Limitations of the current study included the model’s reliance on patients enrolled in clinical trials as opposed to real-world data (the nivolumab and ipilimumab combination was only approved to treat kidney cancer in 2018, however). As a result, there is a lack of long-term survival information on nivolumab plus ipilimumab in RCC. Despite the fact that there is optimism about how well patients will respond to the immunotherapy combination, the coauthors noted that the data for the model “are an extrapolation, and limit our confidence in the results.”

Dr Sarfaty acknowledged an additional limitation: the combination’s toxicity profile, which makes the therapeutic combination more difficult to adopt in community practice settings. “This is indeed problematic,” he said, “as immune-related toxicity may appear in different ways and necessitate[s] prompt management. This requires the education of health care providers, patients, and their caregivers. In time, I believe providers will be able to manage these patients outside of large centers.”

In addition, sunitinib itself has been found to be cost effective in metastatic RCC compared with both sorafenib alone and the combination of bevacizumab plus IFN-α, comparing favorably with other newer treatments.5 But in an interview with Cancer Therapy Advisor, Hans Hammers, MD, PhD, of UT Southwestern Medical Center in Dallas, Texas, stated that while targeted therapies can potentially be cost effective, patient responses to these medications are typically not durable.

“Roughly 22% of patients on the nivolumab plus ipilimumab combination have to come off it because of side effects,” he said. “But we also know that these patients, even if they have to stop, can do just as well as those who continue therapy.”

He shared the story of a patient of his who was entered into the nivolumab plus ipilimumab clinical trial, received the combination, and developed an irreversible side effect after just one dose. His treatment was halted and he was only observed from there; his very aggressive kidney cancer, however, disappeared. He hasn’t needed additional therapy for going on approximately 4 years now.

“It’s like a leukemia model,” he added. “There is a lot of treatment and perhaps a lot of toxicity upfront, but if it works well, you may see a very durable benefit. You may even be able to stop therapy, which could mean costs coming down as well. ‘Cured’ is a strong word to use, but that may be where we’re headed.”

References

  1. Reinhorn D, Sarfaty M, Leshno M, et al. A cost‐effectiveness analysis of nivolumab and ipilimumab versus sunitinib in first‐line intermediate‐ to poor‐risk advanced renal cell carcinoma. The Oncologist. 2019;24(3):366–371.
  2. Motzer RJ, Tannir NM, McDermott DF, et al. Nivolumab plus ipilimumab versus sunitinib in advanced renal-cell carcinoma. N Engl J Med. 2018;378(14):1277–1290.
  3. Bae YH, Mullins CD. Do value thresholds for oncology drugs differ from nononcology drugs? J Manag Care Spec Pharm. 2014;20(11):1086–1092.
  4. Lam SW, Wai M, Lau JE, McNamara M, Earl M, Udeh B. Cost-effectiveness analysis of second-line chemotherapy agents for advanced gastric cancer. Pharmacother J Hum Pharmacol Drug Ther. 2017;37:94–103.
  5. Benedict A, Figlin RA, Sandström P, et al. Economic evaluation of new targeted therapies for the first-line treatment of patients with metastatic renal cell carcinoma. BJU Int. 2011;108(5):665–672.