As much as the IO combinations have filled the treatment space, there is another narrative ongoing that also should capture our attention, although it may not serve as a focus as much as the clinical story. And in the age of social media and Twitter, it might not be considered as “hot.” To be sure, the bulk of attention remains focused on various shifts in the treatment paradigm and how we are to appropriately integrate these shifts into our clinical practice. And yet, I am impressed by the voluminous content surrounding the use of IO therapy and the myriad issues many authors raise for us not only as clinicians but for us as part of the larger sphere of oncology and its place in the overarching public health sector.
Consider, for example, a paper published earlier this year by Kaufman, Atkins, Subedi et al (The promise of Immuno-oncology: implications for defining the value of cancer treatment, in the Journal for ImmunoTherapy of Cancer, May 2019.) As the authors address this topic, they note: “Responding to ongoing efforts to generate value assessments for novel therapies, multiple stakeholders have been considering the question of ‘What makes I-O transformative?’ Evaluating the distinct features and attributes of these therapies, and better characterizing how patients experience them, will inform such assessments.” The authors explore key aspects and attributes of IO therapies that should be considered in any assessment of their value and seek to address evidence gaps in existing value frameworks given the unique properties of patient outcomes with IO therapy. That is a tall order for anyone to take on but this report gives one of the most comprehensive analyses of IO therapy available. It delves into a broad spectrum of issues that will not only dramatically enlarge your frame of reference but deepen your understanding of the value of IO therapies, particularly as it relates to economic models. For example, the Incremental Cost Effectiveness Ratio (ICER) is used to assess and compare value in healthcare among available treatment options. ICERs are calculated by measuring or estimating the incremental costs and improvements in patient outcomes versus a therapeutic comparator through cost-effectiveness and cost utility models.
This is probably not something the average clinician will be thinking of at the bedside when deciding which IO-IO combination or IO-TKI combination to use, but economic models and metrics are essential in the allocation of health care resources and play a role in how we ultimately assess the value of IO therapy. “The definition of ‘value’ varies among stakeholders. For instance, patients and caregivers mostly overlap in how they define value, but subtle differences often exist between how patients differentially value returning to work or the impact of regaining their activities of daily living. Similarly, subtle but meaningful differences exist among how physicians, researchers, payers and employer groups define ‘value.’ In addition, the views of other stakeholders, such as drug developers, patients’ employers and family members are often not considered in the value assessment.”
As the pillar of IO therapy casts an even longer shadow over our treatment choices, the rationale for our choosing one or another or switching to another treatment class, as always, is primarily based on clinical criteria validated by evidence-based approaches. But the debate over these appropriate strategies is informed as well by the broader discussion on “the definition of value.” And the literature does not disappoint us in delineating these concepts and challenging our understanding of them.