Immuno-oncology therapies are increasingly being hailed as the fourth pillar of cancer treatment alongside surgery, chemotherapy and radiation therapy. Described as the ‘holy grail’ bringing about a ‘new era’ in cancer treatment, in the coming years a deluge of these therapies will move from the ideal treatment setting of clinical trials to enter the marketplace for use in clinical practice. One could argue that only then will we see beyond the ‘hype’ to more fully understand the potential of these therapies to impact patients’ lives.
Immunotherapies are designed to harness the natural tumour killing mechanisms of the patient’s immune system, thus improving the targeted killing of cancer cells. Unlike some other cancer drugs, these therapies tend to be suitable for only a sub-section of patients who can be identified using biomarkers. However, developing and manufacturing immuno-oncology therapies is costly and therefore the end products are expensive. For example, one recently approved checkpoint inhibitor priced at $51.79 USD per milligram can run over $1 million USD per patient per year.1 Another highly anticipated immune system activating therapy (CAR T-cell therapy) has been launched with a price tag of $475,000 USD per treatment.2 Healthcare systems worldwide are expected to fund these therapies but first they must understand the clinical benefits and cost effectiveness. In the case of cancer therapies this means seeking proof as to whether these therapies extend patients’ lives and/or improve their quality of life.
Investigating therapy value
These therapies have been developed following years of innovative research, yet they are often brought to market before there is sufficient evidence that they extend or improve patient’s quality of life. Overall survival remains the most compelling primary endpoint in oncology studies, however achieving this can take several years.3 In the case of potentially lifesaving therapies there is increased urgency and often the ‘hype’ puts pressure on governments to approve and fund these drugs by relying on surrogate endpoints.4 Of course, no payer wants to refuse to fund a drug due to the high cost and as yet uncertain clinical value only to find out the therapy could have saved many lives. However, the flipside is a potentially unfavourable benefit:risk ratio which does little to improve the patient’s prognosis.
Indeed, a recent study of oncology therapies approved by the European Medicines Agency (EMA) found that between 2009-2013 most oncology drugs entered the market without conclusive evidence of benefit to survival or quality of life.5 Furthermore, after a minimum of 3.3 years follow up, only 35 out of 68 cancer indications approved by the EMA had shown a survival or quality of life gain over existing treatments or placebo. For the remaining 33, uncertainty remains over whether the drugs extend survival or improve quality of life.
As oncology research continues to advance, more targeted and personalised therapies will become available and it will inevitably become increasingly difficult for governments to fund these therapies.6 Therefore, governments and payers may need to negotiate new funding mechanisms such as “conditional” funding deals.4 These deals require commitment from companies to provide post-marketing proof that their therapies are performing better than current treatment options and causing minimal toxicity while extending and/or improving patients’ quality of life. This could facilitate manageable funding of expensive therapies to ensure ongoing affordable access to those patients who will truly benefit.
CRC’s experienced Medical Affairs team are well equipped to demonstrate and communicate the value of innovative oncology therapies and develop effective engagement and market access strategies tailored to a client’s needs.
CAR T-cell therapy:
Treatment that attempts to boost the natural ability of T-cells to fight cancer. T-cells are a type of white blood cell and part of the immune system. Researchers take T-cells from the tumour, isolate the T-cells that are most active against the patient’s cancer or modify the genes in them to make them better able to find and destroy cancer cells. Researchers then grow large batches of these T-cells in the lab and they are injected back into the patient.7
Check-point inhibitor therapy:
Therapy that blocks certain proteins made by specific types of immune cells such as T-cells and some cancer cells. These proteins help keep immune responses in check and can keep T-cells from killing cancer cells. When these proteins are blocked, the “brakes” on the immune system are released and T-cells are able to kill cancer cells better. Examples of checkpoint proteins found on T-cells or cancer cells include PD-1/PD-L1 and CTLA-4/B7-1/B7-2.8
Overall survival (OS):
The length of time from either the date of diagnosis or the start of treatment for a disease, such as cancer, that patients diagnosed with the disease are still alive. In a clinical trial, measuring the OS is one way to see how well a new treatment works. OS has long been regarded by the oncology community at large, as well as drug regulatory bodies such as the U.S. Food and Drug Administration (FDA), as the gold standard for demonstrating clinical benefit.9
Progression free survival:
The length of time during and after the treatment of a disease, such as cancer, that patient’s live with the disease without it getting worse. In a clinical trial, measuring the progression-free survival is one way to see how well a new treatment works.10
The healthcare landscape is changing and companies providing products and services to the industry need to evolve to keep up. In the spirit of a New Year almost upon us, CRC has selected what we believe may be hot topics for the pharmaceutical and medical device industries in 2018.
Biosimilars – much ado about nothing?
The pharmaceutical industry is experiencing a second wave of patent expiry and some of the most successful biological drugs may soon have competition from biosimilar products. The Australian government has pledged to drive the uptake of biosimilars and so has implemented the ‘Biosimilar Awareness Initiative’ to support awareness of, and confidence in, the use of biosimilars (1). Furthermore, changes in the way doctors prescribe biosimilars and new pricing mechanisms are planned to take effect in 2018 (2). While the intention is to encourage greater uptake, controversy around biosimilars remains. So what’s fueling this controversy?
In 2017, the first biosimilar product dispensed largely in community pharmacy was listed on the Pharmaceutical Benefits Scheme. The product is eligible for ‘a-flagging’ meaning that, like generics, it could be substituted by the pharmacist at the point of dispensing without input from the prescribing clinician (3, 4). As shown in Table 1, generic medicines are simple molecules identical to the reference product (5), therefore switching from brand to generic products is considered safe. Biosimilars, on the other hand, are complex molecules that cannot be considered identical to the original brand and so switching between brand and biosimilar is causing some concern (5, 6). However, it is recognised that education is key to building confidence in biosimilars, and so for this reason industry representatives raised the alarm when a planned online government education resource for HCPs was cancelled (7). Yet HCPs and consumers need unbiased, consistent, responsive and user-friendly information developed by independent credible sources (4, 6). Indeed, with the introduction of many new biosimilars expected in 2018 and beyond, now is the time for companies to address concerns around potential issues with multiple switches, product interchangeability and other relevant matters that will impact patient care (4, 6). More to come on this topic in a future blog…
Table reproduced from Biosimilars vs Generics (5).
Forging new paths in reimbursement
In a previous blog, we discussed the increasing need to establish new reimbursement pathways for products that do not fit existing funding mechanisms (8). Recently, one company endeavoured to forge a new pathway following multiple rejections by the PBAC. In this case, a proposal was put to government detailing a unique PBS ‘swap out’ deal reported to be successful in another country (9). The deal under consideration by government could see the introduction of a long-term portfolio funding arrangement with the sponsor that has multiple innovative products in their pipeline and an active R&D program. If successful, this innovative funding option could possibly establish a mechanism whereby access to newly approved medicines would be guaranteed for eligible patients. Now that this request has been made, it’s likely we will see more of these types of ‘solutions’ by other companies in 2018.
Regulatory changes for medical devices
Inadequate clinical evidence is said to be the leading cause of rejection of medical device registration submissions by the TGA (10). A recent update of the TGA’s clinical evidence guidelines for medical devices aims to address this issue by detailing how to conduct clinical evaluations and how to present data in a clinical evidence report (10). Furthermore, the European Commission recently introduced a new Medical Devices Regulation (MDR) detailing a number of changes to be implemented over the next three years regarding the registration of medical devices. In keeping with the Australian Regulatory Authority’s policy of harmonisation with European standards, this new framework will likely impact Australian companies (11). Indeed, the impact of these changes may become more evident in 2018 and beyond and so regulatory teams who have been educated on how to implement the changes will likely have a head start over the competition.
CRC’s capability model is designed to deliver strategic and forward-thinking Medical Affairs solutions that can be adapted to external change and so continue to build value for our clients at all stages of the drug development lifecycle.
With little over a month to go until the end of 2017, now is timely to revisit market access as an issue that saw much attention focused on reimbursement delays in Australia, as well as some complex negotiations, which at times fuelled controversy during the year. Most likely market access challenges will continue to be a focus for pharmaceutical and biotechnology companies into 2018 and beyond.
Among various reimbursement challenges that raised an eyebrow was one case involving a company’s refusal to access a substantial 90% reduction in the reimbursed price for their therapy as this would not be commercially viable and could jeopardise their global pricing. However, among reimbursement obstacles identified, it has also been noted that pharmaceutical companies in Australia are not offering their “best price” early in reimbursement discussions due to their international head offices’ pricing policies, which leads to reimbursement delays (1).
In another case, reimbursement approval for a “revolutionary” therapy that would reduce the number of self-injections from two per day to one per week came through five years after product registration.
Taking market access challenges one step further, what about innovative therapies that do not fit into any existing funding mechanisms and so face an almost impossible reimbursement barrier? One could argue there should be as much focus on establishing new funding pathways for these therapies as there is on the Pharmaceutical Benefits Scheme (PBS) process.
Reimbursement pathways – which way?
While regulatory approval pathways are for the most part globally harmonised, reimbursement pathways vary among countries and are often complex and unpredictable (2). Product sponsors provide comprehensive clinical and economic evidence as part of a health technology assessment (HTA) used by government as the (usual) payer when deciding whether or not to fund a therapy. However, often there is difficulty in capturing many value aspects of medicines during the assessment process, which makes the longer-term health outcome and economic benefits of therapies less obvious (3).
Reimbursement may also follow a different pathway depending on the type of therapy. For example, the PBS has a rigorous assessment process for evaluating the cost-effectiveness of medicines and hence the value of innovative therapies, which considers clinical effectiveness, other health outcomes such as quality of life and associated costs. Yet blood products such as recombinant clotting factors are subject to a tender process in Australia for which the key focus is minimising price. This creates considerable challenges in demonstrating therapy value because while procurement tends to minimise the cost to government budgets, it is not a mechanism for recognising and rewarding therapy innovation. Indeed, tendering typically restricts choice of therapy for prescribers and patients.
In general, Australia’s reimbursement environment has caused frustration among pharmaceutical companies’ due to the cost-effectiveness hurdles of demonstrating value at prices often lower than a sponsor company’s global floor price (2, 4, 5). Many companies have also been impacted by “comparator erosion”, which is when a new therapy is priced against a generic product or relatively old therapy with a low price (2,5). Yet there is acknowledgement among stakeholders, namely, government, the Pharmaceutical Benefits Advisory Committee and the pharmaceutical industry of the need for a collaborative approach to improve reimbursement evaluation processes so that new therapies are affordable and accessible to patients (6 – 8).
Communicating therapy value
In recent years, advances in drug discovery and research have led to the development of innovative yet often expensive therapies. Sponsor companies absorb the risk and high cost of the drug development process, which can be offset with higher therapy prices and so the onus is on them to demonstrate the value of their product to achieve timely reimbursement (3). However, this may be difficult where no comparator therapy exists, the current comparator is an old therapy or a generic medicine (2).
It also seems there may be an imbalance between showing cost-effectiveness versus other elements that contribute to demonstrating therapy value and so perhaps the pharmaceutical industry as a whole could improve on how it communicates value to payers and other stakeholders. For example, factors such as meeting a high clinical need, improving quality of life and productivity gains (i.e. returning people to the workforce) are important, yet may not always translate to a cost-effectiveness ratio. Nevertheless, there remains the need to effectively communicate to all stakeholders on how the cost of an innovative therapy is justified by the clinical, economic and social benefits it delivers to patients.
CRC’s dedicated Medical Affairs experts are well equipped to implement effective market access strategies and communicate therapy value for clients bringing innovative products to market.
Increasing consumerism and patient empowerment has driven a change in how the healthcare industry engages with patients to provide therapeutic solutions. The final installment of our three-part blog series explores how the rise of patient centricity is impacting the design of patient support programs (PSPs).
Adding value to patient support programs
Pharmaceutical and medical device companies develop PSPs to help patients gain maximum benefit from their prescribed treatment to improve patient health outcomes and promote the quality use of medicines. These programs play a key role in supporting patients, providing information about their condition, helping patients adhere to their medication taking and making better lifestyle choices. Traditional PSPs have often taken a “one-size fits all” approach to address patient non-adherence. 1
In this era of patient empowerment, however, there needs to be a different approach to designing PSPs that complements the role of healthcare professionals (HCPs) in patient care. Patients need to see the value for themselves in participating in a company’s program. Forward thinking healthcare companies understand the benefits of investing in holistic PSPs and will undertake patient research to gain insights into the support services they really need and provide platforms for patients to participate in their care. Figure 1 shows the structure of a “beyond the pill” holistic PSP whereby the program has clinical relevance beyond simple medication adherence. 1 For example, a valuable support service for patients beginning a biological therapy for example is to provide training on how to administer injections, which is also beneficial for HCPs since this added support can shorten the time to starting the patient on a new therapy. 2 Designing a holistic PSP can have multiple benefits for pharmaceutical companies including enhancing patient engagement, assisting quality use of medicines prescribing, providing evidence to payers of added value for patients and also retaining brand loyalty. 1,3
Adapted from “Creating Value Through Patient Support Programs”. 1
Understanding the patient journey
Each patient’s journey has various phases and companies should consider the needs of individual patients at these different times. 1 It is important to develop a deep understanding of the patient journey from the path to diagnosis, through to ongoing interactions with HCPs, treatment decisions for ongoing care, managing treatment side effects and re-evaluating the treatment plan. Developing knowledge of the patient journey in this way can reveal important opportunities to engage with patients and provide individualised support services at appropriate touch points when they are most receptive. Seeking out these opportunities is important because the way in which a patient and their support network respond to certain situations along the journey can impact their long-term health outcomes. 4
The effects of a patient’s illness on their life and the side effects of their treatment are often subjective and difficult to quantify such as when considering emotional, cognitive, psychological and social factors. Progressive PSPs ensure that patients are supported holistically in these ways in managing their illness and that the program itself is clinically relevant, i.e. has the ability to improve clinical outcomes even without the drug.5 This is particularly important for patients with a chronic illness who suffer relentless psychological, emotional and social effects of their disease and the challenge to remain adherent to their treatment regimen. Therapy adherence involves more than education or reminder services – it’s about the patient correlating an improvement in their overall well-being with medication taking and improved symptoms, which helps build patient loyalty to a brand. 2
CRC’s experienced Medical Affairs team can engage key stakeholders to inform development of PSPs that are not just about the medication taking but also encompass holistic disease management elements.
This second installment of our three-part series discusses how the Medical Affairs function is evolving to provide solutions that address the three areas of change discussed in last month’s blog, i.e. greater consumer empowerment, complex regulatory pathways and informing payers about real-world data.
Looking through ‘multiple lenses’ – the importance of stakeholder engagement
The most competitive pharmaceutical and medical device companies are those who integrate rapid technological developments, use of big-data and real-world evidence into their medical affairs functions (1). Medical affairs teams link scientific and clinical results to patient outcomes and communicate these insights strategically to stakeholders throughout the product lifecycle. Responding to changes in the healthcare industry requires innovative stakeholder engagement strategies driven by understanding the needs of patients, healthcare providers, regulators, payers and government.
One example of the importance of stakeholder engagement in an evolving medical affairs function is the rise of medical science liaisons (MSLs) in response to restrictions on the activities of sales representatives in promoting therapeutic products to healthcare professionals. MSLs are now more likely to gain access to medical key opinion leaders (KOLs) to hold peer-to-peer discussions and gain insights that can inform clinical strategies and contribute to building competitive advantage.
Patient engagement strategies
Harnessing patient insights has been shown to impact positively across multiple business areas in the pharmaceutical and medical device industries, yet patient-centricity remains somewhat an aspiration for some companies (2). The use of digital platforms such as apps to allow patients to communicate with healthcare professionals (HCPs) via video journal during clinical trials is increasingly popular. However, medical affairs teams who embrace this type of technology must be careful to cater first to the patient’s needs before the business needs. For example, apps can allow the HCP to respond to patient queries or schedule an earlier visit if they are concerned with their patient’s progress or side effects. These apps can then have the secondary goal of providing a tool for companies to gather insights that can later be disseminated to regulators, payers and other relevant stakeholders as part of the business strategy. Companies relying solely on data from patient-physician interactions are limiting their potential to gain insights about the patient journey and so need to realise the importance of innovation to improve on current standards of patient engagement (3).
Strategies to engage payers
The rising cost of healthcare has caused payers to seek cost-containment measures and new forms of evidence in showing the cost-effectiveness of therapies (4). Simultaneously, the pharmaceutical industry has become increasingly frustrated with the uncertainty around the funding of new therapies and so there is a growing need for companies to develop a new model of interaction with payers (4). One suggestion is for early and ongoing engagement with payers similar to the approach that pharmaceutical companies often take with KOL engagement (5). Some examples of strategies that can add value to payer engagement are the use of real-world data, incorporating support services that optimise the value of a therapy for patients, as well as tools to help payers assess the quality of those services and negotiating risk-sharing arrangements such as pay-for- performance (4, 5). By developing an evidence based relationship, payers and the pharmaceutical industry can collaborate to bring the most clinically effective and best value solutions to patients.
CRC’s experienced Medical Affairs team can develop effective engagement and market access strategies tailored to a client’s needs for building effective stakeholder relationships.
CRC provides Medical Affairs solutions to the Pharmaceutical industry throughout the Drug Development Life Cycle. Our objective is to maximise the value of therapeutic compounds from pre-launch through to commercialisation and beyond.
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