Payor Challenges for Novel Therapies for Non-Small Cell Lung Cancer

Recent advances in immunotherapy have dramatically improved survival for patients diagnosed with non-small cell lung cancer (NSCLC), but there are several clinical questions that remain to be answered to optimize patient outcomes and minimize the economic burden of treatments, according to a presentation delivered at the 2021 Fall Managed Care Forum.

Gary M. Owens, MD, president of Gary Owens Associates, a consulting practice that provides strategic and tactical services in medical and pharmacy management, discussed the current treatment strategies for NSCLC – a subtype that accounts for 85% of all lung cancers. Most patients are diagnosed with NSCLC at advanced stages, when chemotherapy has only limited efficacy, he noted, but “the advent of molecular targeted therapies against driver oncogenes such as EGFR mutations and ALK fusions have altered the therapeutic landscape of subsets of oncogene-driven NSCLC.” In addition, immunotherapy agents, such as immune checkpoint inhibitors targeting PD-1, PD-L1, and CTLA4, also confer a durable response in certain patients.

When looking at these life-extending advances, the financial toxicity of targeted treatments cannot be overlooked, Dr. Owens stated. They have also required a revision of how payers assess the “value” of personalized treatment that includes screening for driver mutations. “Payers have seen projections that estimate the cost of combination therapy with personalized approaches in the range of $250,000 to over $1 million per year depending on tumor type, patient size, and dosing level,” he explained. “Payers and multiple stakeholders have been considering the question of ‘What makes personalized therapies transformative?’”

Dr. Owens outlined several alternate considerations in the new value-assessment paradigm, including the “value of hope” (acknowledging that a cancer patient with a terminal diagnosis may be willing to risk taking a newer therapy if it could induce a durable response) and societal perspectives (accounting for caregiver costs, productivity gains/losses, etc. in cost-effectiveness analyses).

In summation, he called on payers to leverage patient-reported outcomes, real-world evidence, and other tools to expand the knowledge base of personalized approaches and improve patient outcomes. “From such analysis, payers and providers together must develop careful patient selection that ensures treatments are provided only to those patients most likely to benefit,” Dr. Owens concluded.