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van der Sluis IM, Brigitha LJ, Fiocco M, de Groot-Kruseman HA, Bierings M, van den Bos C, de Haas V, Hoogerbrugge PM, Tissing WJ, Veening MA, Pieters R. Continuous PEGasparaginase Dosing Reduces Hypersensitivity Reactions in Pediatric ALL: A Dutch Childhood Oncology Group ALL11 Randomized Trial. J Clin Oncol 2024; 42:1676-1686. [PMID: 38306592 PMCID: PMC11095866 DOI: 10.1200/jco.23.01797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/24/2023] [Accepted: 12/04/2023] [Indexed: 02/04/2024] Open
Abstract
PURPOSE The primary objective of this randomized study was to determine whether a continuous dosing schedule (without the asparaginase-free interval) would result in less hypersensitivity reactions to PEGasparaginase (PEGasp) compared with the standard noncontinuous dosing schedule. METHODS Eight hundred eighteen patients (age 1-18 years) with ALL were enrolled in the Dutch Childhood Oncology Group-ALL11 protocol and received PEGasp. Three hundred twelve patients stratified in the medium-risk arm were randomly assigned to receive 14 individualized PEGasp doses once every two weeks in either a noncontinuous or continuous schedule after the first three doses in induction (EudraCT: 2012-000067-25). Hypersensitivity reactions were defined as allergies, allergic-like reactions, and silent inactivation. Secondary end points were other asparaginase-related toxicities, asparaginase activity and antibody levels, and outcome. RESULTS During induction, 27 of 818 patients (3.3%) experienced hypersensitivity reactions. After random assignment, 4 of 155 (2.6%) in the continuous treatment arm versus 17 of 157 (10.8%) patients in the noncontinuous treatment arm had hypersensitivity reactions (P < .01), of which two (1.3%) versus 13 (8.3%) were inactivating reactions (P < .01). The occurrence of inactivating hypersensitivity reactions was seven times lower in the continuous arm (odds ratio, 0.15 [0.032-0.653]). In addition, antibody levels were significantly lower in the continuous arm (P < .01). With exception of a lower incidence of increased amylase in the continuous arm, there were no significant differences in total number of asparaginase-associated toxicities between arms. However, the timing of the toxicities was associated with the timing of the asparaginase administrations. No difference in 5-year cumulative incidence of relapse, death, or disease-free survival was found between both treatment arms. CONCLUSION A continuous dosing schedule of PEGasp is an effective approach to prevent antibody formation and inactivating hypersensitivity reactions. The continuous PEGasp schedule did not increase toxicity and did not affect the efficacy of the therapy.
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Affiliation(s)
- Inge M. van der Sluis
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Leiah J. Brigitha
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Pediatric Oncology and Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Biomedical Data Sciences, Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
- Mathematical Institute, Leiden University, the Netherlands
| | | | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Valerie de Haas
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | | | - Wim J.E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
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2
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Nabukalu D, Gordon LG, Lowe J, Merollini KMD. Healthcare costs of cancer among children, adolescents, and young adults: A scoping review. Cancer Med 2024; 13:e6925. [PMID: 38214042 PMCID: PMC10905233 DOI: 10.1002/cam4.6925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/08/2023] [Accepted: 12/30/2023] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVE To collate and critically review international evidence on the direct health system costs of children and adolescents and young adults (AYA) with cancer. METHODS We conducted searches in PubMed, MEDLINE, CINAHL, and Scopus. Articles were limited to studies involving people aged 0-39 years at cancer diagnosis and published from 2012 to 2022. Two reviewers screened the articles and evaluated the studies using the Consolidated Health Economic Evaluation Reporting Standards checklist. The reviewers synthesized the findings using a narrative approach and presented the costs in 2022 US dollars for comparability. RESULTS Overall, the mean healthcare costs for all cancers in the 5 years post diagnosis ranged from US$36,670 among children in Korea to US$127,946 among AYA in the USA. During the first year, the mean costs among children 0-14 years ranged from US$34,953 in Chile to over US$130,000 in Canada. These were higher than the costs for AYA, estimated at US$61,855 in Canada. At the end of life, the mean costs were estimated at over US$300,000 among children and US$235,265 among adolescents in Canada. Leukemia was the most expensive cancer type, estimated at US$50,133 in Chile, to US$152,533 among children in Canada. Overall, more than a third of the total cost is related to hospitalizations. All the included studies were of good quality. CONCLUSIONS Healthcare costs associated with cancer are substantial among children, and AYA. More research is needed on the cost of cancer in low- and middle-income countries and harmonization of costs across countries.
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Affiliation(s)
- Doreen Nabukalu
- School of HealthUniversity of the Sunshine CoastSippy DownsQueenslandAustralia
- Population Health ProgramQIMR Berghofer Medical Research InstituteHerstonQueenslandAustralia
| | - Louisa G. Gordon
- Population Health ProgramQIMR Berghofer Medical Research InstituteHerstonQueenslandAustralia
- School of NursingQueensland University of TechnologyKelvin GroveQueenslandAustralia
- School of Public HealthThe University of QueenslandHerstonQueenslandAustralia
| | - John Lowe
- School of HealthUniversity of the Sunshine CoastSippy DownsQueenslandAustralia
| | - Katharina M. D. Merollini
- School of HealthUniversity of the Sunshine CoastSippy DownsQueenslandAustralia
- Sunshine Coast Health InstituteSunshine Coast University HospitalBirtinyaQueenslandAustralia
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3
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Biasoto HP, Hebeda CB, Farsky SHP, Pessoa A, Costa-Silva TA, Monteiro G. Extracellular expression of Saccharomyces cerevisiae's L-asparaginase II in Pichia pastoris results in novel enzyme with better parameters. Prep Biochem Biotechnol 2022; 53:511-522. [PMID: 35981094 DOI: 10.1080/10826068.2022.2111582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
L-asparaginase (ASNase) is an efficient inhibitor of tumor development, used in chemotherapy sessions against acute lymphoblastic leukemia (ALL) tumor cells; its use results in 80% complete remission of the disease in treated patients. Saccharomyces cerevisiae's L-asparaginase II (ScASNaseII) has a high potential to substitute bacteria ASNase in patients that developed hypersensitivity, but the endogenous production of it results in hypermannosylated immunogenic enzyme. Here we describe the genetic process to acquire the ScASNaseII expressed in the extracellular medium. Our strategy involved a fusion of mature sequence of protein codified by ASP3 (amino acids 26-362) with the secretion signal sequence of Pichia pastoris acid phosphatase enzyme; in addition, this DNA construction was integrated in P. pastoris Glycoswitch® strain genome, which has the cellular machinery to express and secrete high quantity of enzymes with humanized glycosylation. Our data show that the DNA construction and strain employed can express extracellular asparaginase with specific activity of 218.2 IU mg-1. The resultant enzyme is 40% more stable than commercially available Escherichia coli's ASNase (EcASNaseII) when incubated with human serum. In addition, ScASNaseII presents 50% lower cross-reaction with anti-ASNase antibody produced against EcASNaseII when compared with ASNase from Dickeya chrysanthemi.
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Affiliation(s)
- Henrique P Biasoto
- Departamento de Tecnologia Bioquímico-Farmacêutica, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Cristina B Hebeda
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Sandra H P Farsky
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Adalberto Pessoa
- Departamento de Tecnologia Bioquímico-Farmacêutica, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Tales A Costa-Silva
- Centro de Ciencias Naturais e Humanas, Universidade Federal do ABC, Santo André, SP, Brazil
| | - Gisele Monteiro
- Departamento de Tecnologia Bioquímico-Farmacêutica, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
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4
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Subburaj D, Kulkarni K, MacDonald T. Optimizing pegaspargase therapy in patients with hypersensitivity reactions. Leuk Lymphoma 2022; 63:2727-2730. [DOI: 10.1080/10428194.2022.2086251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Divya Subburaj
- Division of Pediatric Hematology/Oncology, IWK Health Center, Halifax, Canada
| | - Ketan Kulkarni
- Division of Pediatric Hematology/Oncology, IWK Health Center, Halifax, Canada
| | - Tamara MacDonald
- Department of pharmacy, IWK Health Center and Faculty of Health Professions Dalhousie University, Halifax, Canada
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5
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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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Lynggaard LS, Vaitkeviciene G, Langenskiöld C, Lehmann AK, Lähteenmäki PM, Lepik K, El Hariry I, Schmiegelow K, Albertsen BK. Asparaginase encapsulated in erythrocytes as second-line treatment in hypersensitive patients with acute lymphoblastic leukaemia. Br J Haematol 2022; 197:745-754. [PMID: 35344210 DOI: 10.1111/bjh.18152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/06/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Abstract
Asparaginase is essential in treating acute lymphoblastic leukaemia (ALL). Asparaginase-related hypersensitivity causes treatment discontinuation, which is associated with decreased event-free survival. To continue asparaginase treatment after hypersensitivity, a formulation of asparaginase encapsulated in erythrocytes (eryaspase) was developed. In NOR-GRASPALL 2016 (NCT03267030) the safety and efficacy of eryaspase was evaluated in 55 patients (aged 1-45 years; median: 6.1 years) with non-high-risk ALL and hypersensitivity to asparaginase conjugated with polyethylene glycol (PEG-asparaginase). Eryaspase (150 u/kg) was scheduled to complete the intended course of asparaginase (1-7 doses) in two Nordic/Baltic treatment protocols. Forty-nine (96.1%) patients had asparaginase enzyme activity (AEA) ≥100 iu/l 14 ± 2 days after the first eryaspase infusion [median AEA 511 iu/l; interquartile range (IQR), 291-780], whereas six of nine (66.7%) patients had AEA ≥100 iu/l 14 ± 2 days after the fourth infusion (median AEA 932 iu/l; IQR, 496-163). The mean terminal half-life of eryaspase following the first infusion was 15.3 ± 15.5 days. Few asparaginase-related adverse events were reported; five patients (9.1%) developed clinical allergy associated with enzyme inactivation. Replacement therapy was successfully completed in 50 patients (90.9%). Eryaspase was well tolerated, and most patients had AEA levels above the therapeutic target after the first infusion. The half-life of eryaspase confirmed that a 2-week schedule is appropriate.
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Affiliation(s)
- Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Goda Vaitkeviciene
- Center of Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | | | | | - Päivi M Lähteenmäki
- Department of Pediatric and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Kristi Lepik
- Department of Hematology and Oncology, Tallinn Children's Hospital, Tallinn, Estonia
| | | | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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7
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Schmiegelow K, Rank CU, Stock W, Dworkin E, van der Sluis I. SOHO State of the Art Updates and Next Questions: Management of Asparaginase Toxicity in Adolescents and Young Adults with Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:725-733. [PMID: 34511319 DOI: 10.1016/j.clml.2021.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 01/23/2023]
Abstract
A wider use of L-asparaginase in the treatment of children with acute lymphoblastic leukemia has improved cure rates during recent decades and hence led to introduction of pediatric-inspired treatment protocols for adolescents and young adults. In parallel, a range of burdensome, often severe and occasionally life-threatening toxicities have become frequent, including hypersensitivity, hepatotoxicity, hypertriglyceridemia, thromboembolism, pancreatitis, and osteonecrosis. This often leads to truncation of asparaginase therapy, which at least in the pediatric population has been clearly associated with a higher risk of leukemic relapse. Many of the asparaginase induced toxicities are far more common in older patients, but since their relapse rate is still unsatisfactory, the decision to discontinue asparaginase therapy should balance the risk of toxicity with continued asparaginase therapy against the risk of relapse in the individual patient. The underlying mechanisms of most of the asparaginase induced side effects are still unclear. In this review we address the individual toxicities, known risk factors, and their clinical management.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet Copenhagen University Hospital, 2100 Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Cecilie Utke Rank
- Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
| | - Emily Dworkin
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
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8
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McCormick M, Lapinski J, Friehling E, Smith K. Premedication prior to PEG-asparaginase is cost-effective in pediatric patients with acute lymphoblastic leukemia. Pediatr Blood Cancer 2021; 68:e29051. [PMID: 33860989 DOI: 10.1002/pbc.29051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND PEG-asparaginase is critical in pediatric acute lymphoblastic leukemia (ALL) therapy but is highly immunogenic. Severe allergic reactions lead to substitution of further PEG-asparaginase with Erwinia. Erwinia is associated with more frequent dosing, increased expense, and limited availability. Premedication may reduce rates of allergic reactions. PROCEDURES This Markov model evaluated the cost-effectiveness of three strategies: premedication plus therapeutic drug monitoring (TDM), TDM alone, and no premedication or TDM. We modeled two scenarios: a standard-risk (SR) B-ALL patient receiving two asparaginase doses and a high-risk (HR) patient receiving seven asparaginase doses. The model incorporated costs of asparaginase, premedication, TDM and clinic visits, and lost parental wages associated with each additional Erwinia dose. We incorporated a five-year time horizon with a societal perspective. Outcomes were Erwinia substitutions avoided and differences in quality-adjusted life years (QALYs). Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS In both scenarios, premedication was the least costly strategy. In SR and HR scenarios, premedication with monitoring resulted in 8% and 7% fewer changes to Erwinia compared with monitoring alone and 3% and 2% fewer changes compared with no premedication/monitoring, respectively. Premedication resulted in the most QALYs gained in the SR patients. Individual variation of model inputs did not change premedication/monitoring favorability for either scenario. In probabilistic sensitivity analyses, premedication/monitoring was favored in >87% of iterations in both scenarios. CONCLUSION Compared with other strategies, premedication use and asparaginase level monitoring in children with B-ALL is potentially cost-saving.
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Affiliation(s)
| | - Jillian Lapinski
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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9
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Gupta S, Sutradhar R, Li Q, Athale U, Bassal M, Breakey V, Gibson PJ, Patel S, Silva M, Zabih V, Pechlivanoglou P, Pole JD, Mittmann N. Health care utilisation and costs associated with different treatment protocols for newly diagnosed childhood acute lymphoblastic leukaemia: A population-based study in Ontario, Canada. Eur J Cancer 2021; 151:126-135. [PMID: 33979728 DOI: 10.1016/j.ejca.2021.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/09/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although different treatment protocols for childhood acute lymphoblastic leukaemia (ALL) all achieve high cure rates, their health care utilisation and costs have not been rigorously compared. METHODS Disease, treatment, and outcome data were chart abstracted for all children with ALL in Ontario, Canada, diagnosed 2002-2012. Linkage to population-based databases identified health care utilisation. Utilisation-associated costs were determined through validated algorithms. Chemotherapy-associated costs were calculated separately. Health care utilisation and costs were compared between patients receiving Children's Oncology Group (COG) versus Dana-Farber Cancer Institute (DFCI)-based treatment. FINDINGS Of 802 patients, 146 (18.2%) were treated on DFCI-based protocols. COG patients experienced significantly higher rates of emergency department (ED) visits (adjusted rate ratio [aRR]: 1.3, 95% confidence interval [CI]: 1.1-1.5; p = 0·01), whereas outpatient visit rates were 60% higher among DFCI patients (aRR: 1.6, 95% CI: 1.5-1.7, p < 0.0001). In adjusted analyses, DFCI-associated cost intensity was 70% higher (aRR: 1.7, 95% CI: 1.5-1.9; p < 0.0001), mainly attributable to outpatient visit costs. Total chemotherapy costs were higher among COG-treated patients ($39,400 ± $1100 versus $33,400 ± $2800; p = 0.02). Among PEG-ASNase-treated patients, total chemotherapy costs were highest among DFCI patients (median $54,200 ± $7400; p = 0.003 versus COG patients). INTERPRETATION COG and DFCI treatments were associated with higher ED visit rates and higher outpatient visit rates, respectively. Overall utilisation-associated costs were increased in DFCI-treated patients. Administration of some intravenous chemotherapy at home and decreases in PEG-ASNase cost would decrease health care utilisation and costs for all patients and mitigate differences between COG and DFCI protocols. FUNDING C17 Research Network.
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Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada; Faculty of Medicine, University of Toronto, 27 King's College Cir, Toronto, ON, M5S 1A8, Canada; Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada; Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada.
| | - Rinku Sutradhar
- Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada; Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada
| | - Qing Li
- Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Uma Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, 1200 Main St W, Hamilton, L8N 3Z5, Canada
| | - Mylene Bassal
- Division of Haematology/Oncology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, K1H 8L1, Canada
| | - Vicky Breakey
- Division of Haematology/Oncology, McMaster Children's Hospital, 1200 Main St W, Hamilton, L8N 3Z5, Canada
| | - Paul J Gibson
- Division of Haematology/Oncology, McMaster Children's Hospital, 1200 Main St W, Hamilton, L8N 3Z5, Canada
| | - Serina Patel
- Division of Haematology/Oncology, London Health Sciences Centre, 800 Commissioners Rd, London, N6A 5W9, Canada
| | - Mariana Silva
- Department of Pediatrics, Kingston General Hospital, 76 Stuart St, Kingston, K7L 2V7, Canada
| | - Veda Zabih
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada; Sickkids Research Institute, The Hospital for Sick Children, 86 Bay St, Toronto, M5G 0A4, Canada
| | - Petros Pechlivanoglou
- Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada; Sickkids Research Institute, The Hospital for Sick Children, 86 Bay St, Toronto, M5G 0A4, Canada
| | - Jason D Pole
- Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada; Center for Health Services Research, University of Queensland, 34 Cornwall St, Woolloongabba QLD 4102, Australia; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada
| | - Nicole Mittmann
- Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada; Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
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10
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Viña-Romero MM, Ramos Díaz R, González García J, Nazco-Casariego G, Díaz-Vera J, Gutiérrez-Nicolás F. Extended enzymatic stability of reconstituted lyophilized PEG-asparaginase in vials. J Oncol Pharm Pract 2020; 27:1102-1105. [PMID: 32854574 DOI: 10.1177/1078155220950001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Asparaginase (ASNase) use as a tumour-inhibitor drug has changed completely the natural course of paediatric acute lymphoblastic leukaemia (ALL) in such a way that it represents a paradigm shift in ALL management. ASNase treatment emergence has significantly improved pathologic responses and increased survival rates of ALL patients. Although different ASNase forms are currently available, only the pegylated form (PEG-ASNase) is recommended by relevant clinic guides. PEG-ASNase form shows longer elimination half-life, reducing the number of administrations, along with an enhanced safety profile. In spite of all of these advantages, PEG-ASNase elevated cost limits enormously its use. PEG-ASNase is commercialised as a lyophilised powder which according to the manufacturer it is stable for 24 hours once reconstituted, as a result, the leftover is usually discarded. In this study we analysed the enzymatic stability of reconstituted PEG-ASNase after conservation in three different temperature conditions for 5 and 14 days, aiming to take advantage of the remaining leftover for the subsequent administration. Our results have shown that PEG-ASNase is stable at 4°C, -20°C and -80°C for at least 14 days, retaining the 95% from the initial enzymatic activity in all three storage temperatures. According to our results, it is feasible to reuse the remaining content of PEG-ASNase vial after reconstitution, which means a 50% reduction of its cost for paediatric patient treatment and, consequently, removes the main barrier to use this drug in a wider population.
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Affiliation(s)
- María M Viña-Romero
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Ruth Ramos Díaz
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), La Laguna, Spain
| | - Jónathan González García
- Servicio de Farmacia Hospitalaria, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
| | - Gloria Nazco-Casariego
- Servicio de Farmacia Hospitalaria, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
| | - Jésica Díaz-Vera
- Servicio de Farmacia Hospitalaria, Complejo Hospitalario Universitario de Canarias, La Laguna, Spain
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11
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Gupta S, Wang C, Raetz EA, Schore R, Salzer WL, Larsen EC, Maloney KW, Mattano LA, Carroll WL, Winick NJ, Hunger SP, Loh ML, Devidas M. Impact of Asparaginase Discontinuation on Outcome in Childhood Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:1897-1905. [PMID: 32275469 DOI: 10.1200/jco.19.03024] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Asparaginase (ASNase) is an important component of acute lymphoblastic leukemia (ALL) treatment, but is often discontinued because of toxicity. Erwinia chrysanthemi ASNase (Erwinia) substitution was approved in 2011 for allergic reactions. Erwinia has, however, been intermittently unavailable because of drug supply issues. The impact of Erwinia substitution or complete ASNase discontinuation is unknown. METHODS Patients aged 1-30.99 years in frontline Children's Oncology Group trials for B-cell acute lymphoblastic leukemia between 2004 and 2011 (National Cancer Institute [NCI] standard risk [SR]: AALL0331; NCI high risk: AALL0232) were included. The number of prescribed pegaspargase (PEG-ASNase) doses varied by trial and strata. Maintenance therapy did not contain ASNase. Landmark analyses at maintenance compared disease-free survival (DFS) among those receiving all prescribed PEG-ASNase doses versus switching to Erwinia but receiving all doses versus not receiving all ASNase doses. RESULTS We included 5,195 AALL0331 and 3,001 AALL0232 patients. The cumulative incidence of PEG-ASNase discontinuation was 12.2% ± 4.6% in AALL0331 and 25.4% ± 0.8% in AALL0232. In multivariable analyses, NCI high-risk patients not receiving all prescribed ASNase doses had inferior DFS (hazard ratio [HR], 1.5; 95% CI, 1.2 to 1.9; P = .002) compared with those receiving all prescribed PEG-ASNase doses. Patients with Erwinia substitution who completed subsequent courses were not at increased risk (HR, 1.1; 95% CI, 0.7 to 1.6; P = .69). NCI SR patients who discontinued ASNase were not at elevated risk (HR, 1.2; 95% CI, 0.9 to 1.6; P = .23), except when restricted to those with slow early response, who were prescribed more ASNase because of therapy intensification (HR, 1.7; 95% CI, 1.1 to 2.7; P = .03). CONCLUSION Discontinuation of ASNase doses is associated with inferior DFS in higher-risk patients. Our results illustrate the severe consequences of Erwinia shortages.
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Affiliation(s)
- Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cindy Wang
- Department of Biostatistics, University of Florida, Gainesville, FL
| | | | | | - Wanda L Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Eric C Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | | | | | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern/Simmons Cancer Center, Dallas, TX
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Benoiff Childen's Hospital and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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Hu X, Wildman KP, Basu S, Lin PL, Rowntree C, Saha V. The cost-effectiveness of pegaspargase versus native asparaginase for first-line treatment of acute lymphoblastic leukaemia: a UK-based cost-utility analysis. HEALTH ECONOMICS REVIEW 2019; 9:40. [PMID: 31885053 PMCID: PMC6935472 DOI: 10.1186/s13561-019-0257-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND L-asparaginase is a key component of treatment for patients with acute lymphoblastic leukaemia (ALL) in the UK. Commonly used forms of asparaginase are native E. coli-derived asparaginase (native asparaginase) and pegaspargase in first-line combination therapy, and native Erwinia chrysanthemi-derived asparaginase (Erwinia asparaginase) as second-line treatment. The objective of this study was to evaluate the cost-effectiveness of pegaspargase versus native asparaginase in first-line combination therapy for patients with newly diagnosed ALL. A combined decision tree and health-state transition Markov cost-effectiveness model was developed to assess the relative costs and health outcomes of pegaspargase versus native asparaginase in the UK setting. RESULTS In base case analyses, first-line pegaspargase (followed by Erwinia asparaginase in cases of hypersensitivity) dominated first-line native asparaginase followed by Erwinia asparaginase; i.e. resulted in lower costs and more quality-adjusted life year gain. The favourable hypersensitivity rates and administration profile of pegaspargase led to lifetime cost savings of £4741 versus native asparaginase. Pegaspargase remained cost-effective versus all treatment strategies in all scenario analyses, including use of the 2500 IU/m2 dose, recommended for patients ≤21 years of age. CONCLUSIONS Pegaspargase, as part of multi-drug chemotherapy, is a cost-effective option for the treatment of newly diagnosed ALL. Based on this study, The National Institute for Health and Care Excellence Technology Appraisal Committee concluded that it could recommend pegaspargase as a cost-effective use of National Health Service resources in England & Wales for treating ALL in children, young people and adults with untreated, newly diagnosed disease. TRIAL REGISTRATION UKALL 2011, EudraCT number 2010-020924-22; UKALL 2003, EudraCT number 2007-004013-34; UKALL14, EudraCT number 2009-012717-22.
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Affiliation(s)
- Xingdi Hu
- GHEOR Analytics, Shire, Cambridge, MA USA
| | - Kingsley P. Wildman
- Medical Affairs for Oncology, UK & Ireland, Servier Laboratories Ltd, Stoke Poges, UK
| | - Subham Basu
- Medical Affairs Oncology, UK & Republic of Ireland, Shire Pharmaceuticals Ltd, London, UK
| | | | | | - Vaskar Saha
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, The Oglesby Cancer Research Building, 555 Wilmslow Road, Manchester, M20 4GJ UK
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India
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13
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Russell HV. Asparaginase products in upfront acute lymphoblastic leukemia therapy: Value, location, and style. Pediatr Blood Cancer 2019; 66:e27497. [PMID: 30318846 DOI: 10.1002/pbc.27497] [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: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Heidi V Russell
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
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