Second-Line NSCLC Coverage Decisions

Bhuvana Sagar, MD: In second-line therapy of lung cancer, we typically follow NCCN [National Comprehensive Cancer Network] guidelines. We have a patient decision support tool that we’ve put in place, which translates NCCN guidelines into an algorithm and walks the provider through what the next best test would be. For example, if the patient has an EGFR mutation and they have progression on Tarceva [erlotinib], it depends on what the provider wants to do next: if they want to order the next step, to see if the patient would be eligible for Tagrisso [osimertinib], or if they would prefer to do PD-1 inhibition. So, we leave that up to the physician and patient, and they have shared decision making at that point: understand expectations, what the patient’s performance status is, and how they think the patient is going to do. Of course, also understanding the toxicity profile and making sure the patient is able to tolerate the drug. All of those factors need to be taken into account when the treatment decision is being made. In some scenarios, best supportive care might be a good option. If the patient’s performance status is very poor and they feel that doing aggressive therapy is not the best option, we have studies, as published by Dr Jennifer Temel, which talked about doing best supportive care and actually adding survival.

At this time, in cancer care, drug costs continue to rise. The value of different therapies and the clinical utility of clinical therapies need to be taken into consideration. We all recognize that there’s no direct correlation between how the drug is being priced and what value the drug is actually adding to the patient’s care. By value I mean clinical utility and clinical benefit. Is it really adding survival benefit or quality-of-life improvements? There’s no direct correlation between if the drug is adding survival benefit and how it’s being priced. That being said, we have not made coverage policy decisions based on drug pricing just yet. I think that is something that all the payers and all the different stakeholders are looking at, considering the cost of care continues to rise. It is becoming unsustainable, truly.