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Divergent Findings With Paclitaxel and Nab-Paclitaxel in TNBC

(Medscape Medical News) Sept 28, 2020 - Certain patients with triple-negative breast cancer (TNBC) may benefit when atezolizumab is combined with nab-paclitaxel but not with paclitaxel, a pair of phase 3 trials suggest. The trials, IMpassion130 and IMpassion131, both enrolled patients with metastatic or unresectable, locally advanced TNBC.

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Stephen M. Schleicher, M.D., MBA (Posted: October 01, 2020)

quotesThe finding that atezolizumab is beneficial only with Abraxane and NOT paclitaxel not only has important implications clinically (i.e. should use atezolizumab in combination ONLY with abraxane for metastatic PD-L1 + TNBC), but also has important implications for value-based care, specifically OCM and its episode cost prediction methodology. In OCM methodology, new drug approvals and existing drugs with new indications are deemed a "novel therapy" for 2 years after FDA approval. This contributes to the "novel therapy adjustment" that helps CMMI adjust expected cost of care based on the rising costs of new drugs. In the case of the IMpassion 130 data, atezolizumab for TNBC would be considered a novel therapy. However, abraxane, which is orders of magnitude more expensive than its counterpart paclitaxel, is NOT considered a novel therapy since it was already approved for breast cancer. Thus, when providers that otherwise would have used single agent paclitaxel (very inexpensive) in TNBC but now appropriately use for PD-L1+ disease the standard of care atezolizumab + abraxane regimen (which is more than 200 times more expensive than paclitaxel based on average sales price), only atezolizumab counts as the novel therapy. Yet, abraxane is almost as expensive. This is similar to the approval of chemotherapy plus pembrolizumab in stage IV lung adenocarcinoma based on KEYNOTE 189, in which case the approved chemotherapy backbone requires pemetrexed instead of the much less expensive paclitaxel. Thus again, the option to replace pemetrexed with paclitaxel – which in the past was an effective way for providers to choose a less expensive or higher value treatment option in non-squamous NSCLC - is no longer evidence-based when in combination with pembrolizumab. With this in mind, the ability for providers to choose a less expensive yet standard of care treatment option is narrowing, and payers should consider this when designing oncology value-based care models that include drug costs in their cost of care targets. quotes

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Tomasz M. Beer, MD, FACP

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