Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1 - Episode 20

Jack West, 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?

Both afatinib and some other EGFR TKIs are available in different doses and [so] it’s relatively easy to do dose adjustments when you need to. You can go from afatinib in about 40 mg to 30 mg or even 20 mg, and it’s still one tablet a day. I would have to be sure, but many of the companies have a trade-in policy where you can turn in any drug that you still have and get back a different dose. In fact, I would say that because these drugs can be so effective for patients, it’s really important for everybody to see that patients get the drug that we intend for them to get.

Fortunately, it is almost always possible for these patients to receive these agents when they need them. In fact, all of the companies that have EGFR TKIs have been committed to patient assistance programs that minimize a co-pay or even give free drug. I have not had a problem with patients being able to get a drug that I would like them to get because of cost issues, and I’m certainly thankful about that, but between payers and these various support systems, I have been able to get patients what they need in a timely way.


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.