Evidence-Based Oncology

Immunotherapy in Cancer Care: Understanding the Impact of Shifting Treatment Paradigms in the Managed Care Setting

Published Online: February 12, 2014
The American Journal of Managed Care convened an expert panel to address the impact of increased use of immunotherapy in treating cancer in a managed care setting. According to the American Cancer Society, immunotherapy is a treatment that wards off disease either by boosting the immune system in general or by training it to attack specific cancer cells. Immunotherapy may be used alone or in combination with standard chemotherapy regimens.

Panelists discussed the positive and negative aspects of using immunotherapy, traditional chemotherapy, and combination regimens. They addressed the importance of promoting both patient and provider understanding of immunotherapy. Finally, panelists discussed the cost associated with immunotherapy in cancer care.

The discussion was moderated by Peter Salgo, MD, a professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at NewYork-Presbyterian Hospital, New York City. The panelists included:

• Jeffrey Weber, MD, PhD, senior member of the H. Lee Moffitt Cancer Center and director, Donald A. Adam Comprehensive Melanoma Research Center, Tampa, Florida.

• Michael A. Kolodziej, MD, national medical director, Oncology Solutions, Aetna, Inc.

• Daniel J. George, MD, Duke Cancer Institute.

Peter Salgo, MD, initiated the discussion by stating that immunotherapy markets were expected to exceed $14 billion this year; of the 12 FDA (US Food and Drug Administration)-approved drugs in 2012, 11 cost more than $100,000 a year. He said this points to a trend toward increasing costs for everyone. Dr Salgo then specifically asked Daniel George, MD, to comment on the previously unmet medical needs that are now being met by cancer immunotherapies.

Daniel J. George, MD: Cancer immunotherapy, and immunotherapy in general, has a long history of almost 100 years or more of recognizing the importance of the immune system in monitoring, preventing, and controlling cancer. We probably have not used this to our best advantage, but recently there’s been a breakthrough in a number of agents and strategies that have harnessed this access of therapy, an endogenous approach to managing this disease and taking advantage of our own immune system and the way it fights cancer.

Dr Salgo: The way I’ve looked at it, if I may, is in the past when you gave chemotherapy, you just killed all the cells and hoped that the rapidly dividing cells went first and then salvaged patients back. That’s not what’s going on.

Dr George: This is a really different paradigm. The immune system is present and we are trying to manipulate it in a way to reactivate it against cancer. There’s a concept called tolerance where, by multiple different strategies, cancer cells can evade recognition by the imanothermune system; there’s a way of reharnessing the immune system by overcoming that tolerance. Unlike chemotherapy or radiation therapy, where the treatment stops when you stop the drug, these are therapies that potentially could keep going and keep working following reactivation. We’re actually sort of vaccinating, if you permit me to use an umbrella term that may be imprecise, against cancer such that you are sensitizing an immune system against a particular tumor. You don’t have to re-vaccinate every 3 days. You give it once and the immune system keeps working.

Jeffrey Weber, MD, PhD: Well, the Holy Grail of cancer immunology is to create a cancer vaccine. Provenge was the first and only cancer vaccine that was ever approved. But that is truly the mantra, that is, the immune system is the ultimate way to perform targeted therapy. So immunotherapy is targeted therapy, and its hallmark is memory.

Michael A. Kolodziej, MD: I was a practicing oncologist until just recently, and there’s an unmet need because what we were doing wasn’t working very well. So now we have the emergence of immunotherapy as an approach. We have the emergence of targeted therapy and even to the point of precision medicine as an approach, and we’ll see what wins. It’s very exciting because the science has advanced quite rapidly, but what we did earlier wasn’t very effective in most patients.

Dr Salgo continued the discussion by asking the panelists to clarify his understanding of the mechanism by which immune therapy works. His understanding was that we continually develop malignant cells every day that are consumed by the immune system to prevent tumor development, and the immunotherapy drugs seem to target the failure of immune recognition and immune response.

Dr Weber: There are certainly data to suggest that this idea of immune surveillance is indeed valid. On the other hand, people on immunosuppressants don’t always present with 30 different types of solid tumors. Transplant patients often develop squamous skin cancers, especially virally related squamous skin cancers. So there are data to suggest that we always have immune surveillance to prevent cancer from developing.

In response, Dr Salgo queried the panelists on the different types of immunotherapy drugs that are now available and the types of cancers they treat. In their expert opinion, which of the available treatments could be considered clinical successes with a meaningful impact on patient outcomes?

Dr Weber: You can divide immunotherapies into 4 or 5 categories: these include chemicals like cytokines; antibodies…cells, which are not really well developed; vaccines, which is always the Holy Grail to try to vaccinate someone against his or her own cancer. You’ve got 1 approved vaccine. One of the antibodies, which are the most exciting and promising, is approved. That’s ipilimumab, the anti-CTLA4 antibody. In terms of the cytokines, in 1996 and 1998 IL-2, interleukin-2, was approved for kidney cancer and for melanoma. The cell therapy is immature, and you will hear a lot more about the antibodies coming up in the next couple of years.

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