Response-adapted immunotherapy cost-effective, may push melanoma to ‘individualized care’
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Response-adapted therapy in melanoma, which involves removal of certain immunotherapeutic agents in a combination, can reduce costs without a decrease in efficacy, according to a study.
Zachary Cartun, MD, head of clinical integration at Pulsenmore, noted that while combination therapy with nivolumab (Opdivo, Bristol Myers Squibb) and ipilimumab (Yervoy, Bristol Myers Squibb) have yielded significant improvements in melanoma outcomes, the expense of the combination can be prohibitive for some patients. In the current study, the researchers determined whether discontinuing ipilimumab could provide the same tumor response at a lower cost.
“Response-adapted treatment is exciting for several reasons,” Cartun, who was of the departments of radiology at both the University Hospital LMU Munich and the University of Massachusetts Chan Medical School at the time of the study, told Healio. “Idealistically, it fits well into the notion of personalized medicine, with drug regimen and dosage dictated by the individual patient’s early response. It also leverages the multidisciplinary nature of medical care — in our case dermatology, oncology and radiology — by combining the most advanced features of each field to provide the best treatment.”
Clinically, this approach can not only “shed dollars” from medical expenses, but also reduce toxicities associated with cancer therapeutics, according to Cartun.
“As the trials of interest have demonstrated, smart treatment de-escalations reduced patient costs with no detriment to outcomes,” he said. “We think quantifying these benefits may motivate more clinicians to develop response-adapted protocols.”
The current cost-effectiveness analysis used data for 41 patients from the ADAPT-IT trial, which had a follow-up duration of 33 months, and 314 patients from the CheckMate 067 trial, with a follow-up of 6.5 years. The total study population was 355 patients. Literature published over the 33 months of ADAPT-IT follow-up also underwent analysis.
Objective response served as the primary endpoint of ADAPT-IT, whereas overall survival and progression-free survival served as primary outcomes for CheckMate.
A U.S. payer perspective was used, with a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.
Results showed that response-adapted treatment was the more cost-effective option in 94% of clinical scenarios.
The incremental cost-effectiveness ratio was “dominant” in those scenarios. An incremental net monetary benefit of $28,849 was reported for response-adapted treatment versus standard of care.
The estimated cost savings for response-adapted therapy per patient was $19,891 compared with standard of care.
In analysis of specific scenarios, current standard of care was found to be cost-effective when the best survival assumptions were factored in, and if the willingness-to-pay threshold was greater than $630,000 per quality-adjusted life-year.
The group was surprised by the “sheer magnitude” of the cost-effectiveness they observed for response-adapted treatment.
“This serves to highlight just how game-changing this treatment protocol can be,” Cartun said.
Cartun also addressed the potential utility of response-adapted therapy overall. “Understanding the cost-effectiveness stems from understanding what makes immunotherapy unique; meaning, it does not attack cancer directly,” he said. “Instead, it primes the patient’s own immune system to recognize and eliminate cancerous cells.”
It is for this reason that once the immune system “learns” what cancer looks like, additional immunotherapy treatment can become less effective, according to Cartun.
“A simple analogy would be like teaching a child to ride a bike, after she has already learned how to ride a bike,” he said. “The cost-effectiveness of response-adapted treatment is derived from this redundancy, empowering clinicians to spare patients both adverse-effects and enormous bills.”
It is important for Healio readers to understand that less expensive treatment is not the same as less effective care, according to Cartun.
“This is not a new idea, but it is often hard to make it a reality,” he said. “When a new such example arises, it is incumbent upon the field to both understand what features impart this rare quality and to design more protocols that take advantage of these developments.
“In the long term, continued development of response-adapted treatments will further cancer care toward the goal of truly individualized care,” Cartun concluded.