Evaluating Total Cost Considerations in Non–Small Cell Lung Cancer Care

Key Takeaways: 

• Administration route drives total cost of care: Intravenous therapies require significant infusion center time, specialized staff, and prolonged monitoring, while subcutaneous options may reduce chair time and patient burden but still carry implementation costs.
• Monitoring needs shape workflow and staffing: Newer immunotherapies and bispecific antibodies introduce complex safety considerations, often requiring extended observation, additional training, and contingency planning that strain clinic resources—especially in smaller centers.
• Operational flexibility is essential for sustainability: To adopt newer formulations successfully, practices may need to redesign infusion spaces, invest in education and digital monitoring tools, and balance patient-centered care with financial and operational realities.

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Estelamari Rodriguez, MD, MPH: I'm Dr Estelamari Rodriguez. I am a thoracic oncologist at the Sylvester Comprehensive Cancer Center at the University of Miami. I'm also the clinical research lead for our thoracic site disease group.

When we look beyond drug acquisition cost, how do differences in administration routes—such as intravenous versus subcutaneous therapies—shape the true total cost of care for non-small cell lung cancer (NSCLC) patients across various practice settings?

Dr Rodriguez: That is a great question, and it's a new question because now we have some subcutaneous formulations that are new, especially for the thoracic oncology space. But if we think beyond the price of the drug to what it costs to administer a drug to a patient, this becomes a major driver of the total cost of care that we experience for some of our cancer treatments.

Intravenous therapies, which is what we are used to up to this point, require infusion center time. You have to have specialized nursing and pharmacy compounding. In our cancer center, an academic cancer center, we have several satellites that are able to do this. But for some smaller centers, patients have to drive to have the right care. You have some competition in terms of chair availability if you have a large practice.

In some cases, there's time added to pre-medication and we're seeing now that some of the new treatments, such as some of the bispecific antibodies, require extended observation for up to 6 to 8 hours after an infusion that lasted 20 minutes. It's not only the time of the IV infusion, sometimes it's the time of the patient sitting there for observation, and that's definitely part of the cost.

[We now have several subcutaneous therapies.] In thoracic oncology, we have immunotherapies that are available in the subcutaneous setting. It becomes interesting because now we have protocols where the immunotherapy is available subcutaneously, but not the chemotherapy. You still have to get an IV, and then the subcutaneous option is there.

We don't know if that's saving a lot of time, but in some settings where the treatment the patient is getting is only that drug, that can help us support patients and treat more patients at the same time. They don't take a lot of chair time, but there are some costs involved that have to be taken into consideration.

From the patient's perspective, this is really wonderful because patients can travel less. For some of these formulations, you can do them less often or they take less time, so you don't have to come for 2 infusions when you're at the beginning of the treatment. It's easier for patients to come in and stay on treatment.

How do evolving monitoring needs—particularly with newer targeted or immunotherapies—affect workflow, staffing, and resource utilization in oncology clinics treating NSCLC?

Dr Rodriguez: It depends on the treatment you're talking about. Some of the more complex treatments right now are bispecific T-cell engagers that require 3 admissions to the hospital so that patients can be monitored for 24 hours for potential cytokine release syndrome, which can present like low blood pressure. Some people have had to receive medications to manage that in an urgent matter. There's also fever and immune effector cell-associated neurotoxicity syndrome (ICANS), which is a neurological side effect that needs to be managed. There are newer side effects related to these immunotherapies that need to be acted on urgently with drugs that are available in the hospital. That adds to the complexity.

Fortunately, some of these regimens—at least for tarlatamab, the one that is currently in the market—these things happen only in the first 1 or 2 treatments, and then patients can be managed as outpatients. But there's a lot of concern about how long these patients have to be monitored. While some agents that are subcutaneous are opening the door to shorter durations of infusion, they're also opening the door to the question of how we monitor patients that are getting formulations that may be faster in the clinic.

I'll give you some examples. Amivantamab, which is a bispecific antibody used for EGFR-positive lung cancer that targets EGFR and MET, was initially formulated as an IV antibody that can cause an infusion-related reaction in upward of 50% of patients. [These patients] will have that on the first day test dose and then they have to come back on the second day to receive the rest of the treatment.

On the second day, patients may have to be monitored for a while. When you now have an approval for this drug in the subcutaneous formulation, they were able to demonstrate that the infusion rate reactions were much less. The patients didn't need to be monitored, and they didn't need to come as often.

That's definitely an improvement for patient care, but also an improvement for patient tolerance of treatment. Some subcutaneous formulations not only make it easier for the practice in terms of taking less chair time, but it also makes it easier for the patient in terms of toxicity. We welcome those changes and are excited to see how that comes out in our practice.

I will say that as many formulations have become available, they haven't become readily available in practice. There have still been a lot of hurdles to get them into practice and determining how we will get them in. Some of the clinics have to invest not only in education but also in triage pathways and really work with insurers to see how to get these drugs into our practices more quickly.

From your clinical experience, how do administration methods influence the incidence or severity of infusion-related reactions, and what does that mean for management strategies and associated costs?

Dr Rodriguez: Administration can definitely influence the incidents and the management of these infusion-related reactions. The more obvious choice for a thoracic oncologist is amivantamab, which was recently approved for these patients. During the initial doses, it has very high incidences of hives and some get shortness of breath. It becomes an experience that is traumatic for a patient who gets newly diagnosed, that they will have this infusion-related reaction.

Getting rid of that is wonderful for patients as they start their treatment and to build trust with the patient. But sometimes when patients get infusion-related reactions—and we've seen this for a long time with other hematologic drugs like rituximab—you have to slow the infusion rate. A patient that could have been treated for an hour and a half or 2 hours can now have a 2-, 3-, 4-, or 5-hour infusion rate because it requires such a slow infusion. Some patients are definitely more sensitive to this drug despite having pre-medication.

When reactions occur, what it means is that treatment gets delayed and it takes more chair time. [In addition,] the nurse who is now handling a patient with an infusion reaction cannot attend to the other patients. Some of the advantages of these drugs that cause less reactions are that we will have our nurses be free to give the treatment and send the patient home and not really be following this patient, which is potentially really harmful to the patient and also to the flow of that clinical treatment unit (CTU).

It requires extra training. You have some cases where patients need to be transferred to an emergency room setting. That is another level of complexity for smaller centers. There's a key cost not only from the drug, but from all these other things that could happen when patients have a reaction.

As NSCLC treatments diversify in dosing formats and delivery routes, what operational changes do you foresee oncology practices needing to implement to maintain efficiency and financial sustainability?

Dr Rodriguez: Everything being flexible and data-driven is key for oncology practices. Obviously, bigger cancer centers can have more room to accommodate these changes. They have more staff that can go through this process. For the smaller practices, it becomes a challenge. That being said, it requires that infusion suites get redesigned.

For example, some of our newer cancer centers have settings where if you're getting a faster treatment, you don't have to wait as long. You get an expedited infusion because it's a shorter visit. You can create these cancer spaces that are more patient-friendly and patient-centered, where patients are not in a big room waiting but they get expedited for shorter visits that don't require as much monitoring.

You also have to work with pharmacy and nursing to have the workflow to accommodate for that. It's important that the practices are flexible to create this fast-track setting, but it’s also [important] to invest in the digital tools to monitor toxicity at home or be able to—if patients are being sent home faster—show how to follow these patients at home in a way that is safe for patients. From a financial standpoint, it requires an investment, even if, in the long term, it’s an advantage for the cancer center.

I also think that one of the biggest hurdles to implementing subcutaneous formulations has been that there's a lot of hesitation from big cancer centers that these services will be moved out of a cancer center, that the drug delivery methods may change completely from being in hospital settings to being outpatient settings or a tertiary site where patients will go. It will remain to be seen how this plays out. Our cancer centers and oncologists have to be comfortable sending patients out for treatments that, although they can be given easier and closer to home, still need to be monitored by doctors.

There is going to be some flexibility and a lot of data collection that needs to happen about the safety and the cost effectiveness for the cancer centers to do these treatments in-house and not lose the revenue of having these patients be sent out.