U.S. Physician and Payer Forum

June 2013

Defining Optimal Sequential Treatment with Targeted Agents in Colorectal Cancer: How Are U.S. Physicians and Payers Responding to New Treatment Options in the Metastatic Setting?

Report Authors
Gemma McConnell, Ph.D.

Introduction:

Colorectal cancer (CRC), which collectively represents cancers of the colon and the rectum, is one of the most common forms of cancer for both men and women. Current treatment for CRC is dependent on the stage of the disease, the tumor and patient characteristics, and the patient response to previous lines of treatment. Stage IV or metastatic CRC (mCRC) refers to disease that has metastasized to at least one distant organ, most commonly the liver or lung. The 2012 U.S. launch of Regeneron/Sanofi’s decoy antibody Zaltrap (aflibercept) and Bayer HealthCare’s small molecule multitargeted kinase inhibitor Stivarga (regorafenib) increased the number of targeted agents approved for the treatment of mCRC to five, adding to Roche/Genentech/Chugai’s Avastin (bevacizumab), Bristol-Myers Squibb/Eli Lilly/Merck Serono’s Erbitux (cetuximab), and Amgen/Takeda’s Vectibix (panitumumab). Furthermore, in January 2013, the FDA approved a label extension for the continuation of Avastin treatment into the second-line setting for mCRC patients whose disease has progressed on a first-line Avastin-containing regimen. EGFR-targeting agents, Erbitux and Vectibix, are now indicated only in KRAS mutation-positive patients.  Despite KRAS testing becoming routine clinical practice, many U.S. physicians indicate that Avastin, which does not have biomarker for predicting patient response, is typically preferred as a first-line treatment and EGFR-targeted agents are reserved for second- or subsequent lines of treatments. With the approvals of Zaltrap or continuation of Avastin beyond disease progression adding to second-line treatment options, EGFR-targeted agents will face increased competition. Considering the wealth of treatment options in the advanced, mCRC setting, physicians have multiple options when deciding upon their sequential targeted treatment approach for patients. This report will survey medical oncologists and MCO pharmacy directors, and will cover reimbursement and prescribing trends for approved targeted agents in mCRC and explore which factors impact their optimal sequence of prescribing of these agents.

Questions Answered in This Report:

  *   Medical oncologists’ current use of targeted agents in the metastatic setting: What is the most frequently prescribed sequential treatment for mCRC? What factors impact the choice of targeted agent in the first-line setting? What factors determine the choice of targeted agent in the second- and subsequent line settings? In what setting are EGFR-targeted therapies most frequently prescribed? How has the U.S. launch of Zaltrap and line extension of Avastin for continuation of treatment beyond disease progression affected prescribing of EGFR-targeted agents? Has the label expansion for Avastin for treatment beyond disease progression impacted prescribing of other targeted agents? Do physicians anticipate changes in sequential treatment with targeted agents in light of recent approvals/line extensions?

  *   Medical oncologists’ and payers’ attitudes towards treating mCRC as new therapies have entered the market: How have physicians integrated Zaltrap into their treatment practice? How does the level of prescribing of Zaltrap compare with that of Avastin in the second-line setting? How do physicians select between Avastin and Zaltrap? How have physicians integrated Stivarga into their practice? Which therapies are most at risk of losing share following Zaltrap and Stivarga’s launch? What factors influence formulary inclusion of Zaltrap and Stivarga? How do managed care organization (MCO) reimbursement constraints, including tiering and formulary restrictions, impact the potential patient share of these recently approved drugs?

  *   Emerging therapy, ramucirumab, for treatment of mCRC: Based on ramucirumab’s clinical profile and expected price points presented to respondents, how do physicians surveyed expect to prescribe this emerging therapy? What clinical attributes are most likely to persuade physicians to switch from their most frequently prescribed second-line therapy to ramucirumab? Based on ramucirumab’s profile and expected price points presented, how do payers surveyed expect to reimburse this agent?

Scope:

This U.S. Physician & Payer Forum reveals physicians’ and payers’ insights into prescribing and reimbursement decisions for mCRC in the United States. The report is based on a survey of 102 medical oncologists, who treat at least 10 mCRC patients per month, and 30 MCOs (20 pharmacy directors and 10 medical directors) that offer commercial health insurance. We highlight current prescribing and reimbursement practices in mCRC and the factors that influence these decisions, with particular focus on the impact of recent label expansions for current targeted agents and the approvals of new targeted agents on physicians’ prescribing practices, in addition to the expected prescribing and reimbursement of emerging agent ramucirumab.

Markets covered: United States.

Primary research: Online survey of 102 medical oncologists and 30 MCOs (20 pharmacy directors and 10 medical directors)

Epidemiology: All mCRC; first-line, second-line, third-line, and forth-line (separated by wild-type and mutant KRAS disease)

Population segments: Where appropriate, our analysis is segmented by line of therapy (first to forth-line) and KRAS mutational status. We also provide separate analyses segregating patients based on eligibility for first-line oxaliplatin-based therapy.


Search Reports

Mentioned in this report:

  • - Amgen
  • - Bayer HealthCare
  • - Bristol-Myers Squibb
  • - Chugai
  • - Eli Lilly
  • - Genentech
  • - ImClone Systems
  • - Merck Serono
  • - Regeneron
  • - Roche
  • - Sanofi
  • - Takeda
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