ESMO-IO 2019 – Reducing immunotherapy costs

  • Carolina Rojido
  • Univadis
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  • Reducing costs could benefit patients, clinicians, hospitals, and payers but it is a priority to reduce financial burden while maintaining clinical efficacy.
  • Clinicians and clinical pharmacologists are key to managing drug costs in light of the practice-changing evidence they generate.

Why this matters

Reducing immunotherapy costs is important because:

  • Immunotherapy is expensive, and may deliver poor value, with only about 10-50% of patients benefiting due to ineffective therapy or unacceptable toxicity.
  • Reliable response evaluations are only possible after months of treatment.
  • The UK's NHS spends 18% of its yearly budget on chemotherapy drugs. NSCLC immunotherapy costs 200 million €/year in the Netherlands.
  • Reducing doses of anti-PDL1 drugs may offer benefits (reduces toxicity, visits to medical centres, time on treatment, and facilitates breaks or holidays).

Dose reduction strategies can be achieved:

  • Reducing individual doses:
    • Pembrolizumab (2 mg/kg) administered at 200 mg every 3 weeks could be reduced to 150 mg if dosing was weight-based, considering the average patient weighs 75 kg.
    • Obstacles: fixed vial sizes (requiring vial sharing) and legal concerns.
  • Increasing the time between doses (solves fixed dose/vial problems):
    • Nivolumab (3 mg/kg) administered at 480 mg every 8 weeks (instead of every 4 weeks), starting at the third dose, can still maintain a conservative target level of 6.9 µg/ml in 88% of patients.
  • Limiting treatment duration:
    • Many of these drugs have licensed indications for 2 years of treatment but they tend to be used for a longer time.
    • NICE UK put a maximum of 2 years for atezolizumab and nivolumab based on clinical and cost-effectiveness.
  • A stop and go approach to treatment duration has been tried in advanced melanoma.
  • Opportunities to decrease doses when using drug combinations.

Future directions:

  • Short term: additional clinical trials (ELISA validation, standard versus reduced frequency dosing) funded by healthcare payers and cost-savings generated from patient participation.
  • Long term: Personalised dosing (adapting dosing schedule depending on response to first dose).

Expert commentary

“Stopping treatment sooner than two years could be risky on many levels.” Dr Thomas Powles. Professor of Genitourinary Oncology, Director, Barts Cancer Centre, Lead for Solid Tumour Research, London, UK.