Response-adapted de-escalation of immunotherapy in patients with advanced melanoma may lead to considerable savings for payers — close to $20,000 per patient — compared with standard immunotherapy, an economic analysis found.
“The rising costs of cancer therapies are becoming untenable for both patients and payers, and there is both clinical and economic benefit to finding less expensive treatment alternatives,” Wolfgang Kunz, MD, University Hospital, LMU Munich, Germany, told Medscape Medical News.
This economic analysis “highlights that leveraging modern diagnostic capabilities can do just that: pairing drug regimens with CT-image analysis to optimize dosages can reduce healthcare costs and improve clinical outcomes,” Kunz said.
The study was published online Oct. 19 in JAMA Dermatology.
While the use of immunotherapies over the past decade has improved the prognosis for patients with advanced melanoma, these drugs come with a hefty price tag.
One potential way to help reduce costs: de-escalate therapy. The ADAPT-IT trial, published earlier this year, demonstrated similar progression-free and overall survival among patients who received response-adapted ipilimumab discontinuation and those who received standard of care.
In the current analysis, Kunz and colleagues wanted to understand whether this response-adapted approach was also cost-effective.
The team applied economic modeling to data from the ADAPT-IT trial as well as CheckMate 067, in which patients received standard of care four doses of combination ipilimumab-nivolumab followed by nivolumab monotherapy. In the ADAPT-IT trial, patients also initially received the immunotherapy combination but had CT scans to determine their response after two doses; if they responded, patients discontinued ipilimumab and continued with nivolumab monotherapy.
Overall, ADAPT-IT showed that responders could forego the additional two doses of ipilimumab plus nivolumab while maintaining similar progression-free survival and overall survival seen at 18 months in the CheckMate 067 trial.
The current economic analysis, based on 41 patients from ADAPT-IT and 314 from CheckMate 067, showed a potential reduction in healthcare costs of $19,891 per patient with the response-adapted approach.
Response-adapted treatment was the cost-effective option in 94% of simulated scenarios.
When extrapolated to 2019 incidence rates of distant melanoma cases, yearly national savings could reach about $58 million.
“In the relatively small space of immunotherapies in advanced melanoma, we hope this analysis motivates clinicians to consider response-adapted treatment,” Kunz told Medscape Medical News.
“On the larger scale, this analysis serves as a stepping stone to more response-guided treatment protocols,” Kunz added. “With drug costs rising and imaging capabilities growing, more frequent image-guided adjustments are a perfect fit into the personalized care model.”
When applying the cost savings noted in this analysis across all treated patients, “the economic impact may be profound,” said Joseph Skitzki, MD, surgical oncologist, Roswell Park Comprehensive Cancer Center, Buffalo, New York, who wasn’t involved in the study. The “financial toxicity of cancer care is increasingly recognized as a potential barrier to optimal outcomes and any measures to mitigate cost may be impactful.”
However, Skitzki said several caveats need to be considered.
One is that the data included from ADAPT-IT only included 41 patients compared with 314 patients from CheckMate 067.
“It is possible that a larger real-world study utilizing the ADAPT-IT protocol may not be as favorable in terms of outcomes and could lessen the economic impact of de-escalation, although any form of de-escalation is likely to have a cost benefit,” Skitzki told Medscape Medical News.
A real-world response-adapted de-escalation clinical trial, with an emphasis on costs and a benchmark of similar progression-free and overall survival, should be conducted before the de-escalated option becomes “practice-changing,” Skitzki said.
Jeffrey Weber, MD, PhD, deputy director, Perlmutter Cancer Center, NYU Langone Health, New York City, also urged cautioned in interpreting the results.
“I would not base treatment decisions on a small sampling of 41 patients in the absence of a randomized comparison,” Weber told Medscape Medical News. “Without a proper comparison, I would not advocate using only two doses of ipilimumab-nivolumab to make decisions on treatment.”
Skitzki added that while “studies like this one are desperately needed to lessen the economic impact of new and emerging combination immunotherapies,” there is likely also a “disincentive for pharmaceutical companies to conduct this type of research.”
This research had no specific funding. Kunz and Skitzki reported no relevant conflicts of interest. Weber disclosed relationships with Merck, Genentech, AstraZeneca, Pfizer, Regeneron, and GSK, among others, and holds equity in Cytomx, Biond, NexImmune, and Immunomax.
JAMA Dermatol. Published online Oct. 19, 2022. Abstract.
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