Non-small cell lung cancer (NSCLC) is a high-cost category with an increasing number of therapies that treat different subtypes of the condition. To help stakeholders absorb datapoints and perceptions from all directions and synthesize those insights into a tangible strategy for NSCLC, Zitter Insights surveys a leading panel of pharmacy and therapeutics (P&T) decision makers at payers and integrated delivery networks. The Managed Care Oncology Index combines deep payer insights with the industry standard in market access information to produce quarterly reports and insights summaries on leading oncology brands.
Payers with more than three-fourths of covered commercial lives said they manage NSCLC drugs to label at the time of the survey. Slightly less said they expect to manage NSCLC medications to label within 12 months, while respondents revealed that they expected to increase their management of the agents more restrictively than their approved label.
More than one-third of payers said that National Comprehensive Cancer Network (NCCN) guidelines were highly influential in their management of NSCLC. But almost two-thirds of oncologists said that they viewed the evidence-based guidelines as the standard of care for NSCLC (see chart).
In the 12 months prior to the survey, oncologists prescribed Merck & Co., Inc.’s Keytruda (pembrolizumab) most often, followed by Bristol Myers Squibb’s Opdivo (nivolumab) and AstraZeneca’s Imfinzi (durvalumab). On the other end, the drugs least prescribed include Eli Lilly and Co.’s Portrazza (necitumumab), Novartis Pharmaceuticals Corp.’s Zykadia (ceritinib) and Takeda Pharmaceuticals U.S.A., Inc.’s Exkivity (mobocertinib). Respondents cited cost, lack of indicated patient population, use of competitors and absence of formulary coverage as common reasons to not prescribe NSCLC therapies.
The FDA has approved a handful of programmed death-1/programmed death-ligand 1 (PD-1/PD-L1) agents to treat NSCLC. Payers with almost two-thirds of lives said they are unlikely to prefer one PD-1/PD-L1 therapy over another in the 12 months following the survey (see chart). Of the respondents who said they were likely to take this action or were undecided, those with almost two-thirds of lives said they manage all of the therapies at parity, and those covering more than half said they wanted to provide all options for oncologists to choose from. Those representing almost half of lives said that not enough information exists to prefer only one PD-1/PD-L1.
Payers covering more than half of commercial lives said that their organization covers companion diagnostics for NSCLC treatments. And those with more than three-quarters of lives require test results from a companion diagnostic in order for patients to gain access to a NSCLC therapy. Payers representing more than half of commercial lives require test results for all NSCLC therapies as opposed to specific therapies. Among payers covering Medicare lives, those representing almost all lives require companion diagnostic results for all NSCLC medications.
Message: “Tepmetko was approved late 2021 for the treatment of non-small cell lung cancer. It was given a fast-track approval due to efficacy data in phase 3 trials, so as phase 4 data is released, this may pull back. Importantly, Tepmetko targets MET 14 and is thought to only be effective in cancers expressing this variant.”
Payer Thoughts: “The data is strong though admittedly a small subset with the exon mutation requirement. With the accelerated status it will play an important role but will be necessary to have NCCN guideline adoption.”
Biomarker Testing Is Not Keeping Up With Drug Innovations
Despite the tremendous progress made over the past decade in developing targeted oncolytic therapies, testing for specific mutations — or biomarkers — to determine the proper candidates for those treatments lags behind. For example, an article published July 7, 2021, in Cancer Therapy Advisor — which summarized a presentation at the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting — revealed that less than half of people with metastatic NSCLC received a test for five analyzed biomarkers before starting first-line treatment. A few states have passed or are considering legislation requiring insurers to cover biomarker testing, with California becoming the most recent state to pass such a law.
FDA Gives Accelerated Approval to Exkivity
In September 2021, the FDA gave accelerated approval to Takeda Pharmaceutical Company Ltd.’s Exkivity (mobocertinib) for the treatment of adults with locally advanced or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations as detected by an FDA-approved test whose disease has progressed on or after platinum-based chemotherapy. The agency also approved Thermo Fisher Scientific’s Oncomine Dx Target Test as a next-generation sequencing companion diagnostic for Exkivity.