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Turcotte LM, Watson D, Tanner L, Hoover A, Gilchrist L, Finch M, Messinger YH. Real-World Cost of Pediatric Acute Lymphoblastic Leukemia Care Among Commercially Insured Individuals in the United States: Effect of Era and Age at Diagnosis. JCO Oncol Pract 2022; 18:e1750-e1761. [PMID: 36166724 PMCID: PMC9653200 DOI: 10.1200/op.22.00344] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/21/2022] [Accepted: 08/15/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Five-year survival is approaching 90%. In efforts to further improve outcomes, it is critical to consider the cost of ALL care. MATERIALS AND METHODS Commercial insurance data from OptumLabs Data Warehouse were used to identify patients with ALL, age 1-30 years, diagnosed in 1993-2017 in the United States, with 36 months of continuous insurance coverage. Patients treated with hematopoietic cell transplantation were excluded. Inpatient and outpatient utilization and cumulative reimbursements (inflation-adjusted to December 2020) were computed 8 and 36 months from diagnosis and stratified by age (1-9, 10-12, and ≥ 13 years) as proxies for National Cancer Institute risk groups. Regression models were constructed to assess associations with demographic and clinical characteristics. RESULTS Among 927 patients (median age, 6 years; interquartile range, 3-12 years; 43% female), individuals age ≥ 10 years had 23-25 more inpatient days and 22 more outpatient encounters compared with younger patients. The 36-month median cost was $394,000 (USD) (interquartile range, $256,000-$695,000 [USD]), and 64% of the total cost was incurred during the initial 8 months. The 36-month cost was 1.5-fold higher for those age 10-12 years and 1.7-fold higher for those age ≥ 13 years compared with 1-9 years. The cost for those diagnosed in 2013-2017 was 70% higher compared with 1993-2002, and was not different on the basis of sex, race, or ethnicity. CONCLUSION Older age was associated with higher utilization and cost, and the cost of treatment increased significantly over time. These data provide valuable benchmarks for future studies examining the cost-benefit of ALL therapy modifications.
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Affiliation(s)
| | | | | | - Alex Hoover
- University of Minnesota Medical School, Minneapolis, MN
| | - Laura Gilchrist
- Children's Minnesota, Minneapolis, MN
- St Catherine University, St Paul, MN
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2
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Tong WH, Uyl-De Groot CA. Comment on: "Premedication prior to PEG-asparaginase is cost effective in pediatric patients with acute lymphoblastic leukemia". Pediatr Blood Cancer 2022; 69:e29474. [PMID: 34889044 DOI: 10.1002/pbc.29474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Wing H Tong
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden, The Netherlands.,Argos Zorggroep "DrieMaasStede", Center for Specialized Geriatric Care, Schiedam, The Netherlands
| | - Carin A Uyl-De Groot
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
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3
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Sidhu J, Masurekar AN, Gogoi MP, Fong C, Ioannou T, Lodhi T, Parker C, Liu J, Kirkwood AA, Moorman AV, Das K, Goulden NJ, Vora A, Saha V, Krishnan S. Activity and toxicity of intramuscular 1000 iu/m 2 polyethylene glycol-E. coli L-asparaginase in the UKALL 2003 and UKALL 2011 clinical trials. Br J Haematol 2022; 198:142-150. [PMID: 35348200 PMCID: PMC9314843 DOI: 10.1111/bjh.18158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Abstract
In successive UK clinical trials (UKALL 2003, UKALL 2011) for paediatric acute lymphoblastic leukaemia (ALL), polyethylene glycol‐conjugated E. coli L‐asparaginase (PEG‐EcASNase) 1000 iu/m2 was administered intramuscularly with risk‐stratified treatment. In induction, patients received two PEG‐EcASNase doses, 14 days apart. Post‐induction, non‐high‐risk patients (Regimens A, B) received 1–2 doses in delayed intensification (DI) while high‐risk Regimen C patients received 6–10 PEG‐EcASNase doses, including two in DI. Trial substudies monitored asparaginase (ASNase) activity, ASNase‐related toxicity and ASNase‐associated antibodies (total, 1112 patients). Median (interquartile range) trough plasma ASNase activity (14 ± 2 days post dose) following first and second induction doses and first DI dose was respectively 217 iu/l (144–307 iu/l), 265 iu/l (165–401 iu/l) and 292 iu/l (194–386 iu/l); 15% (138/910) samples showed subthreshold ASNase activity (<100 iu/l) at any trough time point. Older age was associated with lower (regression coefficient −9.5; p < 0.0001) and DI time point with higher ASNase activity (regression coefficient 29.9; p < 0.0001). Clinical hypersensitivity was observed in 3.8% (UKALL 2003) and 6% (UKALL 2011) of patients, and in 90% or more in Regimen C. A 7% (10/149) silent inactivation rate was observed in UKALL 2003. PEG‐EcASNase schedule in UKALL paediatric trials is associated with low toxicity but wide interpatient variability. Therapeutic drug monitoring potentially permits optimisation through individualised asparaginase dosing.
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Affiliation(s)
- Jasmeet Sidhu
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India
| | - Ashish Narayan Masurekar
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manash Pratim Gogoi
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India
| | - Caroline Fong
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tasos Ioannou
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Taha Lodhi
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Catriona Parker
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jizhong Liu
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Amy A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, UCL Cancer Institute, University College, London, UK
| | - Anthony V Moorman
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Kiranmoy Das
- Interdisciplinary Statistical Research Unit, Indian Statistical Institute, Kolkata, India
| | - Nicholas J Goulden
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Vaskar Saha
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India.,Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Shekhar Krishnan
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India.,Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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4
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Impact of Antibodies Against Polyethylene Glycol on the Pharmacokinetics of PEGylated Asparaginase in Children with Acute Lymphoblastic Leukaemia: A Population Pharmacokinetic Approach. Eur J Drug Metab Pharmacokinet 2021; 47:187-198. [PMID: 34878584 PMCID: PMC8917038 DOI: 10.1007/s13318-021-00741-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/04/2022]
Abstract
Background and Objectives Besides allergic reactions, antibodies against polyethylene glycol (PEG) have been associated with reduced PEG-asparaginase (PEG-ASNase) activity. Population pharmacokinetics (popPK) allow for an in-depth investigation of the influence of anti-PEG antibodies on PEG-ASNase pharmacokinetics. Methods PEG-ASNase activity (6261 samples) and anti-PEG antibodies (2082/6412 samples prior to/post administration) in 1444 children with acute lymphoblastic leukaemia treated in the AIEOP-BFM ALL 2009 trial were evaluated. Patients received two doses of PEG-ASNase during induction (2500 U/m2, intravenous, biweekly) and a third dose during reinduction treatment. Anti-PEG IgG and IgM measured prior to and post administration were explored for their influence on the initial clearance of PEG-ASNase using a previously established popPK model. Categorical and continuous antibody data, including each isotype individually as well as in combination, were assessed. Results High pre-existing levels of anti-PEG antibodies increase the initial drug clearance. Analysed separately, both anti-PEG IgGprior and IgMprior were significant covariates; the stronger effect was observed for anti-PEG IgMprior. Hockey stick models best described the data. For anti-PEG IgMprior, each additional log unit above the estimated cut point was related to a 41.4% increase in initial clearance after the first dose in induction. Antibody levels below the cut point were not associated with an effect on clearance. The combination of both isotypes did not provide additional information compared to anti-PEG IgMprior alone. Antibody levels post administration were not associated with an effect on clearance. Conclusion Pre-existing antibodies against PEG-ASNase significantly increased the initial clearance in a subgroup of patients showing high antibody levels. (Trial registration: EU clinical trials register; EudraCT No: 2007-004270-43; first registered 23 October 2009.) Supplementary Information The online version contains supplementary material available at 10.1007/s13318-021-00741-w.
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Dos Santos AC, Dos Santos JMB, da Costa Lima E, Land MGP. L-asparaginase doses number as a prognostic factor in childhood acute lymphoblastic leukemia: A survival analysis study. Cancer Rep (Hoboken) 2021; 5:e1533. [PMID: 34431241 PMCID: PMC9351670 DOI: 10.1002/cnr2.1533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022] Open
Abstract
Background The survival of children with acute lymphoblastic leukemia (ALL) has improved due to changes in the treatment and the disease diagnosis. A significant advance was the incorporation of asparaginase. However, hypersensitivity reactions are a common cause of early discontinuation of this drug. Aim The proposed study aims to evaluate early interruptions and the influence of the number of asparaginase doses effectively administered on the prognosis of patients with ALL. Methods and Results An observational cohort study was carried out, with retrospective data collection, in medical records. The prognostic variables indicated in the protocol applied were used, and the principal outcomes were 5 years event‐free survival (EFS) and 5 years of overall survival (OS) probability. Statistical analyzes were performed using SPPS 20.0 and R. In Cox's proportional hazards model for EFS and OS, variables of prognostic importance (n = 126 children) were: high‐risk group (HGR), by the protocol classification, and less than 10 doses of asparaginase. The increased risk of events and death in HGR, who did less than 10 doses, was 3.6 and 7 times, respectively. The study did not show statistical significance for the number of asparaginase doses in patients who were not at high risk. Conclusions We demonstrated that the early interruption of asparaginase treatment could negatively impact the prognosis of patients with ALL, especially HGR, reinforcing the need for careful diagnosis of reactions and the availability of alternative types of asparaginase.
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Affiliation(s)
- Amanda Cabral Dos Santos
- Instituto de Puericultura e Pediatria Martagão Gesteira - Federal University of Rio de Janeiro, PPGCM - FM (Graduate Program in Medical Clinic -Medical School), Rio de Janeiro, Brazil.,PPGCM - FM (Graduate Program in Medical Clinic -Medical School), Rio de Janeiro, Brazil
| | | | | | - Marcelo Gerardin Poirot Land
- Instituto de Puericultura e Pediatria Martagão Gesteira - Federal University of Rio de Janeiro, PPGCM - FM (Graduate Program in Medical Clinic -Medical School), Rio de Janeiro, Brazil.,PPGCM - FM (Graduate Program in Medical Clinic -Medical School), Rio de Janeiro, Brazil
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6
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Mesegué M, Alonso-Saladrigues A, Pérez-Jaume S, Comes-Escoda A, Dapena JL, Faura A, Conde N, Català A, Ruiz-Llobet A, Zapico-Muñiz E, Camós M, Rives S. Lower incidence of clinical allergy with PEG-asparaginase upfront versus the sequential use of native E. coli asparaginase followed by PEG-ASP in pediatric patients with acute lymphoblastic leukemia. Hematol Oncol 2021; 39:687-696. [PMID: 34397119 DOI: 10.1002/hon.2914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/28/2021] [Accepted: 07/07/2021] [Indexed: 11/08/2022]
Abstract
Asparaginase (ASP) is an essential component for the acute lymphoblastic leukemia (ALL) treatment, but toxicities, such as allergy, frequently limit its use. Although the potentially lower PEG-ASP formulation immunogenicity, few studies with conflicting results have compared the allergy incidence between Escherichia coli-ASP and PEG-ASP in the same protocol. We aimed at comparing the allergy incidence in children receiving native E. coli-ASP versus PEG-ASP within the same clinical protocol (Spanish Society of Pediatric Hematology and Oncology ALL-SEHOP-PETHEMA 2013). One hundred and twenty-six children (1-19 years) diagnosed with ALL from 2013 to 2020 were included. Patients in group 1 received a sequential scheme of native E. coli-ASP 10,000 IU/m2 intramuscularly (IM) followed by PEG-ASP 1000 IU/m2 IM. Patients in group 2 received PEG-ASP 1000 IU/m2 IM upfront. Clinical allergy incidence was compared between both groups. Serum ASP activity (SAA) was measured in a subgroup of patients, and silent inactivation was recorded. The cumulative incidence of clinical allergy was significantly higher in group 1 (native followed by PEG-ASP) than in group 2 (PEG-ASP upfront), 24.7% versus 4.1% (p = 0.0085). Adequate ASP activity was achieved with PEG-ASP 1000 IU/m2 dose in most patients (median SAA 412.5 and 453.0 IU/L at days 7 and 14). The incidence of silent inactivation in PEG-ASP upfront patients was very low. PEG-ASP-used upfront was associated with a lower incidence of clinical allergy than that observed in the sequential use of native E. coli-ASP followed by PEG-ASP. PEG-ASP at 1000 IU/m2 was effective in achieving enough ASP activity in most patients.
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Affiliation(s)
- Montserrat Mesegué
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Anna Alonso-Saladrigues
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Sara Pérez-Jaume
- Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Ariadna Comes-Escoda
- Oncohematology Unit, Pharmacy Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - José Luís Dapena
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Anna Faura
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Nuria Conde
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Albert Català
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Anna Ruiz-Llobet
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Edgar Zapico-Muñiz
- Biochemistry Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Mireia Camós
- Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.,Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu Barcelona, Barcelona, Spain.,Hematology Laboratory, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Susana Rives
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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7
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Santos AC, Land MGP, Lima EC. Response to comment on Ammonia level as a proxy of asparaginase inactivation in children: A strategy for classification of infusion reactions. J Oncol Pharm Pract 2021; 27:1053-1054. [PMID: 33847194 DOI: 10.1177/10781552211007549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amanda C Santos
- Instituto de Puericultura e Pediatria Martagão Gesteira, PPGCM -- FM (Graduate program in medical clinic -- medical school) Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo G P Land
- Instituto de Puericultura e Pediatria Martagão Gesteira, PPGCM -- FM (Graduate program in medical clinic -- medical school) Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Elisangela C Lima
- School of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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8
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Aly N, El-Ahwany A, Ataya FS, Saeed H. Bacillus sonorensis L. Asparaginase: Cloning, Expression in E. coli and Characterization. Protein J 2020; 39:717-729. [PMID: 33106988 DOI: 10.1007/s10930-020-09932-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
L-asparaginases (L-ASNases; EC 3.5.1.1) are aminohydrolases that catalyze the hydrolysis of L-asparagine (L-Asn) to L-aspartic acid and ammonia, resulting in the death of acute lymphoblastic leukemic cells and other blood cancer cells. In this study, Bacillus sonorensis (accession number MK523484) uncharacterized L-ASNase gene (accession number MN562875) was isolated by polymerase chain reaction (PCR), cloned into pET28a (+) vector, and expressed in Escherichia coli as a cytosolic protein. The recombinant enzyme was purified by affinity chromatography at 23.79-fold and 49.37% recovery. Denaturing polyacrylamide gel (10%) analysis of the purified enzyme resulted in a single protein band at 36 kDa that immunoreacted strongly with 6His-tag monoclonal antibody. The purified enzyme exhibited optimal activity at 45 °C and pH 7.0 and retained 92% and 85% of its initial activity after incubation for 60 min at 37 °C and 45 °C, respectively. The purified enzyme exhibited substrate specificity toward L-asparagine and low glutaminase activity (15.72%) toward L-glutamine at a concentration of 10 mM. The Km and Vmax values were 2.004 mM and 3723 µmol min1-, respectively.
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Affiliation(s)
- Nihal Aly
- Botany and Microbiology Department, Faculty of Science, Alexandria University, Alexandria, Egypt
| | - Amani El-Ahwany
- Botany and Microbiology Department, Faculty of Science, Alexandria University, Alexandria, Egypt
| | - Farid Shokry Ataya
- Biochemistry Department, College of Science, King Saud University, Bld. 5, Lab AA10, P.O. Box: 2454, Riyadh, Kingdom of Saudi Arabia.,National Research Centre, 33 El-Bohouth St. (former El-Tahrir St.), Dokki, P.O. 12622, Giza, Egypt
| | - Hesham Saeed
- Department of Biotechnology, Institute of Graduate Studies and Research, Alexandria University, Alexandria, Egypt.
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9
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Vithanachchi DT, Maujean A, Downes MJ, Scuffham P. A comprehensive review of economic evaluations of therapeutic drug monitoring interventions for cancer treatments. Br J Clin Pharmacol 2020; 87:271-283. [PMID: 32692416 DOI: 10.1111/bcp.14494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Therapeutic drug monitoring (TDM) of cancer drugs has been shown to improve treatment effectiveness and safety. The aim of this paper was to comprehensively review economic evaluations of TDM interventions for cancer drugs. Searches were conducted in 4 electronic databases, Medline, EMBASE, and Centre for Reviews and Dissemination databases (Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database), from their inception to June 2019. Studies were included if they were economic evaluations of TDM interventions for an active cancer treatment. The quality of reporting of economic evaluations was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS checklist). Of the 11 publications identified, imatinib with TDM and 5-fluorouracil with TDM were the most commonly assessed interventions (4 publications each). Overall study quality was good, with publications meeting 61 to 91% (median 80%) of CHEERS checklist criteria. A variety of studies were used to estimate the clinical effectiveness inputs for the cost effectiveness models. All publications considered TDM to be cost-effective based on an incremental cost-effectiveness ratio below the willingness to pay threshold (64%) or being cost-saving (36%). TDM interventions were considered cost-effective across the economic evaluations. Further clinical research assessing the impact of TDM on overall survival or other long-term health outcomes may enhance the evidence base for TDM in oncology. Future economic evaluations of TDM should explicitly consider uncertainty in the underlying clinical evidence and incorporate changes in the use of newer targeted drugs that form the current standard of care.
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Affiliation(s)
- Dinusha T Vithanachchi
- Centre for Applied Health Economics, School of Medicine, Griffith University, Nathan, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, QLD, Australia
| | - Annick Maujean
- Centre for Applied Health Economics, School of Medicine, Griffith University, Nathan, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, QLD, Australia
| | - Martin J Downes
- Centre for Applied Health Economics, School of Medicine, Griffith University, Nathan, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, QLD, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, School of Medicine, Griffith University, Nathan, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, QLD, Australia
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10
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Kloos RQH, Pieters R, Jumelet FMV, de Groot-Kruseman HA, van den Bos C, van der Sluis IM. Individualized Asparaginase Dosing in Childhood Acute Lymphoblastic Leukemia. J Clin Oncol 2020; 38:715-724. [PMID: 31922920 DOI: 10.1200/jco.19.02292] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE In the DCOG ALL-11 protocol, polyethylene glycol-conjugated Escherichia coli asparaginase (PEGasparaginase) and Erwinia asparaginase treatment of pediatric acute lymphoblastic leukemia are individualized with therapeutic drug monitoring (TDM). The efficacy of TDM and its effect on asparaginase-associated toxicity are reported. PATIENTS AND METHODS After induction with 3 fixed intravenous doses of 1,500 IU/m2 PEGasparaginase, medium-risk patients (n = 243) received 14 individualized doses that targeted trough levels of 100-250 IU/L, standard-risk patients (n = 108) received 1 individualized dose, and high-risk patients (n = 18) received 2-5 fixed administrations (1,500 IU/m2). After a neutralizing hypersensitivity reaction, patients were started with 20,000 IU/m2 Erwinia asparaginase 3 times per week, and l-asparagine was measured to monitor asparaginase efficacy. Several asparaginase-associated toxicities were studied. RESULTS The final median PEGasparaginase dose was lowered to 450 IU/m2. Overall, 97% of all trough levels of nonallergic patients were > 100 IU/L. Asparagine was < 0.5 μM in 96% and 67% of the PEGasparaginase and Erwinia asparaginase levels > 100 IU/L, respectively. Ten percent developed a neutralizing hypersensitivity reaction to PEGasparaginase, of which 40% were silent inactivations. The cumulative incidence of grade 3-4 pancreatitis, central neurotoxicity, and thromboses was 12%, 4%, and 6%, respectively, and not associated with asparaginase activity levels. During medium-risk intensification, 50% had increased ALT and 3% hyperbilirubinemia (both grade 3/4 and correlated with asparaginase activity levels), and 37% had grade 3/4 hypertriglyceridemia. Hypertriglyceridemia occurred less in intensification compared with ALL-10 (37% v 47%), which is similar to ALL-11 but with higher asparaginase levels during intensification. CONCLUSION TDM of asparaginase results in a significant reduction of the PEGasparaginase dose with adequate asparaginase activity levels and sufficient asparagine depletion. In addition, with TDM, silent inactivation and allergic-like reactions were identified. However, the effect of reduced asparaginase activity levels on toxicity is limited.
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Affiliation(s)
- Robin Q H Kloos
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Florine M V Jumelet
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Hester A de Groot-Kruseman
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Pediatric Oncology and Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Inge M van der Sluis
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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11
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Hernández-Marqués C, Andión M, Perez-Somarriba M, Madero L, Lassaletta A. Can monitoring asparaginase activity help us to manage toxicity in pediatric acute lymphoblastic leukemia? Leuk Lymphoma 2019; 61:990-992. [PMID: 31749392 DOI: 10.1080/10428194.2019.1691191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Carmen Hernández-Marqués
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Maitane Andión
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Marta Perez-Somarriba
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Luis Madero
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Alvaro Lassaletta
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Kloos RQH, Pieters R, van den Bos C, van Eijkelenburg NKA, de Jonge R, van der Sluis IM. The effect of asparaginase therapy on methotrexate toxicity and efficacy in children with acute lymphoblastic leukemia. Leuk Lymphoma 2019; 60:3002-3010. [PMID: 31120351 DOI: 10.1080/10428194.2019.1613537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Asparaginase and methotrexate (MTX), both essential for pediatric acute lymphoblastic leukemia therapy, are often used concomitantly. Depending on the sequence, in vitro, asparaginase inhibits MTX-polyglutamate (MTXPG) formation, and side effects overlap. MTX toxicity and efficacy, reflected by intracellular erythrocyte MTXPG's, were compared between children treated with and without asparaginase during high dose MTX (HD-MTX) courses of the DCOG ALL-11 protocol (NL50250.078.14). Seventy-three patients, of whom 23 received asparaginase during the HD-MTX courses, were included. Grade 3-4 leukopenia and neutropenia occurred more often (59% and 86% vs. 30% and 62%). The number of infections, grade 3-4 hepatotoxicity, nephrotoxicity, and neurotoxicity did not differ. Patients with asparaginase had lower MTXPG levels, although to a lesser extent than in vitro studies. Although patients with asparaginase during HD-MTX courses showed more myelosuppression, this had no (serious) clinical consequences. Regarding the MTX efficacy, the schedule-related antagonism seen in in vitro seems less important in vivo.
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Affiliation(s)
- Robin Q H Kloos
- Department of Pediatric Oncology and Hematology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Academic Medical Center, Amsterdam, The Netherlands
| | | | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - Inge M van der Sluis
- Department of Pediatric Oncology and Hematology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Kloos RQH, van Litsenburg RRL, Wolf S, Wismans L, Kaspers GJL, Uyl-de Groot CA, Pieters R, van der Sluis IM. A cost-effectiveness analysis of Erwinia asparaginase therapy in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2019; 66:e27458. [PMID: 30246496 DOI: 10.1002/pbc.27458] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Erwinia asparaginase is used as a second-line formulation after a neutralizing hypersensitivity reaction to the first-line formulation of asparaginase. Here, we have performed a cost-effectiveness analysis of Erwinia asparaginase treatment. METHODS Children with acute lymphoblastic leukemia treated according to the Dutch Childhood Oncology ALL-10 or ALL-11 protocol were included and initially treated with PEGasparaginase in the intensification phase. The total treatment costs of this treatment phase, quality of life (QoL), and life years saved (LYS) were studied for two scenarios: (a) patients were switched to Erwinia asparaginase treatment after a hypersensitivity reaction, or (b) asparaginase would have been permanently stopped. RESULTS Sixty-eight patients were included. There was no difference in QoL between patients with and without a hypersensitivity reaction. The mean costs of the intensification phase per patient were $40,925 if PEGasparaginase could be continued, $175,632 if patients had to switch to Erwinia asparaginase, and $21,190 if asparaginase would have been permanently stopped. An extrapolation of the literature suggests that the 5-year event-free survival would be 10.3% lower without intensive asparaginase treatment if asparaginase is stopped after a reaction. Thus, the costs per LYS were $1892 for scenario 1 and $872 for scenario 2. CONCLUSIONS Switching to Erwinia asparaginase increases the costs per LYS by $1020, which is modest in view of the total costs. Moreover, when asparaginase treatment can be completed by switching to Erwinia asparaginase, relapses-and consequential costs-will be avoided. Therefore, from a cost perspective, we recommend a switch to Erwinia asparaginase to complete asparaginase treatment.
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Affiliation(s)
- Robin Q H Kloos
- Department of Pediatric Oncology and Hematology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Sarah Wolf
- Institute of Health Care Policy & Management/Institute for Medical Technology Assessment Erasmus University, Rotterdam, The Netherlands
| | - Leonoor Wismans
- Department of Pediatric Oncology and Hematology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Carin A Uyl-de Groot
- Institute of Health Care Policy & Management/Institute for Medical Technology Assessment Erasmus University, Rotterdam, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Vyas C, Jain S, Kapoor G, Mehta A, Takkar Chugh P. Experience with generic pegylated L-asparaginase in children with acute lymphoblastic leukemia and monitoring of serum asparaginase activity. Pediatr Hematol Oncol 2018; 35:331-340. [PMID: 30488741 DOI: 10.1080/08880018.2018.1538277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pegylated asparaginase (P-Asp) though integral to acute lymphoblastic leukemia (ALL) therapy is often not accessible to patients in developing countries. We share our clinical experience with generic P-Asp along with monitoring of asparaginase activity. METHODS In this prospective observational study, patients ≤18 years of age with ALL were assigned to receive either generic P-Asp or native asparaginase (N-Asp) in a non-randomized manner. Treatment protocol was based on ALL BFM-95 backbone. The dose of P-Asp was 1500 IU/m2 by intravenous route during induction (Ia) and re-induction (IIa) phase of therapy. RESULTS N-Asp or P-Asp was administered to 52 and 54 of the 106 eligible patients respectively. Demographic and disease characteristics were comparable in both arms. The mean trough levels for N-Asp and P-Asp were 156.87 ± 22.35 IU/L and 216.03 ± 73.40 IU/L, respectively (p value <0.001) and all patients achieved therapeutic levels during Ia. Incidence of asparaginase-attributable toxicity was similar in the two arms in both phases of treatment, although hospitalization due to noninfectious causes was more common in P-Asp arm during Ia (13% versus 0%, p value, 0.01). Clinical hypersensitivity and silent inactivation were not observed during Ia while these occurred in 13% and 5% of patients in the N-Asp arm and P-Asp arms of IIa, respectively. The 2-year event free survival for P-Asp and N-Asp groups was 84% and 80.7%, respectively (p value 0.85). CONCLUSION Generic P-Asp was observed to be efficacious and well tolerated in our patients and adequate therapeutic levels were sustained for 2 weeks.
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Affiliation(s)
- Chintan Vyas
- a Department of Pediatric Hematology Oncology , Rajiv Gandhi Cancer Institute and Research Centre , New Delhi , India
| | - Sandeep Jain
- a Department of Pediatric Hematology Oncology , Rajiv Gandhi Cancer Institute and Research Centre , New Delhi , India
| | - Gauri Kapoor
- a Department of Pediatric Hematology Oncology , Rajiv Gandhi Cancer Institute and Research Centre , New Delhi , India
| | - Anurag Mehta
- c Department of Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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