Melanoma: From Impossible to Treat to Poster Child for Targeted Therapies | Page 3
Published Online: October 23, 2013
Produced by Nicole Beagin
Fendrick: That is very helpful. I am going to ask our clinician experts 1 broader question, and I’m going to tee you up, Dr Malin. With all this activity going on, and all of this enthusiasm and trials in place, how do payers actually assess value and ultimately determine access to these agents? The question I would like to ask is, I was involved in a medicine panel that released a report yesterday on geographic variation in healthcare delivery, particularly showing a variation tends to be greatest when even the experts in the field don’t know what the right path is for a particular condition. We have a faculty member from Southern California and one from Northern California, but you are obviously engaged nationally and internationally. What can you say about a standard of care, or a lack thereof in metastatic melanoma, given all of this exciting innovation going on in the field? Is it the wild, wild west, or are there guidelines similar to what we used to see from the National Comprehensive Cancer Network?
Weber: Well, there are NCCN guidelines for metastatic melanoma, and a lot of private practice doctors in South Florida where I practice in our academic center will follow them. In fact, they will write it into the notes. Dr Ribas and Dr Malin, I assume in your area that is the same, isn’t it?
Malin: I think NCCN has done a tremendous service to the field of oncology in that we do have very comprehensive guidelines, and they are updated very frequently. This is very helpful in an exciting area like melanoma, where there is so much innovation and so many new therapies that there are not hard data on how to sequence them, so you really have to rely on experts to provide that kind of guidance to people out there in the community treating patients. I will say, however, that before this call, I checked how NCCN was recommending use of the 2 new B-RAF inhibitors and they were FDA approved in May, and NCCN hasn’t updated its guideline. So, there is a little bit of a lag, and I think it is challenging. It is a good challenge to have, so many new therapies all at once that you are not sure yet how to choose among them and how to sequence them. I think we will see over the short period, as we are all struggling to figure this out, a lot of heterogeneity in practice, and I think that is understandable.
Weber: Also, I think practices will vastly vary at an academic center like mine where you have 25 melanoma trials. At UCLA I’m sure it’s the same. It is going to be a little different than if you are in Albuquerque, New Mexico, at a good private practice with 5 other oncologists. It is going to be very, very different as to what you can offer the patient.
Malin: Right. Maybe this brings up the issue of access. These therapies are very, very exciting and the benefits that some patients have are really tremendous. It is very exciting to see someone go into a complete remission following 4 treatments of ipilimumab and stay in remission even for a year, which wouldn’t have happened before. But, the wholesale cost of just the drug for that is $120,000, combination of B-RAF inhibitors, or start with immunotherapy, hopefully a PD-1 so most private practices, most small, independent practices (are) concerned about even taking on the financial risk of a drug that is that expensive without knowing whether the patient’s insurance is going to cover it, whether the patient can afford whatever their copay might be. If they have a 10% copay, that is $12,000 right there, so the cost of these drugs, at least in combining them, is going to bring new questions regarding access for people. We’ve seen this recently with CML where CML is the 1 disease that I think the treatment has transformed since I was in training with Dr Ribas, and these drugs really are unbelievablein terms of the dramatic change in terms of the impact of the disease on people’s lives. They really do live in symbiosis with their disease for probably, it appears now, to “what their natural life expectancy would be.” But the drugs cost over $100,000 a year. Even some of the original ones like imatinib, the price has been going up each year quite steadily. So much so that recently there was an editorial in The New York Times, signed by a large number of the hematologists that treat these patients, that the crime is profiteering. I think if we are looking at imatinib in combination with another drug, an anti-PD-1 drug, we don’t know what the price is going to be of those other therapies, but it is easy to envision that we would be looking at several hundred thousand dollars a year of therapy, and a therapy that someone might get retreated with.
People can have long remissions and some people do benefit from retreatments so we don’t know, to achieve that vision of 10 or 15 years of symbiosis, does it mean someone is going to need to repeat treatment every couple of years? I was mentioning earlier that many independent practices feel that it is too costly, but when someone gets the treatment in an outpatient hospital setting, usually the cost is double or triple, so just for ipilimumab, we are looking at a cost to the patient’s payer, which eventually is actually their employer, of $240,000, $360,000. That is really what the true cost of the therapy ends up being after whatever the markup is from the hospital. The price of these we need to be very conscious of to insure that people have access to these therapies.
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