Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1 - Episode 10

Corey J. Langer, MD: Options for Treatment and Reimbursement After Dose Reduction

What are the options for treatment access and reimbursement in this patient, who required dose reduction for diarrhea?

Hopefully, a woman like Ingrid, who’s not yet Medicare eligible and is fully employed, has commercial insurance, but even then the co-pays can be quite onerous and there are programs now that help mitigate the co-pays, help reduce at least to more accessible amounts. By and large, these agents are FDA approved, so they are easily available commercially. Every now and then we encounter a patient who is either uninsured or underinsured. That is increasingly less common, at least in the northeast part of the country, not so in other states.

But most people fortunately will have some coverage and occasionally have to make use of expanded access programs and specialized payer programs. It’s important if we encounter a patient who has insurance issues of this sort that they be hooked up with the appropriate programs for individual companies and also with social work at our institutions. This can become an ongoing problem, particularly in individuals who will often be on these agents for not just many months but several years.


Ingrid C. is a 62-year-old corporate accountant from San Antonio, Texas. Her medical history is notable for depression, which is being treated with an SSRI, and she has no history of smoking.

At the start of busy tax season, she presents to her PCP with back and chest pain, a persistent cough, and intermittent dyspnea.

Her cardiac workup is negative, and her PCP orders a chest x-ray, which shows bilateral lung nodules and a large upper right lung mass with pleural effusion; she is referred for a follow-up CT scan.

The CT confirms the presence of multiple lung nodules and additional lesions in the thoracic vertebra; she is referred for further diagnostics.

Core biopsy of her lung mass shows adenocarcinoma stage IV; mutational testing showsEGFRdel 19.

Her performance status was 1.0 at diagnosis.

Ingrid has a family vacation in Tuscany planned for next year, and hopes to be able to keep her travel plans; her oncologist initiates her on afatinib 40 mg daily.

She returns to her oncologist in 2 weeks with persistent diarrhea (>5 stools/d) that has not responded to antidiarrheal medications, which were suggested by the nursing team, and her normal work day is being affected.

Her oncologist reduces her afatinib dose to 30 mg/day, and she continues therapy.

Nine weeks after initiating therapy, she reports to the nursing team symptoms of redness and swelling in her fingers and fingernails, and management strategies are recommended.

At her next follow-up 2 months later, her CT scan shows the right lung mass to be stable, with no new lesions. She has improved symptomatically.

Her diarrhea has improved sufficiently to allow her to resume her normal work load; her paronychia has been effectively managed with vinegar soaking and topical antibiotics.