Debu Tripathy, MD: Cost is an important part of everything we do, and I always share with my patients when a drug is on the expensive side or when a test is on the expensive side, although it’s always difficult for us as physicians to know what the burden on the patient is. We don’t know what their co-pays are. We don’t know what the insurance is ultimately going to approve or not. It’s very hard for us to give them the kind of advice that would be very tailored. However, it is important for us to share with them when they are receiving a very expensive drug or test. We should always project to them what the benefit is because they need to have that information not only for cost issues but also to balance that against the side effects so they can use that information as they need to.

As I mentioned, it’s very difficult to put physicians in a position to go beyond discussing to actually making recommendations based on cost because we don’t know what the cost burden to the patient is. We all, as physicians—and I think I share this view with many of my colleagues—would love to see more transparency in cost issues so that patients know up front what their cost responsibilities are and can make a decision based on real numbers. Unfortunately, oftentimes patients don’t even know what they owe and what their burden is going to be until well after the therapy is completed and all the decisions have been made.

Ruta D. Rao, MD: Practically speaking, cost does not factor into our discussions with patients on an individual basis. If you ask patients, they’re going to want to do everything they can to try to reduce their risk of recurrence. Oftentimes, as long as you’re treating within the indications, insurance companies will pay for these indications. But I think as a community, we really have to think about cost on a global basis regarding what percentage of improvements we’re getting in terms of disease-free survival, and eventually we’ll see the overall survival results and fit cost into that equation.

Debu Tripathy, MD: I think that the area of HER2-positive breast cancer has really moved a lot. When you think about it, it’s the only disease in which we’ve really made an impact on survival in the metastatic setting. In the adjuvant setting, it’s also a disease in which we’ve clearly improved the cure rate. It’s actually hard now to get new drugs approved because patients are doing quite well. Look how large the APHINITY trial had to be, over 4000 patients, to make a 1.5% difference. So the field is incrementally improving and getting better, and I think that it’s great that we’re able to offer these therapies and give people the best outcomes.

On the other hand, we’re always looking for the patients who might not need all that extra therapy. Can we actually develop tests that tell us who can get away with less? I mentioned earlier the trial that looked at weekly paclitaxel, and that was a bold trial to do because we were giving less than is typically given in hopes of avoiding toxicities and still hoping that patients had an excellent outcome. We were able to show that, and that has now become a standard for low-risk cancers. So the question for the higher-risk cancers—maybe on the basis of how well people respond to neoadjuvant therapy—is might we at some point be in a position where we can actually scale back? What about patients who achieve a complete pathologic response? Maybe they don’t even need the full year of a maintenance antibody. We’re certainly not in a position to say that at this point, but a trial could conceivably be done where that is tested in a randomized fashion.

Transcript Edited for Clarity