Jack West, MD: We need to distinguish between a cosmetic improvement in something that’s remarkably less expensive, and notably so, a game changer. A treatment coming in as a second or much later entrance in the EGFR market and still being 85% or 90% the cost, isn’t going to be enough to displace our general, strong affinity for osimertinib [Tagrisso].

Mark Socinski, MD: One of the hats I continue to wear is the cochair of what used to be the Oncology Pathways, and are now Elsevier Pathways.Ross Camidgeand I cochair the lung committee, and Elsevier asked us to make a decision about 1 pathway choice, based first on efficacy, second on toxicity, and third on cost. I can think of at least 3 instances in which we couldn’t differentiate a lung cancer treatment based on efficacy or toxicity, but we made a decision based purely on cost. Sometimes the cost difference was only 6%, in the case of 1 of the immunotherapeutic agents. But in 1 of the driver subsets, there was a 50% difference in the cost of the 2 drugs that were in the class.

One of the drugs came first, and that was on the pathway, so we took it off the pathway because when the other drug was approved, it was priced 50% less. It was priced 50% less because in addition to the indication we were considering, the drug also had a second indication in lung cancer. Maybe our lung cancer people can figure out which drugs I’m talking about, but the drug was priced more to compete with drugs in the other driver subsets vs the driver subset that only had a single drug in that setting.

The point is that these costs can influence pathway decisions or guideline decisions in this setting. Let me ask my 2 friends, Jack and Gilberto—I often use this as an example in the high PD-L1 expressors. Let’s assume this agent was approved in the United States. They need your recommendation. You see a patient with exon 19, and your recommendation is to give osimertinib as your first-line choice. Two days later, your office calls you, or your clinic calls you, and says, “The patient’s insurance company doesn’t cover osimertinib, but it does cover aumolertinib.” Knowing what we know now, would you say, “That’s not acceptable. We have to fight this because osimertinib is a better drug.” Or would you say, “The patient will be financially better off sticking with their insurance payer’s choice”?

Gilberto Lopes, MD: This is a discussion I would definitely have with the patient. Without a doubt, I’d be more comfortable once we see overall survival data. But if the option is between getting aumolertinib vs gefitinib plus erlotinib, I’d be very happy going with aumolertinib if we can’t get osimertinib.

Jack West, MD: I agree. There are things we would love to have, to be as comprehensive as possible, and there are things we do because it’s a preference. I—and I suspect both of you do as well—generally use pembrolizumab [Keytruda] in first-line setting for high PD-L1. I haven’t used atezolizumab [Tecentriq] or cemiplimab [Libtayo] in this setting. The data look very comparable, but why would I change? It has to break a pattern, and there hasn’t been a reason not to. If an insurance company says that it’s significant and that they’re going to cover 1 but not the other, I’m not going to die on that yolk. That’s fine.

Gilberto Lopes, MD: I’m not going to do that peer-to-peer call as well.

Jack West, MD: No, it’s not a wrong choice.

Gilberto Lopes, MD: We’ve taken the path of least resistance, and using the cemiplimab where the atezolizumab vs the—

Jack West, MD: Exactly. If a company doesn’t necessarily have to be 50% less expensive, if it’s enough that a company or an insurer will intervene and say, “We preferentially use 1 but not the other,” then I’ll say it works for me. That’s good enough.

Gilberto Lopes, MD: Me too.

Mark Socinski, MD: I’ve used that example specifically in the high PD-L1 space, and there’s an opportunity for some price disruption. We’ll see if it happens because we know that there are other PD-1, PD-L1 compounds coming in the future.

Transcript edited for clarity.