Spring/Summer 2024
Regimen review in addition to National Comprehensive Cancer Network (NCCN) guideline compliance can fine-tune cancer treatments for improved outcomes, reduced toxicity and cost.
Immunotherapies and other costly medications have proven to be groundbreaking and effective cancer treatments. While NCCN guidelines offer sufficient usage direction for these drugs, they do not consider all quality and outcome factors often used in comprehensive UM programs. Any NCCN Category 1 drug recommendation is not only based on “high-level evidence,” but also “uniform NCCN consensus that the intervention is appropriate.”1
However, clinical appropriateness is just one aspect to consider with any regimen. Pembrolizumab (Keytruda) and ipilimumab (Yervoy) in combination with nivolumab (Opdivo) are considered standard of care for advanced melanoma and are NCCN Category 1 treatments. Yet one study comparing pembrolizumab to ipilimumab concluded that “pembrolizumab prolonged progression-free survival and overall survival and had less high-grade toxicity than did ipilimumab in patients with advanced melanoma.”2 (See spotlight). The addition of nivolumab to ipilimumab would most likely further increase treatment related toxicities that patients may experience.
In addition, a one-year regimen of pembrolizumab costs nearly 35% less than ipilimumab which is paired with nivolumab. Simply implementing a guideline compliant regimen may not sufficiently consider all significant factors including impact on quality of life and cost. One way to evaluate the entirety of a regimen’s arc is through a well implemented treatment review process (see sidebar). Guideline compliance does not necessarily address how one drug may have advantages over others for an individual patient.
Optimizing Regimens with Professional Resources
NCCN Category 1 regimens may have uniform consensus that a treatment is appropriate, but a patient’s cancer care can be optimized by having a treatment plan reviewed for additional factors such as overall survival, progression free survival, possible toxicities and cost. Utilizing subspecialty oncologist panels to consider these additional regimen elements in conjunction with NCCN guidelines enhances cancer care and mitigates downstream clinical and financial challenges. In comparison, many pathway solutions do not offer individualized care considerations such as age or comorbid conditions. Moreover, other aspects such as a patient’s physical ability to tolerate chemotherapy along with appropriateness of palliative services, would be within the scope of advanced treatment reviews, but outside the scope of most pathway services.
Spotlight: Treatment Comparison
Though both pembrolizumab and ipilimumab (given in combination with nivolumab) are NCCN Category 1 guideline regimens for advanced melanoma, the study comparing pembrolizumab and ipilimumab concluded that pembrolizumab resulted in significantly prolonged overall survival.
Source: Pembrolizumab versus ipilimumab in Advanced Melanoma. N Engl J Med. 2015 Jun 25;372(26):2521-32