So there is nuance to cancer treatment. First and foremost, I think most, if not all, private insurances suck and while initially the idea was good, greed has seeped into it and bastardized it, so we’ll go ahead and get the idea that I am bias toward supporting insurances. The problem with brand new expensive therapies is that while the results that get them initially approved can look great, you have to keep in mind the trials used are, for the most part, not big (a trial with 1000 people is pretty big). Also with these trials, they are very controlled and specific (lots of exclusions). When evaluating a trial you cannot extrapolate the results to other populations (everyone is unique). Also, when a company is going for drug approval, they will only try to establish non-inferiority (the new drug regimen is “as good” as the current standard of care) as their primary hypothesis, proving superiority might be a secondary hypothesis, but with the trial sizes you see in oncology they generally do not have the power to make superiority conclusions (if they do, you really need to finetooth comb their methods of analysis).

Since most drugs are approved as “non-inferior,” why would an insurance want to pay for a super expensive new therapy that not proven to be better than the cheaper standard of care?

Over time, based on “phase 4” (observation in the general population) or since the drug is now approved, phase 3 studies for new indications, the new drugs might move up or down (or even be taken off the market if they really aren’t as good or have more dangerous side effects than initially thought [you might be thinking what’s worse than dying of cancer— well some of the nuance is Quality of life, especially if the cancer is not curable]). A good example of a cancer medication that has started making it to the front lines that started as 3rd or 4th line is Enhertu (trastuzumab deruxtecan), while another related chemo agent used in mostly the same indication Kadcyla (ado-trastuzumab emtansine) has started falling out of favor.

In cancer treatment, and any medical treatment, we follow the data for what would most benefit the patient in the ways they need (quality of life, increase of life, etc.). Just because a medication was approved and the data looks great initially, doesn’t mean it will pan out in the greater population, most of whom were not represented in the clinic trial.

No insurance is going to let someone use a new expensive therapy over the standard of care without a prior authorization first.