Beyond efficacy: What really drives treatment choice in crowded oncology markets?

Authored by: Anthony Greenwood, Director and Oncology Center of Excellence Lead, Inizio Ignite, Research Partnership

Drawing on insights from several recently completed oncology engagements, Anthony Greenwood, Director and Oncology Center of Excellence Lead from Inizio Ignite, Research Partnership, explores how communicating value in the oncology space is rapidly evolving, and the keys to better understanding this shift in narrative.

Efficacy is still king when unmet need is high

Ask an oncologist what matters most when choosing a treatment and efficacy will almost inevitably come first. Where unmet need is high, that makes perfect sense. A meaningful improvement in survival can transform the treatment landscape and give a new therapy an immediate, compelling point of differentiation.

But how do you win when efficacy is similar in a crowded market?

Many oncology markets are creating a more complicated question; what happens when several treatments are already highly effective.

This is a scenario that is becoming more common, for example in multiple myeloma we have three BCMA targeted bi-specifics are currently approved with a fourth on the way.  In breast cancer, multiple CDK4/6 inhibitors compete alongside a rapidly expanding ADC landscape, with tens of ADCs in development.  Lung and prostate cancer are similarly becoming populated by different mechanisms, modalities and combinations competing for increasingly specific patient populations.

As such we are hearing questions such as the following with increasing frequency over the last year in oncology research.

• How do Oncologists choose between multiple similar options?
• How do we stand out in a crowded market?
• What will drive choice between several highly effective options?
• What is the opportunity for an asset that is good, but not dramatically more efficacious than currently available options?
• Which attributes can support a compelling and distinctive position?

These questions require us to think differently about treatment choice.

Once several treatments cross the threshold of being considered clinically credible, characteristics that might previously have seemed secondary can become influential. These could include safety and tolerability, dosing frequency, route of administration, treatment duration, monitoring requirements, speed of initiation, site of care, patient burden, healthcare capacity, financial toxicity, sequencing flexibility, familiarity, etc.

Yet simply asking oncologists to rank these attributes rarely tells the whole story. Efficacy still rises to the top and yet Oncologists still have to choose between treatments with similar efficacy. Other factors must therefore be influencing the final choice.

Understanding what that ‘something’ is – and whether a brand can credibly own it – requires us to get underneath stated treatment drivers and closer to how decisions are really made. Multiple approaches can be considered to better understand this decision-making dynamic, and help better understand what will get your product chosen?

1. Get beyond what Oncologists say is important

The more complicated a treatment landscape becomes, the less realistic it is to assume that Oncologists consciously compare every available option attribute by attribute for every patient. This is particularly the case among time-poor community oncologists who are often overwhelmed by the number of new options presented to them, across multiple tumors, where they may struggle to parse out small differences in clinical data.

Instead, complexity encourages shortcuts.

• “This is my go-to ADC.”
• “This is the one I use for fitter patients.”
• “This is the easier one to manage.”
• “This is the one I trust when I need a rapid response.”

These heuristics are enormously important commercially. But traditional drivers-and-barriers questioning can struggle to reveal them.

Oncologists are experts. When asked why they made a decision, they can readily provide a clinically rational explanation. That explanation may be entirely valid – but it may not reveal all the factors that tipped the balance between two clinically acceptable choices.

This is where more sophisticated qualitative questioning can identify these short cuts. Rather than asking only what drives treatment choice, qualitative research can reconstruct a real decision: Which treatments did you consider? Which came to mind first? What ruled one out? At what point did you favor another? What ultimately tipped the balance?

Case reconstruction, cognitive interviewing, decision ladders, and carefully designed choice exercises can help us move from what oncologists say is important toward understanding what changes a decision.

2. Uncover the hidden value of ‘secondary’ attributes

Another challenge is language. Consider convenience. On a TPP, the difference between monthly or bi-monthly dosing may appear relatively minor. In practice, less frequent administration could mean fewer hospital visits, less disruption to a patient’s work or family life, and additional capacity for a busy clinic. Suddenly, the value represented by “convenience” becomes much more tangible.

The same applies to ‘toxicity’. Oncologists do not necessarily respond simply to the frequency or severity of an adverse event. Predictability, reversibility, monitoring requirements, patient characteristics and confidence in management can all influence how burdensome a toxicity feels in practice.

One of the key roles of qualitative research is therefore to deconstruct broad attributes into their constituent parts, particularly as new and different toxicity considerations come to light with novel options. As such it is not whether convenience matters. It is why it matters, when it matters, for whom it matters – and the extent to which it is a consideration in changing behaviour.

3. Create the choice the market will face

Another way to uncover these hidden drivers is to deliberately remove efficacy as the obvious answer. This may occur naturally – for example as treatment options improve a couple of months difference in outcomes across different TPPs becomes less meaningful if all are delivering years of extra life.

Alternatively, we can create a hypothetical competitive environment in which several treatments offer clinically compelling and broadly comparable outcomes and ask Oncologists to choose between them.

• What happens if one offers marginally greater efficacy but substantially greater toxicity and treatment burden?
• What if another offers comparable efficacy with less frequent administration?
• What value is placed on finite rather than continuous treatment?
• What if the easiest treatment to deliver is not the one with the numerically highest response rate?

Approaches such as qualitative choice exercises, SIMALTO, and Research Partnership’s ChoiceQual can help identify the point at which a benefit becomes decision-changing. This enables us to distinguish between hygiene factors, tie-breakers, attributes that compensate for a disadvantage elsewhere, and genuine sources of differentiation.

4. Understand the context in which value changes

Crucially, these trade-offs are context dependent. In a tumor with extremely poor survival, a marginal improvement in OS or PFS efficacy may outweigh everything else. Where several highly effective treatments already exist, confidence and familiarity may become more influential. For chronic treatment, burden and convenience can accumulate over months or years. In earlier-stage disease, long-term toxicity and quality of life may carry greater weight.

These contexts matter. When comparing multiple options from within the same class, e.g. BCMA bi-specifics in MM, being caught ‘in the middle’ can be a risk – these products can struggle because there is no obvious mental hook for oncologists to attach to.

Conversely, in an evolving class such as lung cancer where there are multiple new options and modalities coming to market promising similar outcomes then being ‘caught in the middle’ can be a strength – it can be perceived as a balanced approach, or a simpler de-risked option as multiple new treatments vie for attention.

Differentiation, therefore, is relative. The value of an attribute depends not only on the asset itself, but on the alternatives against which oncologists will evaluate it.

Understanding these dynamics will increase in importance

As oncology pipelines become more crowded, efficacy will remain fundamental. But the next source of competitive advantage may lie in factors oncologists understate, struggle to articulate, or only recognize when faced with a genuine choice.

Understanding those factors requires research to recreate the choice, rather than simply ask about it. By uncovering the heuristics, trade-offs, and contextual influences behind treatment decisions, we can help teams identify not only which attributes matter, but which their asset can credibly own.

Because when several treatments are highly effective, the commercially important question changes: what will make yours the one that gets chosen?

At Inizio Ignite, Research Partnership, our oncology and qualitative specialists combine deep therapeutic understanding with approaches designed to uncover these hidden trade-offs and decision rules.  Get in touch to find out more.