Melanoma: From Impossible to Treat to Poster Child for Targeted Therapies | Page 7
Published Online: October 23, 2013
Produced by Nicole Beagin
Fendrick: You are not penalized. Just so you know, Dr Weber, the Cleveland clinic, for instance, has multiple contracts with multiple large employers for employers around the country to send their patients to Cleveland, which I call negative medical tourism, for their cardiovascular procedures, so I’m not suggesting that they raise cost sharing to go to certain places but to lower it for others, and I’ll just say, and Dr Malin certainly knows, this has been the core contract behind networks and health insurance products for at least 4 decades. Dr Weber, you probably have a health contract with lower costs for you to go to certain doctors as opposed to others.
Fendrick: I know these exist, these types of products exist, so I would not spend a lot of time on that. I just want to get your impressions and opinion on evidence-based steerage.
Weber: I think that Dr Ribas and I would probably love the idea, and we would welcome having melanoma patients all go to a specialty center, at least for consultation. Dr Ribas, I assume you would agree?
Ribas: I would agree. Sometimes we see patients on a second opinion coming from the community. The data the community doctor has are the same as we have, the drugs are the same but the usage may be wrong because they are not thinking about melanoma every day. My thinking is always that regardless of the cost, if we treat, it is cheaper than if we don’t treat. I mean treat, not just delivery of a nature, but we actually treat a medical condition and the medical condition improves. That is always going to be cheaper, regardless of the price of the drug, not an absolute, but we don’t give drugs that don’t work or give them in the wrong way...
There may be a value in having a centralized guidance of treatment adapted to a particular patient. We have NCCN guidelines, but that has to be interpreted for individual patients and that requires a clinic visit. With all of this discussion I just wanted to bring up 1 thing which is, even though things have come so rapidly, Dr Weber and I know it is going to change even further, that the PD-1, PDL-1 antibodies are going to change in the treatment of melanoma again within the next 2 years, and none of the price structure that we may be discussing now, it is going to be a problem for just a couple of years because the PD-1, PDL-1 antibodies, if we look at the data right now, suggest that we will get a significant fraction of patients with metastatic melanoma to have durable responses with therapies that are basically non-toxic or serious side effects that need to be intervened and will leave the patient in the hospital. It is basically non-existing, now that we know we have to anticipate what it is. There are 7 of those PD-1, PDL-1 antibodies in the clinic being developed right now, and probably there are going to be more that will be developed. There are 3 of them that are positioned to have licensing potential in melanoma and maybe many other cancers. I would assume that would drive down the cost, and instead of going the path of ipilimumab where it was to the maximum that it could, there was no competition, not a second CTLA-4 because the Pfizer one was negative and the trametinib, the clinical trial was negative for a whole bunch of reasons, and then there was not a similar agent besides high-dose IL-2 that could give durable responses in melanoma, but high-dose IL-2 would assume it is even more expensive than giving ipilimumab, so the field backing will go into what we are talking about which is adapting the prices to the benefit because there will be more competition and the existing drugs will become second-line drugs, and companies will not be able to be charging as much anymore.
Weber: I think Dr Ribas raised a very interesting point. The essence of the capitalist system is that competition brings down the price for the consumer, and if you have 3 PD-1 or PDL-1 antibodies, how are you going to choose? If they seem equally effective, obviously whoever cuts the price the most, that is the one that is going to get used, and here you have in front of you an example, what is the price per month of dabrafenib, a drug that arguably is equally effective as vemurafenib, and has a slightly different toxicity profile that may or may not be superior. Its price is significantly less than debrafenib’s, and does anyone think that is an accident? I don’t think so. One of the solutions to the problem is as companies develop competing drugs, the price will to some degree come down, and look who is developing B-RAF met combinations, 3 companies, Novartis, Genetech, and GSK. The same thing is going to happen, it is not going to be $16,000 a month because someone will come in with a new approval and it will be $13,000 a month, and the next one will be $10,000 a month, so perhaps there is some relief on the horizon in terms of pricing because of competition, the classic essence of capitalism.
Fendrick: The relief for price will fall only if the drugs remain equally effective. Evidence over 50 years would suggest that the prices will go up in toto as opposed to likely going down per agent, but I did want to let Dr Malin comment on this. What I find most interesting and learned a lot about over this session is that from a scientific and clinical outcomes perspective, the field of metastatic melanoma can be held out as exemplary in terms of innovation and science, and actually lead to better outcomes for individuals with this 1-time, nearly always fatal disease as you said, Dr Weber, so clearly that glass is half full, if not more than half full regarding where we are going on the health outcome side. Dr Malin, in terms of cost, are we half full or half empty, given the pressures that Dr Weber and Dr Ribas mentioned clearly on not only individual patients, but the healthcare system as a whole?
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