Access and Disparity Questions Around Rilvegostomig+T-DXd: Coral Omene, MD, PhD

Why It Matters

De‑escalating chemotherapy could improve outcomes and reduce costs, but without equitable access the benefits may widen existing health disparities.

Key Takeaways

• 64% of responders avoided chemotherapy; 97% avoided anthracyclines
• ILD events were low‑grade; all patients recovered
• R/T‑DXd cost may be offset by reduced neutropenia hospitalizations
• Black women with immune‑positive TNBC remain underrepresented in trials
• Community outreach and financial aid are essential for equitable trial enrollment

Pulse Analysis

The neoadjuvant pairing of rilvegostomig and trastuzumab deruxtecan marks a pivotal shift toward treatment de‑escalation in HER2‑positive breast cancer. By eliminating traditional chemotherapy for the majority of responders, the regimen reduces exposure to cardiotoxic anthracyclines and the long‑term risk of secondary leukemias. Real‑time CT monitoring every six weeks proved effective at catching low‑grade interstitial lung disease early, and all cases resolved without recurrence, underscoring the safety net that modern trial designs can provide.

From an economic perspective, the high price tag of antibody‑drug conjugates like T‑DXd often sparks concern, yet the I‑SPY 2.2 data suggest a nuanced cost balance. Avoiding chemotherapy eliminates routine G‑CSF prophylaxis, which can add $3,000‑$8,000 per cycle, and prevents febrile neutropenia hospitalizations that average $20,000‑$30,000 per episode. When these savings are aggregated across a population, they partially offset the drug’s acquisition cost, offering a compelling argument for payers to consider value‑based contracts and copay‑assistance programs.

Equity remains the most pressing challenge. Black women, particularly those with immune‑positive triple‑negative disease, stand to gain the most from a chemo‑free approach, yet they have historically been underrepresented in oncology trials. Addressing this gap requires intentional enrollment targets, satellite trial sites in community oncology practices, and robust financial support for transportation, childcare, and lost wages. Policymakers and manufacturers must collaborate to embed these resources into trial infrastructure, ensuring that the promise of innovative therapies translates into real‑world benefit for all patient groups.