Dr Akhade on Navigating Immunotherapy Cost and Value in Cancer Care

I generally do not call it low-dose. I tend to call it an optimal-dose immunotherapy. We give that option to the patients, and we tell them that this is not part of the guidelines, but based upon our real-world experience and our studies which are done from our part of the world, we generally see that they have reasonably good results.

In an interview with OncLive, Amol Akhade, MD, a medical oncologist at Fortis Hospitals, discussed how the cost of anti–PD-1/PD-L1 therapy shapes treatment decisions in routine practice and what conventional cost-effectiveness measures omit when applied to individual patients.

Access to checkpoint inhibition remains constrained across much of South Asia. In a retrospective audit at Tata Memorial Centre in Mumbai, 15,674 patients with thoracic or head and neck cancers were identified as eligible for immunotherapy between 2015 and 2019; 444 (2.83%; 95% CI, 2.58 - 3.10) received it. Cost has similarly driven scrutiny of subcutaneous checkpoint inhibitor formulations.

When a patient is eligible for immunotherapy but cannot meet the cost of the approved dose, Akhade said he reviews the available efficacy data, establishes whether treatment is curative or palliative in intent, and then raises reduced dosing as an option. Full dose remains the first choice whenever a patient can access it, and reduced-dose treatment proceeds only with consent.

Insurance coverage in his practice setting reaches approximately 40% of patients, according to Akhade, leaving the remainder to fund treatment out of pocket. A 2025 systematic review he coauthored identified 32 studies of low-dose anti–PD-(L)1 regimens, most from low- and middle-income countries; more than two-thirds estimated savings of at least 80% vs list prices, although risk of bias was serious in over half.

Cost-effectiveness thresholds vary by country and are benchmarked against GDP, Akhade noted, but he argued that published analyses rarely specify whether costs are borne by government schemes, private insurers, or patients themselves, a distinction he said is missing from how value is defined. Treatment goals also differ, with some patients prioritizing quality of life over the most aggressive option.