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Pemetrexed in Nonsquamous Non–Small-Cell Lung Cancer The Billion Dollar Subgroup Analysis

(JAMA Oncology) July 27, 2017 - Pemetrexed, a next-in-class antifolate drug, was first approved by the US Food and Drug Administration (FDA) in 2004 in combination with cisplatin for the treatment of pleural mesothelioma.

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H. Jack West, MD (Posted: July 28, 2017)

quotesIt's important to note that while the statistics may well be over-interpreted/misinterpreted to imply that pemetrexed demonstrates meaningfully superior efficacy vs. other partner agents for a platinum in advanced non-squamous NSCLC, I and most of my colleagues who have a particular focus and expertise in thoracic oncologists try to be very judicious in our interpretation of the landscape. Few if any of us would consider pemetrexed to be the clear best choice among the various options, and I don't think any expert would consider alternatives to be a wrong choice. That said, there is near uniformity in favoring carbo/pemetrexed +/- bevacizumab in advanced non-squamous NSCLC not because it's overwhelmingly better but because it's just better enough in its therapeutic index to bubble up to the top. We need to choose one regimen, and for nearly all thoracic oncologists who have a full range of options available, the combination of good if not markedly superior efficacy combined with the favorable side effect profile, convenient schedule, and several other factors make it the best option to nearly all of us, even if not by a wide margin. That it is expensive, and specifically more expensive than some very inexpensive and perfectly serviceable alternatives is a separate question. The reality of the situation is that few specialists in thoracic oncology are forced to weigh or even carefully consider the question of the incremental value of pemetrexed over other alternatives. Unless that issue becomes prioritized enough for US oncologists to be incentivized to carefully consider the relative costs of agents, we will focus far more on the patient experience and patient/physician satisfaction without feeling compelled to seek a relative bargain option.quotes

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