John Fox, MD, MHA: An important element to the pathways program is to assess what the patient’s preferences and goals of care are. Almost all patients will want an initial round of some kind of treatment, whether it be chemotherapy or targeted therapy or immunotherapy. But after they fail or become resistant to initial therapy, the patient and physician have a decision to make about what the next round of therapy is or even if, in fact, the patient wants additional treatment.
For patients who choose to have additional treatment, there are multiple second-line options in non–small cell lung cancer: chemotherapy, chemotherapy plus an anti-VEGF (anti-vascular endothelial growth factor), or an anti-VEGF or immunotherapy. I think that the emerging data, especially around immunotherapy, when compared to chemotherapy with docetaxel, is that outcomes are better with immunotherapy compared to chemotherapy alone.
In fact, patients who are PD-L1 (programmed death-ligand 1) positive, at a threshold of 50% or more, have even better outcomes than those who don’t. So, I think the choice for physicians is, what information do they have to share with patients about what the likely outcomes are, given those multiple different choices? And again, as a health plan, as long as you’re consistent with the evidence, as long as the options are in the NCCN Guidelines, we’ll allow them to make that choice.
I think the interesting emerging concept, now with physicians at risk for the total cost of care, is, what choices are they going to make? And what minor improvements in health outcomes or overall survival are going to be important to them? If you look, for example, at Keytruda in second-line non–small cell lung cancer, you get a 17-month overall survival benefit compared to docetaxel, which is around 8 or 9 months—a significant benefit.
For patients who have a negative PD-L1 titer or have a lower PD-L1 titer, there are still multiple options available (although the differences between the outcomes in those different regimens are much narrower). For example, in patients who get PD-L1 or immunotherapy versus chemotherapy plus anti-VEGF therapy, the differences aren’t significant. Certainly, they are better than chemotherapy alone, but those options and the side effects have to be considered in choosing which therapy a patient wants to receive.