Affordable Strategies for the Treatment of Myelomacme-utilities.com/mailshotcme/Material for...
Transcript of Affordable Strategies for the Treatment of Myelomacme-utilities.com/mailshotcme/Material for...
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Mayo Clinic College of MedicineMayo Clinic Comprehensive Cancer Center
Affordable Strategies for the Treatment of Myeloma
S. Vincent RajkumarProfessor of Medicine
Mayo Clinic
Scottsdale, Arizona Rochester, Minnesota Jacksonville, Florida
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S. Vincent Rajkumar, and Jean Luc Harousseau Blood 2016;128:2757-2764
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S. Vincent Rajkumar, and Jean Luc Harousseau Blood 2016;128:2757-2764
©2016 by American Society of Hematology
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Number of new myeloma patients in the US in 2017: 30,000
Excludes spending on hospital, infusion, laboratory, imaging, physician, nursing, and
ancillary costs
Total lifetime costs to treat all patients diagnosed in 2017 : $22.4 billion
Mailankody S. ASCO 2016
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What’s going on?
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Rajkumar SV. ASCO Ed Book. 2018
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Rajkumar SV. ASCO Ed Book. 2018
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1 week of VRD
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Active Drugs in Multiple Myeloma
Alkylators Steroids Interferon Anthracyclines
Old Drugs
Carfilzomib Pomalidomide Panobinostat
Ixazomib Daratumumab Elotuzumab
Recently ApprovedDrugs (2013-2015)
Bortezomib Thalidomide Lenalidomide Liposomal
doxorubicin
Older Drugs(2003-2007)
Rajkumar SV. 2018
Oprozomib Marizomib
Isatuximab
Filanesib LGH 447 Venetoclax Dinaciclib CAR-T Selinexor Anti-BCMA ab
Future Drugs
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FACTS
All new cancer drugs approved by FDA in 2014: >$120,000/year
Average annual household gross income in USA:
$52,000
1 in 3 get cancer
• Compliance
• Bankruptcy
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Its not just new drugs….
http://www.nytimes.com/2015/09/21/business/
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Daraprim $4477 at Costco with coupon! (from @goodrx)
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Life in the last 20 years
Courtesy: Twitter user @lollydaggle
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Courtesy: Twitter user @lollydaggle
Insulin
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Why are prices so high?
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#1
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Why are prices so high?
• Blatant and Occult Patent Evergreening• Cost of drug development• Seriousness of Cancer
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Why are prices so insanely high?
Unique to USA• Medicare cannot negotiate• Ban on personal importation• Reimbursement System encourages more
expensive option• Liberal Off-Label use • No equivalent of Health Authorities
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Lack of Allies
• Physicians• Professional Organizations/ Societies• Patients • Patient care organizations• Insurance companies
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What can we do?
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What can we do?
• Establish Value-based pricing • Medicare allowed to negotiate• Allow importation for personal use• Facilitate easy entry of generics and bio-similars
Unique to USA
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But what can we do?
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1. Choose best possible option
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Alternative lower cost approach to the treatment of multiple myeloma.
S. Vincent Rajkumar, and Jean Luc Harousseau. Blood 2016;128:2757-2764
©2016 by American Society of Hematology
VCD or VTD instead or VRD
Limit maintenance to 1-2 years
Consolidation instead of maintenance
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Attal M et al. N Engl J Med 2017;376:1311-1320.
VRD
Early versus Delayed ASCT
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2. Recognize how US drug prices matter worldwide
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• Global cancer drug spending
• >US$ 100 billion each year
• United States is nearly half (46%) of this market
Modified from: Prasad V, Dejesus K, and Mailankody S. Nature Reviews Clinical Oncology, 2017.
$ 100 billion
Why?
? France
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3. Generate Careful, Powerful Guidelines
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Why what we say matters
Drug Bortezomib Carfilzomib 27/m2 Carfilzomib 56/m2
ASP 50,000 130,000 260,000
6% (Doctors office) 3000 7800 15,600
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Why what we say matters
Drug VCd VRd Dara‐VRD
ASP 60,000 220,000 340,000
6% (Doctors office) 3600 13,200 20,400
National Guidelines combined with the US reimbursement system makes it easy to justify more expensive option
Ease of Off-Label Use facilitates this
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What can we do
•Strict guidelines – true metric of benefit•Regulatory Trials ≠ Practice Changing
•Careful with words like “Standard of Care”
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4. Conduct Strategic Trials
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Strategic Trials
• Response Directed Therapy• Curative Strategies (CESAR, ASCENT)
• Limited Duration Therapy• Targeted Trials
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6-12 months and STOP should be our long-term Goal
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MAF MMt(14;16) (C-MAF) t(14;20) (MAF-B)
TrisomicMM
t(4;14) MM
Kumar S, Rajkumar SV. Nature Rev Clin Oncol 2018
t(11;14) MM
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Tefferi, Kantarjian, Rajkumar et al. Mayo Clinic Proceedings 90: 996; Jul 2015
5. Advocacy
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1. Access2. Doctor vs Expert Role
CHALLENGES
For more info: @VincentRK on Twitter