The Complexity of Choosing Biosimilars in Oncology



Adam M. Brufsky, MD, PhD: I know Lee Schwartzberg has talked about his experience at the West Clinic. But I’ll just give you a little bit of where we are now. We went through the same issues with the biosimilar pegylated G-CSF [granulocyte colony-stimulating factor], and we did a conversion. We still have problems with that, unfortunately, because a lot of people come to the University of Pittsburgh. Again, we’re a big academic center, but we have a large network that’s now actually probably 60% of Pennsylvania in terms of area. We’ve gone all the way across almost to Harrisburg, almost to Scranton.

Kashyap Patel, MD: Interesting.

Adam M. Brufsky, MD, PhD: Yes, so we have sites all over. And the payer mix is a little bit different in the eastern part of the state than the western. But nonetheless, we have a large experience really with a conversion to both the biosimilar G-CSF and the biosimilar pegylated G-CSF. And the big issue with us with the biosimilar pegylated G-CSF, before we start talking about trastuzumab, the big issue was you have the Neulasta Onpro device, which is very easy to use.

Kashyap Patel, MD: Same day.

Adam M. Brufsky, MD, PhD: Very easy to use. You just put it on the patient, wait for the light to turn green 24 hours later, and you take it off. The problem though is if you’re going to give the biosimilar, I think it’s Udenyca. We use Udenyca. There are other ones, but we decided.…

Kashyap Patel, MD: Fulphila.

Adam M. Brufsky, MD, PhD: Fulphila. We decided on Udenyca for a variety of reasons. I can get into that in a minute. But the issue with Udenyca is that we have to have the patient get an injection a day later. We have to find somewhere, especially if someone comes to see me from 4 hours away. A lot of people want to stay and get their chemotherapy with us even though it’s a long distance. If you’re getting an every 3 week regimen for breast cancer, or every 2 week if you use dose-dense chemotherapy, you have to figure out where the patient is going to get it. Either they’re going to give it themselves or they’re going to find someone to give it. And a lot of times they can’t give it to themselves. The payers require they have to be given it in an oncology office. So it’s a really interesting decision. We went through this whole thing and made all the decisions. And then we decided on Udenyca, but we still had probably…we track our use, as I’m sure you do.

Kashyap Patel, MD: Yes.

Adam M. Brufsky, MD, PhD: And we actually have an oncology P&T [pharmacy and therapeutics] committee that’s comprised of pharmacists and oncologists representing all of our various constituencies. We have community oncologists. We have academic oncologists. I think there are some nurses, and we have pharmacists.

Kashyap Patel, MD: Do you have 340B drug pricing program as well?

Adam M. Brufsky, MD, PhD: We do, and that’s the issue with us, we have 340B for a lot of our practice.

Kashyap Patel, MD: You are also an OCM [oncology care model] practice as well.

Adam M. Brufsky, MD, PhD: Our community practice. It’s interesting. Our community practices are OCM, but the academic ones are not. It’s very complicated. We have 2 different EMRs [electronic medical record systems]. It’s an interesting dilemma. But the bottom line is that our oncology P&T, in fact, we just met yesterday to discuss a lot of this. The way it works with us is that we have a lot of issues that go into it because a 340B issue with a drug is much different than the commercial issue.

Kashyap Patel, MD: Correct.

Adam M. Brufsky, MD, PhD: And much different than the payer mix. It’s very complicated. I thought naively that it was simply, if all 3 are the same price, or all 5 in the case of trastuzumab, if they’re all the same, we’ll just pick the 1 that gives us the best, I don’t know, support or the best company that we could be assured that there won’t be a supply problem.

Kashyap Patel, MD: Correct.

Adam M. Brufsky, MD, PhD: We would assume that we would do all that, but I didn’t realize how complicated it really was. And it’s interesting, we have this huge spreadsheet now. You have to put in all these variables for it to spit out what we think the best 1 is for us. It gets very complicated. And we’re a complicated system, but I think that there are a lot of things that go into this, as you said, beside cost. We decided that we know, for example, there’s going to be a certain amount of Onpro use, the Amgen [Inc] device. There’s going to be a certain amount of that no matter what, I think because there are patients that come from 4 hours away. But someone who maybe doesn’t come from 4 hours away and basically can get it in either a doctor’s office, or an oncology office, or themselves. The perfect is the enemy of the good. And I think if you can get up to maybe 70%, 80% conversion, I think that’s fine.

Kashyap Patel, MD: Absolutely.

Adam M. Brufsky, MD, PhD: Chasing 100% is where you run into trouble. You spend all your time chasing an extra 20% for no reason.

Kashyap Patel, MD: You are absolutely right, Adam. I think at the end of the day, we all became doctors to help patients. So, when you have a patient who has to drive 4 hours, if I use 20% Onpro, my contract may not be the best, I may actually lose money, but I still would use it because I do not want to look at finance as the bottom line for what I do.

Adam M. Brufsky, MD, PhD: Correct, right.

Kashyap Patel, MD: At the same time, if I have an option of using it in 80% of the patients, I definitely will be happily using it. But I’m really happy to see that we all are thinking alike, that at end of the day, we do not want someone to drive 4 hours to come to the clinic.…

Adam M. Brufsky, MD, PhD: Just to save a certain amount of money, right. And it’s interesting, if you have a company that actually has biologics, has generics plus the originator….

Kashyap Patel, MD: It does help.

Adam M. Brufsky, MD, PhD: Maybe they’re 2 different classes. Maybe what you can do is you can cut a deal where even though you’re using 20% of Onpro, maybe you’re using other biosimilars from the same organization, and you can hold a contract that makes everybody happy. These are the complexities.

The issue of how we’re sourced, we’re still trying to decide. There are 5, as you know, different trastuzumab biosimilars now, where really it’s a very complicated decision, but it’s made by a P&T committee. We have a P&T committee that meets, an oncology P&T committee. It’s kind of a subcommittee of the larger P&T of the health system. It is comprised of the various stakeholders, and we sit and we talk, and the thing is, again, it’s a very complicated decision. That’s why it’s taken us so long to make that decision, because there are so many variables that go into it.

Transcript Edited for Clarity

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