Evidence-Based Oncology

Immunotherapy in Cancer Care: Understanding the Impact of Shifting Treatment Paradigms in the Managed Care Setting | Page 4

Published Online: March 20, 2014
Part Two
Dr Weber: I’m not in private practice, so it’s not something I’ve thought extensively about, but I don’t see that point. I think that if you’re practicing value medicine, you should be able to survive in a

small group or a large group.

Dr Salgo asked whether the days in which the doctor could treat a patient, unmindful of the associated cost, were numbered.

Dr Kolodziej: I think so, and we need to get comfortable with the idea that…As a healthcare consumer, I appreciate that we’re getting to a record-and-verify point in healthcare. Doctors who do a good job are thinking of ways to continue to do a good job going forward, while those who don’t want to be told what to do, well, you know what? Sorry.

Dr Weber: Data talks. To paraphrase an old radio commercial from New York when I was growing up, data talks and nobody walks.

Dr George: Just so we don’t lose sight. Cost is really not the equation. We’re talking about value, which is quality over cost. What I don’t want to see happen (are limits) on practitioners who do a good job and actually keep a patient alive longer. By selecting the right therapy for the right patient, they actually get a really good treatment response that’s going to cost more inevitably. And so, to some extent, you’re penalized for doing a quality job. I think we have to recognize in the end that it’s not the lowest cost that wins here.

Dr Salgo: Although, if you listen to the debate in Congress, that’s often what you hear.

Dr George: That’s what I worry about.

Dr Kolodziej then asked the other members on the panel their definition of quality.

Dr Salgo: It’s amorphous, isn’t it?

Dr Weber: Quality-adjusted years of life prolonged would be a reasonable parameter.

Dr George: Life prolonged. The problem is on an individual basis; how do you know you prolong that life? On an individual basis, we can use prognostic models and nomograms. It’s an imperfect science.

Dr Salgo pointed out that the focus is always on the length and quality of life, disregarding aspects like physician interaction with the family to discuss outcomes and options.

Dr Kolodziej: So the answer is, if you look at some of the proposals for quality metrics, and some of them are outcomes like quality adjusted life years and some of them are process measures. Patient satisfaction is typically included in that. I think that the time has long passed where we need to be more transparent about our outcomes. We need to be more transparent about what people think of us. We all remember that cardiothoracic surgery was such a big deal, and reporting the outcomes of cardiothoracic surgery was such a big deal. And now it’s held up as the model for transparency, and fairness, and shared decision-making, consumerism. But people would not be comfortable with that in oncology.

Dr Salgo then raised a chicken-or-egg argument. Of the 12 cancer drugs approved by the FDA in 2012, 11 cost more than $100,000 a year, either coincidentally or maybe these are just expensive technologies to develop. The technology cannot be developed unless someone pays for it, and unless you got the $100,000 for a therapy that does seem to work, we wouldn’t have it. How would this argument fit in the model?

Dr Weber: Well, the companies will only develop the drugs if they can make money selling them. But if the companies are convinced that, at the end of the day, they’ll be able to sell the drug for a profit, whatever that may be, they will continue to develop new and innovative drugs that will benefit patients.

Dr Salgo asked panelists for their final thoughts.

Dr Weber: Immunotherapy has arrived. It’s only going to get better, and the best is yet to come. Americans will anguish about change; but as for the future of being a physician, I don’t think that much will change. I think there will still be a place for the great physician who has an intuitive grasp of what the best treatment for a patient is. I don’t see how we’re going to be hurt by being more data-driven. As a research oncologist, like Dr George, we’re certainly more data-driven than most, but a lot of what we do is not data-driven. I think the society, the patients, the insurers, will be better off when the practice of oncology, which we pursue, is done in a more rigorous and data-driven way. I don’t have any problems with that at all.

Dr George: I agree with Dr Weber and I’m very excited about the future of immunotherapy as well. I’m a little bit concerned that there is an educational lag, both for patients and for some providers, so there’s still a learning curve there like with any new modality. However, with immunotherapy branching into numerous fields and not simply a niche of oncology, we’re going to overcome that pretty quickly. I look forward to being able to be smarter about how we use our immunotherapies like with all our other therapies in precision medicine, helping identify the right patients. However, the oncologist will always play a role in making individual decisions on patients, and we can’t lose sight of that. We have to have mechanisms to do that. I think

the future is bright for oncology and immunotherapy, in particular.

Dr Kolodziej: As both an oncologist and as a person who works for a payer, but largely as an oncologist, we are living in a golden age. So much of work that has been done for a long time is coming now to fruition. We’re understanding personalized therapy. We’re understanding immunology. It is tremendously exciting. Some people might look at healthcare reform and

grappling with quality and value as a hardship. It’s an opportunity. It’s an opportunity for oncology, for the pharmaceutical industry, for the entire healthcare enterprise, to redefine itself. And, at the end of the day, we’ll have enhanced benefit for our members or our patients, we’ll have more transparency, and it will be driven by data.

Dr Salgo: I agree, this is a remarkable time. I have never seen so much excitement, so much real progress on the part of oncologists before. This is a magical time. Immunotherapy is something that is just ridiculously interesting and ridiculously exciting. It is heading us where we need to go and based on my experience in medicine and based on my experience with the folks I’ve met here, we’re going to get there.