It comes as rebates as well.

Adam M. Brufsky, MD, PhD: I understand that. And so, do people need education about these drugs? Did they think they were different? How did you say, listen, other than this is cheaper, how did you make the point to them that yes, this is kind of the same? You said, “We think this is the same, but it’s cheaper?” How did you make that argument to them?

Kashyap Patel, MD: Actually, I took a lot of training in the biosimilar space, and then I started a solo battle at my clinic and then started talking at the COA [Community Oncology Alliance]. At 2 organizations, I steered the formation of a biosimilars committee. It was almost like I was self-propelling myself to do that. At the end of the day, when you start doing something very vigorously, they say, “Well, you become the chairman.” I didn’t know what I was asking for but, now I’m dealing with that.

Adam M. Brufsky, MD, PhD: Do you have any points? You were able to do this. You were self-motivated. You learned on your own. Do you have any points for somebody who wants to get involved in this at their level or their part of the country? How would you do it?

Kashyap Patel, MD: Absolutely. I think in my experience, it’s the education of the payers, when you look at the payer battle. Education of physicians about the process of approval of biosimilars, education of physicians there. Europe has been using it since 2006. They have used over 700 million unique doses and still have not seen any adverse outcome.

Adam M. Brufsky, MD, PhD: People don’t understand that. That’s a very big point to make, yes.

Kashyap Patel, MD: Yes. They are safe, they’re effective, they’re less expensive, and they reduce the cost of care by anywhere between 36% to 50% in Europe, almost 35% in the United States for those that are in the market so far. I think education will definitely help us bridge that gap that we are facing right now.


Transcript Edited for Clarity
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