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PBMs, AI in Cancer Care, Mergers, and More
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Released: October 01, 2024

Expiration: September 30, 2025

John Marshall
John Marshall, MD

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Segment 1: Industry News and Science

[00:00:05]

John Marshall, MD:

Hey, everybody, John Marshall back for oncology unscripted. If you've been silly enough to further away your time with me, we're now on the 7th episode, believe it or not. Goodness gracious, the sponsors of this are crazy to let me keep going.

But we do have some really cool stuff to talk about today, and I hope you'll listen in as I review not only sort of what's going on in our world, a little bit of gossip, a little bit of business, we're going to talk about the latest science, but as you remember, this is the third in three parts about the middle men, the middle people in oncology. And so, we've done pharmacy benefit managers. We've done the EMR. Now, the next one is Clinical Research Organization, CROs. So, stick around for some discussion about the impact of CROs on us, on clinical research, and maybe, are they helpful or not? You'll have to decide after you listen in.

[00:01:11]

Vermont Sues PBMs

But let's start with a little bit of gossip. So, if you remember, we talked about PBMs before, and just so happened that the state of Vermont, their attorney general has sued the pharmacy benefit managers for illegally driving up drug costs. You thought that was just me saying that? No, the Attorney General of Vermont also thinks that.

[00:01:29]

ACS CEO Steps Down

Sort of on a business note too, Karen Knutson, who's a really very prominent member of our cancer community, was or still is briefly the CEO for the American Cancer Society and the American Cancer Society Action Network. She has decided to step down, she's going to do a lot more work in that space. So, we will be seeing a new ACS leader. I always want to think about the ACS. It is the largest private nonprofit funder of cancer research in the United States. And, so, we do want to make sure and hold them accountable for their product beyond their journals and the like and what comes out of their science, but I think they've had a great impact over time. So, congratulations to Karen and we look forward to the transitions ahead.

[00:02:16]

NCI Puts Millions into AI Efforts in Breast Cancer

Sort of a crazy thing we came across is that, you know, there's a lot more AI in health care today. But the NCI just dropped 3. 7 million in an effort for AI to predict breast cancer risk and also sort of to try and wrap in health disparities to try and level that up a bit. But there's another one looking at AI outperforming conventional methods for prostate cancer. management. So, we're increasingly seeing AI being used, just like every time you drop something in your Google browser, AI being used to try and help us be better at what we do.

[00:02:59]

Honoring Dr. Jeff Weber

I do want to give us a bit of an update. There's a really important obit that I'm sure you saw a guy named Jeff Weber. Jeff Weber was 72 and he died. He actually. died of pancreas cancer, but we will know him forever as one of those people who's made a major impact in the world of cancer. His work in melanoma, his work in immunotherapy, frankly, his work as a mentor and making sure that for generations to come, we are going to see that kind of high quality clinical translational researcher, educator, the whole bit. We lost a big one when Jeff Weber died of one of my diseases, sadly, pancreatic cancer. I wish he was working on this one, because maybe he would've solved that one. I feel like we let him down, but here's to him and all that he has done and all the lives that he has touched.

[00:03:48]

McKesson Wins Bid for Florida Cancer Specialists

Just one little bit of business news. You may remember a few episodes back, we talked about sort of the interface about the You know, our industry and how groups are buying other groups, etc. Well, I mentioned Florida cancer specialists was being looked at by a bunch of different parties. Well, we now know McKesson, I guess, won the bidding for a low 2. 5 billion. McKesson bought Florida Cancer Specialists. And then if you think about everything from patient care all the way up the business chain is owned and organized by one group. And so, I do think we need to watch this space carefully because are things going to improve? Are they going to get more expensive? Are they going to get more efficient? We really need to see how this kind of structure works, because we know more and more of that is going to happen. In fact, I've heard some people predict that not too long from now, the entire United States might be covered by just 10 different health systems that there'll be mergers and acquisitions up and down the chain. so that will be just about 10 of us nationwide. We'll see if that comes too fast. But there's the 1st pass at it with Florida cancer specialist and McKesson working together.

[00:05:06] ​

John Marshall, MD:

What Did We Learn From the 2024 ESMO Congress?

So, let's look at a little science at this point. As you may not know, 34,000 of our closest friends gathered in Barcelona. Have you ever been to Barcelona? It's one of the greatest cities on the planet. The food is fabulous. The weather is fabulous. The views are spectacular. So, if you ever have a chance to go there, go to Barcelona.

Well, 34,000 heme/onc docs descended for the annual ESMO meeting. It moves around, unlike ASCO, which is always Chicago. ESMO moves around this year to Barcelona, and I thought it would be useful just to take a look.

I'm going to show you a few high-level abstracts and make sure you guys have seen these. You probably did. Because both the New England Journal of Medicine and Lancet Oncology had featured publications with the full articles that reviewed some major new science that was out there. So, I encourage you to browse both of those editions because there's a lot of practice changing stuff that went in there. But I thought I would actually feature a couple that maybe didn't make it; were still high value papers,

[00:06:15]

Enzalutamide + Ra223 in mCRPC with Bone Mets

So, one is a prostate cancer study, and this is where enzalutamide was given either alone or with radium 223. As you know, radium 223 is good for painful bony mets and things like that. So here was the question of what if you put the two together on initial treatment and the punchline was. It worked. So, you got a progression free survival of 19.4 versus 16. So, you got a three-month bump by combining these therapies. And I think the conclusions of the authors are probably accurate to what we will see in guidelines and the like is that this will become certainly a new standard option to patients with hormone refractory, metastatic prostate cancer.

[00:07:00]

Retifanlimab + Carboplatin-Paclitaxel in Anal SCC

Now, you don't see a lot of stuff around anal cancer, do you? We haven't made much progress in this space in a long time, and we've tried all sorts of different things. Well, we did get one clinical trial, and I'm going to screw the name of this drug up. It's retifanlimab basically another checkpoint inhibitor in combination with platinum and carbo taxol in patients with metastatic or inoperable squamous cell cancer, the anus and has not been treated with prior chemo. So, these are not common. This is a cancer I take care of. So fortunately, we take care of them most of the time, but this study actually demonstrated an improvement in outcome.

[00:7:43]

Pembrolizumab Plus Chemoradiotherapy for High-Risk Locally Advanced Cervical Cancer

And related to this a little bit further north, I don't know, is pembrolizumab plus chemo radiotherapy in cervical cancer, similar biology, similar risk, chemo radiation treatment, similar this kind of thing. Well, this study did show an improvement, but here the delta, it was not so great. So, if you added the pembro to the chemo radiation, you got 82.5%. Whereas if you just did the chemo radiation, it was 75%. A bump. Most people were cured. The bump was small. Giving everybody pembro for that small bump will be the decision we have to make going forward in cervical cancer patients. Big study, statistically significant. Got to think about the magnitude of the benefit. Is that worth it in these patients?

[00:08:23]

TACE + Lenvatinib and Pembrolizumab in Intermediate-Stage HCC

Another one back in the GI space, which I thought was important. We're seeing more and more HCC around the world. We know about lenvatinib. We know about IO therapy here. Well, what about if you gave TACE? So, you injected the liver lesions and gave the lenvatinib and some pembro. So, some TKI and IO concomitantly. This was the LEAP 012 clinical trial. And guess what? It was positive. It was positive by 4 months. So, 10 months versus 14 and a half months. So, I expect that we will see that moving very quickly to the front line setting as well when you're doing TACE early on in diagnosis. Current standard would be TACE alone. Now it's going to be TACE with combo therapy. So that's a good study. That's moving the bar forward in HCC. 

[00:09:21]

Neoadjuvant Pembro Plus Chemotherapy and Adjuvant Pembro for High-Risk Early-Stage TNBC

Breast cancer cannot be left out. Triple negative breast cancer. You give Pembro to chemo in patients in the neoadjuvant setting with triple negative breast cancer. Overall survival. Of course it was positive, but here again, 82% of patients were cured with the old standard. Adding the pembro to this, bumped it to 86%. So, you got five percentage points more. You gave a hundred women pembro for those five extra points , but it's a bad disease. My wife had it. I'm glad she didn't die; 5 percent may be my wife next time. So, we do understand the importance of adding that to treatment.

[00:10:04]

Neoadjuvant Durvalumab in Muscle-Invasive Bladder Cancer

And then the last one I want to talk about is again, an IO clinical trial. They featured it as well, plus chemotherapy, and in the adjuvant setting, neoadjuvant setting for bladder cancer. So, do you give it before or only after the treatment? And so, basically, the answer was by giving it before you did have an improved event-free and overall survival. So again, I'm expecting that we're going to see more and more neoadjuvant therapy coming in bladder cancer, clearly a trend and almost every cancer there is out there.

So, I sadly did not make it to ESMO, but I wanted to bring just a little bite of ESMO to you. I got no beautiful Barcelonan food to offer you, and you know, to make you feel more at home, but I hope you one day will go. And maybe not when ESMO is there, maybe just go with your family and have some fun.

[00:11:03] ​

This transcript has been edited for clarity.