Dr Akhade on Why 'Optimal' Dosing and Biosimilars Point the Same Way

The best drug is the one that is available to the patient. If the drug is not available to my patient, then for that patient, that is not the best drug.

In an interview with OncLive, Amol Akhade, MD, MBBS, a medical oncologist at Fortis Hospitals in Mumbai, discussed how biosimilars, subcutaneous formulations, and efforts to define optimal dosing each affect what cancer treatment costs and who can obtain it.

Subcutaneous formulations offer real convenience for patients, Akhade said, though he questioned why they often reach the market as a reference product nears patent expiry rather than earlier. A biosimilar of nivolumab has since launched in India — Zydus Lifesciences introduced Tishtha in January 2026 at roughly one-quarter the price of the reference product. Additional checkpoint inhibitors developed in China are entering the Indian market through local partnerships, Akhade noted, which he expects to narrow the gap between approved and reduced dosing over time.

He framed this as a recurring pattern: a new agent arrives at high cost, biosimilars eventually follow, and prices fall, as they have for trastuzumab and pertuzumab. As the cost of full-dose immunotherapy declines, he argued, the price argument for reduced dosing weakens, and attention shifts to newer high-cost classes such as antibody-drug conjugates and bispecific antibodies. For that reason he called for policies that encourage broader biosimilar development.

Akhade said his group prefers the term “optimal dose” to “low dose,” to avoid implying that patients receive less because of cost. He pointed to reduced-dose research with the antibody-drug conjugate trastuzumab deruxtecan, which his group is studying in real-world practice, and to lorlatinib in ALK-positive non–small cell lung cancer, where efficacy has appeared preserved at 75 mg in patients dose-reduced from 100 mg. He acknowledged these approaches lack level 1 evidence and may never attract trial funding.

Access gaps extend well beyond India, Akhade added, noting that some checkpoint inhibitors are not marketed at all in parts of Africa and Eastern Europe. He argued for a middle path between market pricing and subsidy, framing broad access as the shared goal.