Physician Views Poll Results: Like Kisqali, there is some room for Verzenio in an Ibrance-dominated market

In response to the FDA approving Eli Lilly's Verzenio (abemaciclib) for HR+/HER2- breast cancer last week, we snap-polled 37 US-based oncologists with five key questions about future utilisation of the drug.

Download the poll results here

A thumbs-up for more choice

Although Pfizer's Ibrance has achieved considerable market penetration since launching in early 2015 (US sales stood at $2 billion last year), oncologists are pleased to have an additional treatment option in the CDK 4/6 inhibitor class, our snap-poll reveals.

Presumably allowing them greater flexibility to tailor treatment for individual patients (based primarily on the respective toxicity profiles of the three available agents; as efficacy looks remarkably similar), this would echo feedback from physicians at the recent European Society of Medical Oncology (ESMO) congress.

In second-line patients previously treated with endocrine therapy, the pairing of Verzenio and Faslodex increased median progression-free survival to 16.4 months, versus 9.3 months for Faslodex monotherapy. Taking into account the availability of Ibrance and Novartis' Kisqali (approved by the FDA in early 2017), 30 percent of oncologists said the availability of a third drug in class is 'very' compelling from a clinical perspective, while 43 percent described approval of Verzenio as 'moderately' compelling.

Reflecting the third-to-market status of Eli Lilly's agent and its very similar survival data in the second-line setting, however, 11 percent of oncologists described availability of Verzenio as 'slightly' compelling with the same proportion of respondents suggesting the drug is not a compelling addition to the treatment paradigm given availability of Ibrance and Kisqali.

An exclusive opportunity in third-line patients

One way in which Verzenio is differentiated from Ibrance and Kisqali is approved use as a monotherapy in third-line HR+/HER2- patients who have received prior endocrine therapy and chemotherapy. Data from the MONARCH 1 study showed Verzenio was associated with an overall response rate of 19.7 percent, a median time to response of 3.7 months and a median duration of response of 8.6 months in this setting.

Asked to characterise the commercial opportunity for Verzenio in third-line patients, 38 percent of oncologists described it as 'moderate' and 43 percent described it as 'significant'.

Toxicity concerns?

With the efficacy profiles of Ibrance, Kisqali and Verzenio remarkably similar, utilisation by brand will be determined considerably by their respective toxicity profiles. While Eli Lilly's drug is associated with lower rates of neutropenia, it has consistently been shown to cause high rates of diarrhoea, which is reflected in its US label.

According to which, diarrhoea occurred in 86 percent of patients receiving the drug with Faslodex in the MONARCH 2 study and 90 percent of patients receiving Verzenio alone in the MONARCH 1 study. Grade 3 diarrhoea occurred in 13 percent of patients receiving Verzenio plus Faslodex and in 20 percent of patients receiving Verzenio alone. Diarrhoea incidence was greatest during the first month of Verzenio dosing and median time to onset of the first event was 6 days, while the median duration of diarrhoea for grades 2 and 3 were 9 days and 6 days, respectively. Twenty-two percent of patients with diarrhoea required a dose omission and 22 percent required a dose reduction.

Presenting more recent data for Verzenio as a first-line therapy at last month's ESMO congress, lead study author Angelo Di Leo, head of the Sandro Pitigliani Medical Oncology Unit and Chair of the Oncology Department, at the Hospital of Prato, Istituto Toscano Tumori, Italy, described the incidence of diarrhoea as "very manageable with loperamide," noting that just 10 percent of Verzenio patients experienced grade 3 diarrhoea.

Having been presented with the label for Verzenio, practicing oncologists appear to somewhat agree. Taking into account the respective incidence rates of diarrhoea for Ibrance and Kisqali, 51 percent think the frequency and severity of diarrhoea associated with Verzenio will 'moderately' impact adoption, while 24 percent predict a 'minimal' impact. However, 16 percent of oncologists think this particular side effect will 'significantly' limit utilisation of the Eli Lilly drug.

Furthermore, 57 percent of oncologists anticipate that a warning on Verzenio's label for venous thromboembolism (VTE; physicians are recommended to "monitor patients for signs and symptoms of thrombosis and pulmonary embolism and treat as medically appropriate") will 'moderately' impede utilisation, while 27 percent think this will be a 'significant' deterrent. Labelling for neither Ibrance or Kisqali currently include a warning for VTE.

Ibrance entrenchment?

The biggest barrier to adoption of Verzenio, however, could be entrenchment of Ibrance; now approved in the US for 2.5 years. Asked to describe their clinically-led motivation for using an alternative CDK4/6 inhibitor, 49 percent said they would be 'moderately' motivated to look beyond Ibrance, while 24 percent said they have 'minimal' motivation and 5 percent no motivation.

Download the poll results here

As always, FirstWord would very much like to receive your feedback and suggestions.

Note: FirstWord Polls are powered by MedePolls, a fast-turnaround service to conduct instant polls of up to five questions with guaranteed samples that include physicians from dozens of specialities and over 100 markets (for further information click here).

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