Immunotherapy Works For Some Patients, But It Is Costly And Use Remains Suboptimal


In 2021, immune checkpoint inhibitors were used by 12.1% of patients with cancer—however, these agents represent 36.2% of all oncology medication costs.

Immunotherapy Works For Some Patients, But It Is Costly And Use Remains Suboptimal

Immunotherapy Works For Some Patients, But It Is Costly And Use Remains Suboptimal

Although novel immunotherapies hold promise for certain groups of patients, their clinical use remains suboptimal, according to research published by Evernorth Research Institute.1

For example, the total costs for treatment with immune check-point inhibitors (ICI) therapy is largely dependent on the infusion setting.

For patients receiving ICI treatment, outpatient hospital infusions are associated with 80% higher overall drug costs compared with infusions in an office setting. Of note, between 2018 and 2021, the percentage of patients receiving treatment in hospital increased from 59% to 65% and the percentage of patients receiving treatment in the office at a private practice decreased from 40% to 35%. According to the authors, COVID-19 was a key driver for this change, as it prompted a number of acquisitions—4,800 physician practices were acquired by hospitals during this time.

Moreover, in 2021, the average amount of drug costs for a patient undergoing immunotherapy was $132,582. In comparison, the average costs for patients not receiving an ICI were $26,095. Despite only 12.1% of patients receiving this treatment modality, immunotherapy is responsible for over a third (36.2%) of all oncology medication spending. The average cost per patient receiving immunotherapy is 5 times greater than the average cost per patient receiving other anticancer therapies.

“The introduction of immune checkpoint inhibitor drugs has proven to be a game changer for cancer care, reflected in their rising utilization since 2018,” study authors wrote. “When used appropriately, ICI therapy can provide significant benefit over alternative therapy options. However, the site of infusion may drive greater costs, while suboptimal conditions may result in waste and can even worsen clinical outcomes.”

To conduct this research, investigators with the Evernorth Research Institute evaluated medication utilization and cost data from a commercially insured population of approximately 50 million individuals. To narrow their findings, they focused on patients with metastatic lung cancer who were treated with at least 1 infusion of pembrolizumab (Keytruda), which is the ICI most often used to treat this patient population.

The report showed that many patients do not receive proper evaluation prior to ICI treatment. It is mandatory for patients with advanced non-small cell lung cancer to undergo genomic testing for key biomarkers following diagnosis, as these tests help determine which individual might benefit from ICI vs targeted therapies. Despite these guidelines, investigators found that one third of patients receiving pembrolizumab had no record of biomarker testing.

Patients who did not receive genomic testing prior to undergoing immunotherapy were found to be more likely to discontinue treatment (53% vs 44%). According to the investigators, this may suggest that these patients did not experience the anticipated response with pembrolizumab.

“By identifying the most appropriate targeted treatment upon diagnosis, providers can avoid prescribing ICI treatment when tests indicate it isn’t right for the patient,” they wrote.

Investigators noted that patients with higher social needs—which they define as lower incomes, lower educations attainment, limited transportation options, etc.—are less likely to receive the required genomic testing (66% vs 70%).

Lastly, according to investigators, using evidence-based guidelines for ICI treatment leads to optimal use and helps reside unnecessary spending. Both the FDA label and the National Comprehensive Cancer Network recommend that patients with advanced stage non-small cell lung cancer receive a maximum treatment duration of 24 months when receiving ICCI therapy. This is because a study has demonstrated that indefinite immunotherapy does not necessarily improves survival outcomes compared with stopping after 2 years.2

When looking at the population of real-world patients, investigators with Evernorth determined that 22% of patients received at least 1 infusion after the 2-year threshold and that 5% continued to receive infusions for more than 3 years. Therefore, the investigators state that waste could be easily reduced if clinicians adhered to guideline recommendations, arguing that this is especially true for patients who are nearing end-of-life. It has been demonstrated that ICI does not improve survival outcomes for patients nearing end-of-life scenarios.3

“Yet, there is evidence to suggest that ICIs continue to be used for patients who are entering endo-of-life scenarios,” they write, noting that in their study populations, 24% of patients discontinued ICI following their first few infusions; among these 24%, 35% entered hospice within 90 days.1

“In cases where end-of-life scenarios can be identified, supportive care therapy options may be initiated in place of more aggressive treatment,” they said.


  1. Real-world data in cancer care. Evernorth Research Institute. 2023. Accessed August 31, 2023.
  2. Sun L, Bleiberg B, Hwang W, et al. Association between duration of immunotherapy and overall survival in advanced non-small cell lung cancer. JAMA Oncology. Published online June 4, 2023. doi:10.1001/jamaoncol.2023.1891
  3. Parikh RB, Min EJ, Wileyto EP, et al. Uptake and survival outcomes following immune checkpoint inhibitor therapy among trial-ineligible patients with advanced solid cancers. JAMA Oncology. 2021;7(12):1843. doi:10.1001/jamaoncol.2021.4971
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