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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
S. Vincent Rajkumar, and Jean Luc Harousseau Blood 2016;128:2757-2764
S. Vincent Rajkumar, and Jean Luc Harousseau Blood 2016;128:2757-2764
©2016 by American Society of Hematology
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
What’s going on?
Rajkumar SV. ASCO Ed Book. 2018
Rajkumar SV. ASCO Ed Book. 2018
1 week of VRD
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
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
Its not just new drugs….
http://www.nytimes.com/2015/09/21/business/
Daraprim $4477 at Costco with coupon! (from @goodrx)
Life in the last 20 years
Courtesy: Twitter user @lollydaggle
Courtesy: Twitter user @lollydaggle
Insulin
Why are prices so high?
#1
Why are prices so high?
• Blatant and Occult Patent Evergreening• Cost of drug development• Seriousness of Cancer
Why are prices so insanely high?
Unique to USA• Medicare cannot negotiate• Ban on personal importation• Reimbursement System encourages more
expensive option• Liberal Off-Label use • No equivalent of Health Authorities
Lack of Allies
• Physicians• Professional Organizations/ Societies• Patients • Patient care organizations• Insurance companies
What can we do?
What can we do?
• Establish Value-based pricing • Medicare allowed to negotiate• Allow importation for personal use• Facilitate easy entry of generics and bio-similars
Unique to USA
But what can we do?
1. Choose best possible option
Alternative lower cost approach to the treatment of multiple myeloma.
S. Vincent Rajkumar, and Jean Luc Harousseau. Blood 2016;128:2757-2764
©2016 by American Society of Hematology
VCD or VTD instead or VRD
Limit maintenance to 1-2 years
Consolidation instead of maintenance
Attal M et al. N Engl J Med 2017;376:1311-1320.
VRD
Early versus Delayed ASCT
2. Recognize how US drug prices matter worldwide
• Global cancer drug spending
• >US$ 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
3. Generate Careful, Powerful Guidelines
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
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
What can we do
•Strict guidelines – true metric of benefit•Regulatory Trials ≠ Practice Changing
•Careful with words like “Standard of Care”
4. Conduct Strategic Trials
Strategic Trials
• Response Directed Therapy• Curative Strategies (CESAR, ASCENT)
• Limited Duration Therapy• Targeted Trials
6-12 months and STOP should be our long-term Goal
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
Tefferi, Kantarjian, Rajkumar et al. Mayo Clinic Proceedings 90: 996; Jul 2015
5. Advocacy
1. Access2. Doctor vs Expert Role
CHALLENGES
For more info: @VincentRK on Twitter