Advances in immunotherapies continued to make headlines this year at the annual meeting of the American Society of Clinical Oncology, or ASCO, the world’s largest cancer research conference, which opened Friday and closed yesterday in Chicago.
But another big buzz-generator among the 32,000 attendees was research that had nothing to do with next-generation therapies: a study of how we pay for cancer treatment.
In a rare comparison of cancer care in neighboring regions of the U.S. and Canada, Drs. Todd Yezefski and Veena Shankaran from the Hutchinson Institute for Cancer Outcomes Research, or HICOR, and colleagues at BC Cancer in British Columbia looked at chemotherapy use, cost and survival outcomes in newly diagnosed metastatic colorectal cancer patients in British Columbia and western Washington state. The U.S. data came from Americans who had private insurance; Canada has a government-run single-payer health care system.
Outcomes were essentially the same for the two demographically similar populations, but Washington residents paid on average $12,345 per month for chemotherapy treatments compared to $6,196 per month across the border.
“Obviously the most glaring contrast in findings are for costs, which is not surprising but nevertheless demonstrates once more that you don’t have to spend what the U.S. spends on health to achieve outcomes that are at least as good as here,” Fred Hutch’s Dr. Gary Lyman said in an earlier interview. Lyman was not involved in this study, but as HICOR co-director, he frequently studies the high cost of health care and its impact.
The HICOR poster, presented Friday, was one of numerous presentations by Fred Hutch researchers in immunotherapy, health economics and health disparities.
ASCO 2018 highlights also included international awards for breast oncology leaders Drs. Nancy E. Davidson and Julie Gralow, who are on the Fred Hutch clinical research faculty, and recognition for five young investigators from Fred Hutch, one from the University of Washington who was mentored by Lyman and one from Fred Hutch's Global Oncology partner, the Uganda Cancer Institute.
In back-to-back talks Monday, UW and Fred Hutch physician-researcher Dr. Paul Nghiem presented new, long-term data from separate, ongoing clinical trials of two immunotherapy drugs in the treatment of Merkel cell carcinoma, a rare and extremely deadly skin cancer. Early results had been promising enough to gain avelumab (Bavencio) approval from the U.S. Food and Drug Administration, a first for this cancer. The latest results continue to show Bavencio’s remarkable durability in a significant subset of patients, with one-third of participants with chemotherapy-resistant metastatic MCC alive at two years compared to historical data showing only a few months’ survival with additional chemo. New data from a trial of pembrolizumab (Keytruda) continue to show its advantage over chemotherapy, with 68 percent of trial participants still alive, more than double the historical survival rate with chemo.
“This is so different from chemotherapy, and for the people who benefit, it’s an incredibly big change,” said Nghiem in an earlier interview. He and his collaborators are now trying to address how to help those whose cancers seem immune to the drugs or bounce back after an initial response.
Other immunotherapy presentations included presentations from members of the laboratory of CAR T-cell expert Dr. Cameron Turtle’s on why CAR T-cell therapies have led to durable remissions in some — but not all — patients with certain advanced, highly treatment-resistant cancers. (CAR T-cell therapy is an immunotherapy strategy in which patients’ T cells are genetically reprogrammed to kill their cancers.) Dr. Jordan Gauthier discussed the disease-related and CAR T cell–related factors that are linked to longer survival among 57 trial participants with lymphoma. And Dr. Kevin Hay presented data on how a blood biomarker, disease-related factors and pre–CAR T cell conditioning are linked to survival after complete remission in 56 leukemia patients.
In an education session, Dr. Seth Pollack explored the role of immunotherapy in treating patients with bone and soft tissue sarcomas.
In addition to the poster comparing cross-border colorectal cancer care, several other presentations addressed the costs of cancer care.
Fred Hutch’s Lyman led an educational session on biosimilar cancer treatments and what their imminent debut might mean for cancer patients and the health care industry. A “biosimilar” is a highly similar version of a biologic, a new class of drugs that emerged a few decades ago to treat cancer as well as diseases such as rheumatoid arthritis, multiple sclerosis and diabetes. Herceptin (trastuzumab) and Neupogen (filgrastim) and other biological therapeutics have revolutionized medicine but also have contributed to the rise in health care costs. Unlike drugs derived from chemicals synthesized in a laboratory, biologics are large molecules — generally proteins — that are produced in living cells, like bacteria and yeast. They are complicated to make, and their high prices reflect that.
One of Lyman’s concerns, not surprisingly, is whether biosimilars, like generic drugs, will become more affordable.
“If patients can’t afford them or get access to them, they might as well stay in the laboratory,” he said in an earlier interview.
HICOR researcher Dr. Joshua Roth discussed an ongoing study on the cost-effectiveness of combination first-line immunotherapy and chemotherapy for advanced non-squamous, non-small cell lung cancer compared to a stand-alone chemo regimen. In May 2017, the U.S. Food and Drug Administration granted accelerated approval for pembrolizumab and a chemotherapy regimen for such patients. Preliminary findings from Roth’s team show that while the combination regimen is expected to increase survival, it would do so at an additional cost that is not likely to be considered cost-effective.
In another presentation, HICOR’s Dr. Scott Ramsey and colleagues compared “real-world costs” and the National Comprehensive Cancer Network’s affordability ratings for chemotherapy in advanced non-small cell lung cancer patients. The median cost per patient per month was $16,412 with mean (or average) cost per regimen ranging from $12,000 to $67,000 per month. The researchers concluded that the NCCN’s affordability ratings do not provide reliable information on the total costs of NCCN-approved regimens for patients with advanced non-small lung cancer.
And Dr. Lotte Steuten and colleagues examined the data of approximately 5,700 people with advanced lung cancer who had received either multi-gene panel sequencing (testing for various mutations simultaneously) or single-marker genetic testing (screening for one mutation at a time) to determine which testing method was more cost-effective. Multi-gene sequencing identified 8 percent more patients with mutations and enabled 2 percent more to receive targeted therapies. Steuten’s team determined that patients who underwent multi-gene sequencing had higher total costs over their lifetimes, but these patients’ expected total years of life also increased, making multi-gene sequencing moderately cost-effective.
Clinical trials routinely exclude many potential participants from enrolling because of strict criteria for patients’ health status. ASCO recently recommended modernizing these criteria to allow more people to participate in trials. Reflecting Fred Hutch’s longtime interest and expertise in health disparities, health services researcher and biostatistician Dr. Joseph Unger and colleagues investigated how having multiple simultaneous health conditions, or comorbidities, influence patients’ decisions about participating in clinical trials. Unger and team found that patients with one or more comorbid conditions such as cardiovascular disease or diabetes — often prevalent in communities of color — were 24 percent less likely to participate in a trial. Modernizing criteria for trial eligibility could provide opportunity for several thousand more patients to participate in cancer clinical trials each year, the study found.
Unger also presented findings from a study on geographic distribution and survival outcomes for rural cancer patients treated in clinical trials. Previous studies have shown that rural cancer patients have worse outcomes, including higher cancer mortality rates, than urban patients, but studies relying on cancer population data are unable to account for differences in access to care. In contrast, clinical trial participants receive standardized care by design, so large clinical trial databases are ideal for examining the impact of residency on outcomes. Unger and colleagues found that rural and urban cancer patients with the same access to care through clinical trial participation experienced similar outcomes, suggesting that improving access to uniform treatment strategies for cancer patients may help resolve the rural/urban disparity in cancer outcomes.
Davidson and Gralow were honored with ASCO’s most prestigious awards for “their leadership and exceptional service and for making a difference in cancer care,” according to Dr. Daniel F. Hayes, immediate past ASCO president and chairman of its Special Awards Selection Committee. Both are oncologists specializing in breast cancer.
Davidson, senior vice president, director and member of the Clinical Research Division and Endowed Chair for Breast Cancer Research at Fred Hutch, received the ASCO 2018 Allen S. Lichter Visionary Leader Award and Lecture. As a physician-researcher, Davidson, who is also president and executive director of Seattle Cancer Care Alliance and heads the Division of Medical Oncology at UW Medicine, has published key findings on the role of hormone response and epigenetics in breast cancer and has helped to guide several important national clinical trials of new therapies for the disease. A member of the National Academy of Medicine, she has served in several leadership positions, including as president of the American Association for Cancer Research (2015-2016), director of the University of Pittsburgh Cancer Institute (2009-2016) and as president of ASCO (2007-2008).
Gralow received the ASCO 2018 Humanitarian Award, which recognizes oncologists who personify the organization’s mission and values by “going above and beyond the call of duty” to provide patient care at home and abroad through voluntary and noncompensated humanitarian endeavors. Gralow directs Breast Medical Oncology at SCCA and holds the Jill Bennett Endowed Professor of Breast Medical Oncology at UW, where she is also an adjunct faculty member in the Department of Global Health. She is committed to improving quality of life for breast cancer patients through education, exercise and diet, and to promoting breast cancer awareness in the community. She is medical director and team physician for Team Survivor Northwest, a nonprofit focused on helping female cancer survivors improve their health through exercise; the founder of Women’s Empowerment Cancer Advocacy Network, or WE CAN, a program dedicated to educating, connecting and advancing patient advocates in low-resource settings around the world; and co-chair of the Fred Hutch-based Breast Cancer Initiative 2.5 Secretariat, a global campaign to reduce disparities in breast cancer outcomes.
In addition to Davidson and Gralow’s awards, seven researchers affiliated with Fred Hutch or mentored by Fred Hutch faculty members, including one from UW Medicine and one from the Uganda Cancer Institute, received young investigator grants from the ASCO Conquer Cancer Foundation: