ASCO: Combos and Pricing and Pricing of Combos

Casey McDonald presents some highlights from a blustery few days in Chicago, with immunotherapy and cost, predictably taking center stage.

A dreary weekend with temperatures getting down into the 40’s °F was not how I expected to start June in Chicago - but I could have predicted immunotherapies, and notably combinations of them, would produce positive data that would be met by pricing outrage at the annual meeting of the American Society of Clinical Oncology (ASCO). Sunday’s plenary session packed more than one convention center hall with Phase III results for combining Opdivo (nivolumab) and Yervoy (ipilimumab) in treatment-naïve patients in advance melanoma, the 945 patients CheckMate 067 study. Long-term overall survival data on the combo will be awaited, but Michael Atkins, of Georgetown’s Lombardi Comprehensive Cancer Center who discussed the data readout was excited to see a potential for a new standard of care. Atkins expressed his excitement for positive data exclaiming that it wasn’t long ago that metastatic melanoma gave “cancer a bad name”.

Will ipi + nivo become the new standard of care for advanced #melanoma? Read our recap of day 3 of #ASCO15http://t.co/TkYiQVT62Z

- Cancer Research Inst (@CancerResearch) June 1, 2015

and

Atkins re ipi+nivo: "Behooves us to wait for OS" - PFS not good to evaluate immunotherapy, pseudo-progression #ASCO15pic.twitter.com/0rRhcev4yn

- Mary Jo Laffler (@PinkSheetMaryJo) May 31, 2015

Also during Sunday’s plenary session, James Allison from the University of Texas MD Anderson Cancer Center received the ASCO Science of Oncology Award. Allison described his revolutionary work into T-cell activation and inhibition and the paradigm shifting insight to ignore the cancer cells, opting instead to focus on unleashing the immune system.

Allison: "Ignore the tumor, just work the immune system." Hard to emphasize how revolutionary that concept was (is). #ASCO15

- David Miller (@AlpineBV_Miller) May 31, 2015

Allison showed the crowd his vision for the future of Kaplan-Meier survival curves in cancer, with combinations, and targeted immunotherapy, going from adding a few months on the x-axis, to improvements along the y-axis, with more and more patients showing sustained survival. And a conference in 2015 wouldn’t be complete without a pricing discussion. Leonard Saltz, chief of gastrointestinal oncology at Memorial Sloan Kettering Cancer Center spoke to the still mostly full plenary audience with boldly texted slide saying “These Drugs Cost too Much”. Being a cancer conference, Saltz spend just one slide of his assailing talk on Sovaldi. The speaker proceeded break down potential bills for some of the industry’s brightest new products doing the math of mg/kg dosing for overweight Americans.

Saltz on Pembrolizumab: At 10 mg/kg with ASP of $51/mg, 80 kg patient (drumroll...): cost is $1,009,944 for one pt for 1 year. #ASCO15

- Michael Fisch (@fischmd) May 31, 2015

Saltz added a clear definition for the word “unsustainable”, which he claimed many in healthcare don’t take seriously enough and/or to which we have become numb. The hard-hitting talk also took on “value” which is ill defined and needs to include more than just benefit, but a consideration of toxicity and cost, with high cost itself seen as a negative side effect. The speaker finished with a call for an uncomfortable conversation among all stakeholder, drug companies, patients, regulators, et al., on drug pricing that can acknowledge an upper limit on what we, as a healthcare system, can afford to pay. As the system works, drugs are priced, not according to value to the patient and healthcare system, but on previous drugs and what the market will bear. Inadequately discussed by this or other speakers, how drug pricing has become so far divorced from real market forces. See WSJ’s take here.