Is the third time the charm for immuno-oncology?


Bruce Feinberg, DO

Vice President
Chief Medical Officer
Cardinal Health Specialty Solutions

Evidence-Based Oncology (EBO), an indexed news publication of The American Journal of Managed Care, devoted its February 2015 issue to immuno-oncology.

In a commentary that draws on 30 years of waiting on the promise of immune-oncology, Dr. Bruce Feinberg, vice president and chief medical officer of Cardinal Health Specialty Solutions, outlines the key issues facing payers, oncologists, policymakers and patients themselves.

In this Q&A, Dr. Feinberg discusses some of the key issues he addresses in his recently published EBO commentary, entitled “Impacting Stakeholder Adoption of Immuno-Oncology.” For the full text of that commentary, click here.

Q: Tell us about the key topic of your Evidence-Based Oncology (EBO) commentary on Immuno-Oncology.

A: For those who treat cancer patients and for payers who fund their care, deciding whether a treatment has value has always involved what I call “the triad” of efficacy, toxicity and cost. But today, as the third wave of immuno-oncology moves beyond the research phase and into clinical practice, balancing those three factors has never been more challenging. That’s the key issue I explore in this new commentary.

Q: Your EBO commentary focuses on the “third wave” of immuno-oncology. How would you characterize its earlier phases?

A: In the mid-1980s, when I was a fellow at MD Anderson Cancer Center in Texas, the concept of harnessing the body’s own immune system to fight cancer was just emerging. I had conducted significant research on the topic (published in the Journal of the American Medical Association) and also presented my work at the annual meeting of the American Society of Clinical Oncology.

The enthusiasm over this first generation of immuno-oncology agents was eventually tempered by toxicity and limited efficacy, leading to the commercialization of only a handful of agents that would have an impact on relatively small number of patients. A second wave of research into immunotherapy vaccines, led by Steven A. Rosenberg, MD, PhD, at the National Cancer Institute, yielded insights into how tumors circumvent immune-regulatory mechanisms, but widespread commercial success remained elusive.

Q: And the “third wave” of immuno-oncology that you discuss in your EBO commentary?

A: The good news is that immuno-oncology has turned a corner. Approvals of ipilimumab to treat metastatic melanoma and sipuleucel-T to treat minimally symptomatic metastatic prostate cancer offer only a glimpse of what could come with this “third wave.”

Recent FDA approvals of nivolumab and pembrolizumab capitalize on the area of greatest promise: targeting the PD-1, or “programmed cell death” pathway. Blocking this protein can potentially be used to treat a variety of tumor types, under different conditions, and trials abound to learn which patients can benefit. 

Q: Advances in immuno-oncology seem exciting, and great for patients. What’s the challenge?

A: Crossing this frontier is not without a price. Achieving stakeholder buy-in for therapies that will be incredibly expensive—and still not curative—will require collaboration among everyone in oncology, including the drug developers. 

Although the cost versus value can be debated, cost has increasingly become a factor in stakeholder adoption.

With the “third wave” of immuno-oncology upon us, the question of what makes a cancer therapy worth the price cannot be avoided. Rapid responses, durable tumor control, and long-term survival through harnessing the power of the immune system are now realities.