Value-Based Decision-Making in Metastatic Breast Cancer - Episode 12
Debra Patt, MD, PhD, MBA, highlights how value-based care models affect treatment decisions for patients with HER2-positive metastatic breast cancer.
Briana Contreras: Now for our last series of questions, we’ll be looking at value-based care models in precision oncology in HER2-positive metastatic breast cancer. What are some of the challenges with HER2-directed therapy in a value-based care model?
Debra Patt, MD, PhD, MBA: Well, when you have a higher percentage of patients that’s HER2-positive, I think that your total health care resource utilization is going to be higher because you’re using more novel therapies like trastuzumab, pertuzumab, trastuzumab deruxtecan [DS-8201], and tucatinib therapies that are on average, more expensive. In contrast to if you were to look at other types of breast cancer, though I will say for other types of breast cancer for triple-negative breast cancer that is amenable to immunotherapy. Immunotherapy is also expensive. And for ER [estrogen receptor]-positive breast cancer that’s HER2-negative, frontline treatments with estrogen blockade and CDK4/6 inhibition also add cost. Because of the innovation in breast cancer and HER2-positive breast cancer in the last year, I think those therapies in general are more expensive. But I think that all of cancer care is experiencing tremendous innovation, and that does drive up the total cost of care. As we think about value, again value being outcomes over cost, I think you can’t question these incredible outcomes that patients have had, and their improvements in progression-free and overall survival as a natural consequence of these innovator, therapeutic interventions.
Briana Contreras: How does total cost compare with that of standard chemotherapy approaches and how does the cost breakdown vary?
Debra Patt, MD, PhD, MBA: When you’re using chemotherapy in combination with HER2-directed therapy, it is substantially more expensive than chemotherapy alone. But I would argue that chemotherapy alone, unless HER2 therapy is truly contraindicated, really isn’t a reasonable treatment choice for patients with HER2-amplified metastatic breast cancer because it doesn’t give them an optimal outcome.
Briana Contreras: How do guidelines and pathways influence your treatment decisions in value-based care delivery?
Debra Patt, MD, PhD, MBA: I think of guidelines and pathways as a map. For many oncologists, pathways can exist in a clinical decision support system like a nudge for appropriate guideline-based care delivery that’s in the best interest of patients, just like Google Maps is going to get me to my destination in the most efficient possible way. So, I think in general, patients do better when they’re treated in accordance with guidelines and pathways. Those strongly influenced our choices around care delivery. However, just like when I sit, and I drive, and I’m in the driver’s seat of my car, really therapy choices belong in a room with individual patients and their doctors. There may be really reasonable reasons why patients vary from guideline-based choices that are individualized. So, what I would say is, while guidelines and pathways are incredible facilitators of evidence-based decision-making, they don’t supplant the need for clinical decision-making. That still remains an important component of care delivery plans, and patients have a say in how they move forward. I think that they’re really useful tools to try to make sure that most patients are treated in accordance with guidelines and evidence that makes a lot of sense and is in the best interest of patients. But at the end of the day, those are still individualized choices between doctors and patients that can depend on many patient-specific factors.
Briana Contreras: Lastly, what are other considerations regarding HER2-targeted therapy from a value-based care perspective?
Debra Patt, MD, PhD, MBA: Well, again in patients with HER2-positive metastatic breast cancer, they can benefit from these long disease-free intervals more than a decade. I think the question remains, how can we give the most effective therapy upfront, and then keep them on some chronic therapy in perpetuity to keep their disease controlled, and in the most cost-efficient way. With so many innovator products in this space, I think we’re going to have better answers there in the next years to come.
Briana Contreras: Wonderful. Thank you so much.
Transcript edited for clarity.