Dr Davey Daniel Talks Approval of Cemiplimab With Chemotherapy for First-line NSCLC

In November, PDL1 inhibitor cemiplimab (Libtayo) was approved in combination with platinum-based chemotherapy for first-line treatment in adult patients with advanced non-small cell lung cancer (NSCLC). Davey Daniel, MD, chief medical officer for OneOncology, lung cancer specialist, discusses the implications of this approval and how it compares to other treatment options.

Transcript

How has the addition of immunotherapy to chemotherapy changed clinical decision-making and treatment for first-line NSCLC?

The addition of immunotherapy to chemotherapy, the first approval was 4 years ago. At that time, things were fairly straightforward. A small group could take targeted therapy, but in a small group they could do perhaps immunotherapy alone. But really started becoming a much more nuanced decision around 4 years ago with the introduction of immunotherapy first-line where you needed multiple information points before you can make decisions. You needed to have your genetic testing, you needed to have your PDL1. It actually became almost a point of transition where you needed more knowledge before you made the first chemotherapy decisions. That was probably 3 or 4 years ago, and we see that actually increasing importance now as we learn that there are more targeted therapies to screen for and that the timing of which treatment you select is very important, having that information back very early in those treatment decisions.

How does the recent approval of cemiplimab with chemotherapy add to the treatment options available?

For so long, we only had chemotherapy plus pembrolizumab first-line with the additional option of atezolizumab and then, subsequently, combining chemotherapy and nivolumab and [ipilimumab]. Now this is a fourth option, so we're having an increasing number of options to choose from. In today's world, we know that we're going to have to start looking at value. Many of us participated in the Oncology Care Model, and many of us will be participating in the Enhancing Oncology Model. So, value actually is starting to make a bigger and bigger role in our decision-making, particularly when we start to look at these trials, where there seems to be very similar patient populations and similar outcomes repeated in multiple trials.

We would love to see these drugs compared head to head, but all of us realize that's probably unlikely at this point and those trials would be really difficult to complete from a patient standpoint. I think it would be probably a large amount of money invested in it and, more importantly, a large number of patients investing their time, and when we're all ready to move forward with the next options.

How does cemiplimab with chemotherapy compare with other available options, from a cost effectiveness standpoint?

Currently, we think that cemiplimab is actually going to come in at a value compared to others. We'll see what final contracting is, but it does appear that, particularly in those who are in value-based contracting, this may be an important tool to use. Most of our lung cancer research leaders [and] lung cancer disease leaders really feel like these drugs are pretty comparable. And if there is value there, we owe it to payers [and] patients alike to try to decrease the overall cost.

Have there been any issues with access or prior authorization for patients who need this combination?

I've been very pleased to see payers pivoting very quickly. When we saw initial approvals in immunotherapy alone for cemiplimab, we certainly saw approvals fairly quickly. I've already used the combination of cemiplimab and chemotherapy and haven't seen any barriers to this so far, so I appreciate payers being willing to pivot very quickly.

What are you looking forward to next with treatment for first-line NSCLC?

I'm really eager to see what further trials are going to be done with immunotherapy agents. The concept of adding an additional agent, such as a LAG-3 inhibitor or antibody, are really interesting. So, we're hoping that this is just kind of initial steps [with] chemotherapy, immunotherapy with a PD1, PDL1, and then further treatment options, further therapies coming along. We'll see what this approval allows for in other drug development.