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age of social media and Twitter, it might not be
considered as “hot.” To be sure, the bulk of attention
remains focused on various shifts in the treatment
paradigm and how we are to appropriately integrate
these shifts into our clinical practice. And yet, I am
impressed by the voluminous content surrounding the
use of IO therapy and the myriad issues many authors
raise for us not only as clinicians but for us as part of
the larger sphere of oncology and its place in the
overarching public health sector.
Consider, for example, a paper published earlier this
year by Kaufman, Atkins, Subedi et al (The promise of
Immuno-oncology: implications for defining the value
of cancer treatment, in the Journal for ImmunoTherapy
of Cancer, May 2019.) As the authors address this topic,
they note: “Responding to ongoing efforts to generate
value assessments for novel therapies, multiple stakeholders
have been considering the question of ‘What
makes I-O transformative?’ Evaluating the distinct
features and attributes of these therapies, and better
characterizing how patients experience them, will
inform such assessments.” The authors explore key
aspects and attributes of IO therapies that should be
considered in any assessment of their value and seek
to address evidence gaps in existing value frameworks
given the unique properties of patient outcomes with
IO therapy. That is a tall order for anyone to take on
but this report gives one of the most comprehensive
analyses of IO therapy available. It delves into a broad
spectrum of issues that will not only dramatically
enlarge your frame of reference but deepen your understanding
of the value of IO therapies, particularly as
it relates to economic models. For example, the Incremental
Cost Effectiveness Ratio (ICER) is used to assess
and compare value in healthcare among available
treatment options. ICERs are calculated by measuring
or estimating the incremental costs and improvements
in patient outcomes versus a therapeutic comparator
through cost-effectiveness and cost utility models.
This is probably not something the average clinician
will be thinking of at the bedside when deciding
which IO-IO combination or IO-TKI combination to
use, but economic models and metrics are essential in
the allocation of health care resources and play a role
in how we ultimately assess the value of IO therapy.
“The definition of ‘value’ varies among stakeholders.
For instance, patients and caregivers mostly overlap
in how they define value, but subtle differences often
exist between how patients differentially value returning
to work or the impact of regaining their activities
of daily living. Similarly, subtle but meaningful differences
exist among how physicians, researchers, payers
and employer groups define ‘value.’ In addition, the
views of other stakeholders, such as drug developers,
patients’ employers and family members are often not
considered in the value assessment.”
As the pillar of IO therapy casts an even longer
shadow over our treatment choices, the rationale for
our choosing one or another or switching to another
treatment class, as always, is primarily based on clinical
criteria validated by evidence-based approaches. But
the debate over these appropriate strategies is informed
as well by the broader discussion on “the definition
of value.” And the literature does not disappoint us in
delineating these concepts and challenging our understanding
of them.
Robert A. Figlin
Editor-in-Chief
EDITOR’S MEMO
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