Use and costs of oral anticancer agents in the Netherlands in the period 2000-2008

Safety and cost-effectiveness of ponatinib versus other tyrosine kinase inhibitors as second-line therapy in patients with chronic myeloid leukemia in the United States

To evaluate the cost-effectiveness of ponatinib compared with second-line TKIs in the treatment of adult patients with CML who failed, or were intolerant to, first-line TKIs. A Markov state transition model was conducted. Model transition, adverse-effect probabilities, utility data and medical costs were obtained from clinical trials and literature. Measurements included medications, follow-ups, adverse events, allogeneic stem cell transplantation and quality-adjusted life years (QALYs). Univariable and Bayesian multivariable probabilistic sensitivity analyses were conducted using Monte Carlo simulations. Dasatinib resulted in an ICER of $79,086/QALY compared to nilotinib. Ponatinib yielded an ICER of $176,278/QALY and $141,563/QALY compared to dasatinib and nilotinib, respectively. Dasatinib was the optimal treatment at a $100,000/QALY threshold. The probability (36%-40%) for ponatinib or dasatinib optimal treatment was associated with thresholds of $160,000-$180,000/QALY. Dasatinib and ponatinib can be considered cost-effective options and provide clinical benefits compared to other second-line TKIs for CML in the US.

Outpatient oral anticancer agent utilization and costs in Manitoba from 2003 to 2016: a population-based study

INTERVENTION

In April 2012, the Manitoba Home Cancer Drug Program (HCDP) was introduced to allow 100% coverage for eligible oral anticancer agents (OAA) and supportive medications for Manitobans with cancer requiring these therapies.

RESEARCH QUESTIONS

What is the extent of use and cost of OAAs among outpatients in Manitoba from 2003/04 to 2015/16? Did the HCDP change OAA user and prescription patterns?

METHODS

This was a retrospective, population-based study using administrative data to measure the prevalence of drug utilization over time and the impact of HCDP on OAA use and prescriptions using generalized linear models. Manitobans with cancer who filled an OAA or supportive medication covered by HCDP from 2003/04 to 2015/16 were included.

RESULTS

This study included 22,393 people with cancer who filled an OAA prescription. The prevalence of OAA use increased from 222 per 100,000 to 328 per 100,000 from 2003/04 to 2015/16. Hormone therapy for breast cancer was the most common class of OAA used (increased from 154 per 100,000 to 231 per 100,000). We observed a 2.6-fold decrease in the prevalence of oral alkylating agents and a 10.7-fold increase in the prevalence of protein kinase inhibitors during the study period. The total cost of targeted OAAs per year for all Manitobans with cancer increased from $1.8 million to $19 million.

CONCLUSION

We observed an increase in OAA prevalence and the cost of oral targeted chemotherapy is high. Our findings underline the need for addressing these high-cost medications in future developments of a national drug program.

Survey of serious adverse events and safety evaluation of oral anticancer drug treatment in Japan: A retrospective study

The present study assessed the safety of outpatient oral anticancer chemotherapeutic drugs by investigating the type and frequency of serious adverse effects (SAEs). Emergency hospitalization, unplanned consultations and telephone calls were investigated in 1,832 patients who received oral anticancer drug treatment at the National Cancer Center Hospital East between December 1, 2014 and November 30, 2015. Oral cytotoxic anticancer and molecular targeted drugs were administrated to 1,140 (62.2%) and 692 (37.8%) patients, respectively. A total of 52 (2.8%) SAEs were reported, with 32 (2.8%) occurring following cytotoxic anticancer drug administration and 20 (2.9%) occurring after molecular targeted drug treatment. The most common SAE was gastrointestinal toxicity. The median time to SAE occurrence was 32 days (range, 5-1,705 days). The rate of unplanned consultations and telephone calls were 5.5 and 37.9% among all patients, respectively, with skin reactions being the most common reason for unplanned consultations. SAEs often occurred early after treatment initiation. It was concluded that measures against gastrointestinal toxicity are particularly important were administering chemotherapeutic agents.

Real-life adherence in capecitabine therapy using two analysis methods and persistence after 6 months of treatment

Medication adherence in the field of Oncology is crucial in therapy management and can influence the probability of achieving and maintaining efficacy over time. We conducted a cross-sectional study to evaluate adherence and persistence to oral therapy with Capecitabine, using two different calculation methods: therapy diary and indirect prescription refilling patterns. The main objective of the study was to compare the two methods of analysis and to propose a reliable adherence datum, yielded by the application of two complementary methodologies. We consequently set out to verify if data collected from therapy diaries can be superimposed to those gathered from prescription refilling patterns. Furthermore, we included data on patient-perceived quality in relation to Capecitabine therapy, as well as adverse reactions and their duration. Of 594 patients who used the study drug as of January 1, 2012, 45 completed their therapy diary. Adherence to treatment was 0.93 ± 0.10 and 0.84 ± 0.15, calculated using therapy diaries and pharmacy refill data, respectively. In terms of persistence, 53% of patients continued with treatment after six months of therapy. On a 1 to 5 scale, perceived quality was 3.31. In conclusion, when it comes to calculating adherence, it is important to preserve the objectivity of the method, which must be unencumbered by any conditioning. Regardless of the method, also considering what has already been discussed in the available literature, adherence in patients under treatment with Capecitabine, unlike persistence, is good.

The association between patients' perceived continuity of care and beliefs about oral anticancer treatment

PURPOSE

To explore factors associated with necessity beliefs and concerns among patients receiving oral anticancer therapy (OACT) and, specifically, to examine the relationship between continuity of care (COC) and patients' beliefs about OACT.

METHODS

A cross-sectional study was conducted among patients from four oncology centers receiving OACT (either targeted, hormonal, or chemotherapy). Two months after OACT initiation, patients were asked to participate in a face-to-face or telephone survey. The Beliefs about Medicines Questionnaire was used to examine patients' perceptions of their personal necessity for OACT and concerns about potential adverse effects. The Nijmegen Continuity Questionnaire was used to assess patients' perceived COC. Data on clinical characteristics were collected from medical records.

RESULTS

Participants' beliefs about OACT necessity (n = 91) were found to be associated with COC within the oncology team, and with COC between the oncology specialist and the primary care physicians (β = 0.27, p = 0.003; β = 0.22, p = 0.02, respectively), beyond age, depression, and cancer type (ΔR² = 0.14, p < 0.001). Additionally, the difference between participants' beliefs about OACT necessity and their OACT-related concerns was associated with COC within the oncology team (β = 0.30, p = 0.001), beyond age, income, family status, and cancer type (ΔR² = 0.09, p = 0.001).

CONCLUSIONS

This study shows that cancer patients' perceptions about the COC between care providers are related to their beliefs about OACT necessity, thus providing evidence for the importance of health care delivery approaches that support COC within the oncology team and between the oncology specialist and the primary care physician.

Factors Associated With Regorafenib Adherence With Metastatic Colorectal Cancer

INTRODUCTION

Regorafenib is an oral multikinase inhibitor for the treatment of metastatic colorectal cancer (mCRC). The clinical factors that may affect adherence to regorafenib remain unclear. The aim of this study was to evaluate adherence to regorafenib with mCRC and to identify factors that might affect adherence to regorafenib.

METHODS

A total of 108 consecutively enrolled Japanese patients with mCRC received regorafenib. Adherence was measured by pharmacists using pill counts and a self-reported treatment diary for patients at a pharmaceutical outpatient clinic. The median relative dose intensities of regorafenib and the factors adversely affecting adherence were retrospectively surveyed. Logistic regression analysis was then performed using patient socio-demographic factors and clinical factors.

RESULTS

A total of 96 patients were included in the analysis. The median adherence rate was 61.7% in the first cycle. The median relative dose intensity was 57.1%. The most common reason for non-adherence was a hand-foot-skin reaction (35.6%). On multivariate analysis, increased non-adherence to regorafenib was significantly associated with sex (female) [odds ratio (OR) = 4.36; 95% confidence interval (CI): 1.43-13.22, p = 0.01].

DISCUSSION

Hand-foot-skin reactions and female sex were associated with lower adherence to regorafenib. Since these factors could be associated with lower adherence to regorafenib, it would be useful to consider these factors when assessing adherence.

Reliability and validity of the Hebrew version of the Nijmegen Continuity Questionnaire for measuring patients' perceived continuity of care in oral anticancer therapy

To assess the validity and reliability of the Nijmegen Continuity Questionnaire in Hebrew (NCQ-H) for measuring patients' perceived continuity of care in the multiprovider setting of oral anticancer therapy (OACT). Following forward-backward translation of the original instrument into Hebrew, the NCQ-H was administered to adult cancer patients in five oncology centres in Israel, 2-3 months after initiation of OACT (either targeted, hormonal or chemotherapy). Confirmatory factor analysis and Cronbach's alpha were used to assess the validity and reliability of the NCQ-H respectively. A total of 135 patients completed the questionnaire. The postanalysis models for measuring "personal continuity with care provider" (eight items for each provider: the oncology specialist and the primary care physician), and "team/cross-boundary continuity" (four items for each setting: within the oncology team, and between the oncology specialist and the primary care physician) showed good fit for the observed data (root-mean-square error of approximation (RMSEA) = 0.02; RMSEA = 0.015; for each model respectively). Cronbach's alpha was 0.79-0.95 for all subscales. Conclusions. This study provides preliminary evidence for the reliability and validity of the NCQ-H in assessing cancer patients' experience with continuity of care and for its usability in the context of OACT.

Over-adherence to capecitabine: a potential safety issue in breast and colorectal cancer patients

PURPOSE

The aim of the OCTO clinical study was to measure patients' adherence to capecitabine-based treatment.

METHODS

A cohort of ambulatory patients treated with capecitabine monotherapy for either locally advanced or metastatic, breast or colorectal cancer was monitored for 6 cycles. Adherence was assessed in all patients by self-completed questionnaires on disease, pill-count and pharmacological dosage of FBAL (metabolite of capecitabine); and in half of the cohort by electronic medication event monitoring systems (MEMS™) recording the opening times of the device.

RESULTS

Forty patients were enrolled between November 2008 and September 2011 and treated by capecitabine for an average of 4.75 cycles (range 1-6). Hand-foot syndrome (HFS) was the most frequently reported toxicity (35% patients), and to a lesser extent fatigue and/or asthenia (21%), nausea and/or vomiting (13%) and diarrhea (11%). In the MEMS™ cohort, 20 patients were included. Patients' adherence was excellent with very few missing occasions (23/2272 records). Close analysis of MEMS™ data revealed unexpected medication patterns, such as patients taking extra days of medication beyond planned cycle, patients taking extra doses per day and patients missing a day of dosing and "compensating" by taking extra the following day (N = 7, 18%). A trend was found between over-adherence and high-grade toxicity (grades 3 and/or 4): OR 4.74 [0.65-45.2], p = 0.13 and higher AUC (p = 0.16). There was a trend towards increased AUC of FBAL in over-adherent patients (p = 0.16).

CONCLUSION

Adherence to oral anticancer chemotherapy was found excellent in this population suggesting over-adherence to capecitabine and potential safety implications for outpatients' drugs.

Patient satisfaction with information on oral anticancer agent use

Adequate information on oral anticancer agent (OACA) use is an essential element of optimal cancer care. The present study aimed to get insight into the experiences of patients with information on OACA treatment and their characteristics regarding information dissatisfaction. Patients of four Dutch university hospitals using OACA participated in this observational study and completed the Satisfaction with Information about Medicines Scale (SIMS), EORTC Quality of Life Questionnaire-C30, Brief Illness Perception Questionnaire, and Beliefs about Medicines Questionnaire-Specific. Logistic regression analyses were used to determine factors associated with dissatisfaction with information. Patients (n = 208) using capecitabine (35%), lenalidomide (15%), imatinib (14%), temozolomide (12%), sunitinib (11%), thalidomide (5%), dasatinib (4%), erlotinib (2%), and nilotinib (2%) participated. Information on the following SIMS-items was inadequate: how OACA elicit their effect, how long it takes before treatment works, how to conclude that treatment is effective, the risk of side effects and its management, interference with sex life, drowsiness, interference with other medication and alcohol and what to do in case of a missed dose. Younger age, hematological malignancy, dyspnoea, positive perception of consequences of the cancer, low perception of treatment control, and indifferent attitude towards OACA were associated with dissatisfaction with information. In conclusion, a considerable number of patients would have appreciated receiving more information on specific issues relating to the consequences of OACA treatment such as the effects and side effects of OACA and the interference of treatment with various aspects of their daily life. Oncologists, hematologists, lung-oncologists and pharmacists may reconsider the provision of information on OACA treatment.

Supporting adherence to oral anticancer agents: clinical practice and clues to improve care provided by physicians, nurse practitioners, nurses and pharmacists

Background

Healthcare provider (HCP) activities and attitudes towards patients strongly influence medication adherence. The aim of this study was to assess current clinical practices to support patients in adhering to treatment with oral anticancer agents (OACA) and to explore clues to improve the management of medication adherence.

Methods

A cross-sectional, observational study among HCPs in (haemato-)oncology settings in Belgium and the Netherlands was conducted in 2014 using a composite questionnaire. A total of 47 care activities were listed and categorised into eight domains. HCPs were also asked about their perceptions of adherence management on the items: insight into adherence, patients’ communication, capability to influence, knowledge of consequences and insight into causes. Validated questionnaires were used to assess beliefs about medication (BMQ) and shared decision making (SDM-Q-doc).

Results

In total, 208 HCPs (29% male) participated; 107 from 51 Dutch and 101 from 26 Belgian hospitals. Though a wide range of activities were reported, certain domains concerning medication adherence management received less attention. Activities related to patient knowledge and adverse event management were reported most frequently, whereas activities aimed at patient’s self-efficacy and medication adherence during ongoing use were frequently missed. The care provided differed between professions and by country. Belgian physicians reported more activities than Dutch physicians, whereas Dutch nurses and pharmacists reported more activities than Belgian colleagues. The perceptions of medication adherence management were related to the level of care provided by HCPs. SDM and BMQ outcomes were not related to the care provided.

Conclusions

Enhancing the awareness and perceptions of medication adherence management of HCPs is likely to have a positive effect on care quality. Care can be improved by addressing medication adherence more directly e.g., by questioning patients about (expected) barriers and discussing strategies to overcome them, by asking for missed doses and offering (electronic) reminders to support long-term medication adherence. A multidisciplinary approach is recommended in which the role of the pharmacist could be expanded.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3110-2) contains supplementary material, which is available to authorized users.

Towards safety of oral anti-cancer agents, the need to educate our pharmacists

Introduction: The global prevalence of cancer is rising. Use of oral anticancer medications has expanded exponentially. Knowledge about these medications as well as safe handling guidelines has not kept abreast with the rapidity these medications are applied in clinical practice. They pose serious hazards on all personal involved in handling these medications as well as on patients and their caregivers. We addressed the gaps in knowledge and safe handling of oral anticancer agents among pharmacists in institutional based cancer care. Materials and Methods: We used a 41 item questionnaire to explore three domains, pharmacists' knowledge, safe handling practice and confidence and self-improving strategies towards these agents among pharmacists in multicentre specialized cancer care. Results: Participants included 120 pharmacists dedicated to handle and dispense oral anticancer agents. About 20% of Pharmacists have adequate knowledge about oral anticancer agents. Less than 50% apply safe handling principles adequately. Only a quarter are confident in educating cancer patients and their caregivers about Oral Anti-Cancer Agents. Conclusions: Pharmacists' knowledge about Oral Anticancer agents needs to be improved. Safe handling and dispensing practice of these medications should be optimized. Pharmacists' confidence towards educating patients and their caregiver needs to be addressed. Enhancing safety of oral anticancer agents should be a priority. Involving all key players, research and quality improving projects are needed to improve all aspects of the safety of oral anticancer agents.

Adherence and patients' experiences with the use of oral anticancer agents

A rapidly growing number of oral anticancer agents has become available in oncology and hematology. Though these introductions have several benefits, medication adherence is an issue of concern. Little is known about the factors influencing adherence to treatment with oral anticancer agents in daily practice. Material and methods. In this observational, multicenter study including 216 patients, carried out between October 2010 and March 2012, the use of oral anticancer drugs was assessed by means of a telephonic pill count, a questionnaire and a review of the patient's medical file and pharmacy medication records. Parameters collected were patients' demographics, treatment characteristics, beliefs and attitude towards disease and medicines, self-reported adherence, side effects, quality of life and satisfaction about information. Patients off treatment filled out a questionnaire about the reasons for discontinuation. Optimal adherence was defined as ≥ 95%-≤ 105%. Results. The mean adherence rate (AR) (n = 177) was 99.1% with 20.3% of patients having a sub-optimal AR (< 95%, > 105%) consisting both of under- and over-adherence. Multivariate analyses showed that being on a cyclic dosing regimen (rather than a continuous regimen), not living alone and being highly educated increased the chances of optimal adherence (ORs = 4.88, 4.59 and 2.53, respectively). In addition, optimal adherence was found to be less common in patients reporting treatment control (OR = 0.77). One third of 79 patients off treatment reported their experienced side effects as one of the reasons for discontinuation. Discussion. Although most patients are fully adherent to oral anticancer agents, there is a substantial number tending to non-adherence. Patients living alone and those on a continuous dosing regimen are most likely to adhere sub-optimally. Interventions to improve adherence should specifically address these patients and be tailored to the needs of the individual patient.

A review of economic impact of targeted oral anticancer medications

There has been a rapid increase in the use of targeted oral anticancer medications (OAMs) in the past decade. As OAMs are often expensive, economic consideration play a significant role in the decision to prescribe, receive or cover them. This paper performs a systematic review of costs or budgetary impact of targeted OAMs to better understand their economic impact on the healthcare system, patients as well as payers. We present our review in a summary table that describes the method and main findings, take into account multiple factors, such as country, analytical approach, cost type, study perspective, timeframe, data sources, study population and care setting when we interpret the results from different papers, and discuss the policy and clinical implications. Our review raises a concern regarding the role of sponsorship on findings of economic analyses as the vast majority of pharmaceutical company-sponsored studies reported cost advantages toward the sponsor's drugs.

Vandetanib for the treatment of metastatic medullary thyroid cancer

Medullary thyroid cancer (MTC) represents an aggressive form of thyroid malignancy. Some may occur spontaneously or can be associated with Multiple Endocrine Neoplasia syndromes, or Familial Medullary Thyroid Cancer syndrome. In these patients, the protooncogene RET (rearranged during transfection) is mutated. In patients who have unresectable or metastatic disease, the long term prognosis is poor. New treatments for this disease have focused on the use of targeted agents that inhibit the receptor tyrosine kinase of RET. One of these treatments, Vandetanib (Caprelsa, Astra Zeneca), recently has received approval from the Food and Drug Administration for the treatment of patients with progressive locally advanced and/or metastatic disease. This review highlights the studies that led to the drug's approval, and discusses on the potential financial costs of treatment and side effects of this therapy. The main clinical studies evaluating Vandetanib for the treatment of other solid tumors will also be reviewed.