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Aye PS, Barnes J, Laking G, Cameron L, Anderson M, Luey B, Delany S, Harris D, McLaren B, Brenman E, Wong J, Lawrenson R, Arendse M, Tin Tin S, Elwood M, Hope P, McKeage MJ. Erlotinib or Gefitinib for Treating Advanced Epidermal Growth Factor Receptor Mutation-Positive Lung Cancer in Aotearoa New Zealand: Protocol for a National Whole-of-Patient-Population Retrospective Cohort Study and Results of a Validation Substudy. JMIR Res Protoc 2024; 13:e51381. [PMID: 38954434 PMCID: PMC11252616 DOI: 10.2196/51381] [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: 09/04/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Starting in 2010, the epidermal growth factor receptor (EGFR) kinase inhibitors erlotinib and gefitinib were introduced into routine use in Aotearoa New Zealand (NZ) for treating advanced lung cancer, but their impact in this setting is unknown. OBJECTIVE The study described in this protocol aims to understand the effectiveness and safety of these new personalized lung cancer treatments and the contributions made by concomitant medicines and other factors to adverse outcomes in the general NZ patient population. A substudy aimed to validate national electronic health databases as the data source and the methods for determining patient eligibility and identifying outcomes and variables. METHODS This study will include all NZ patients with advanced EGFR mutation-positive lung cancer who were first dispensed erlotinib or gefitinib before October 1, 2020, and followed until death or for at least 1 year. Routinely collected health administrative and clinical data will be collated from national electronic cancer registration, hospital discharge, mortality registration, and pharmaceutical dispensing databases by deterministic data linkage using National Health Index numbers. The primary effectiveness and safety outcomes will be time to treatment discontinuation and serious adverse events, respectively. The primary variable will be high-risk concomitant medicines use with erlotinib or gefitinib. For the validation substudy (n=100), data from clinical records were compared to those from national electronic health databases and analyzed by agreement analysis for categorical data and by paired 2-tailed t tests for numerical data. RESULTS In the validation substudy, national electronic health databases and clinical records agreed in determining patient eligibility and for identifying serious adverse events, high-risk concomitant medicines use, and other categorical data with overall agreement and κ statistic of >90% and >0.8000, respectively; for example, for the determination of patient eligibility, the comparison of proxy and standard eligibility criteria applied to national electronic health databases and clinical records, respectively, showed overall agreement and κ statistic of 96% and 0.8936, respectively. Dates for estimating time to treatment discontinuation and other numerical variables and outcomes showed small differences, mostly with nonsignificant P values and 95% CIs overlapping with zero difference; for example, for the dates of the first dispensing of erlotinib or gefitinib, national electronic health databases and clinical records differed on average by approximately 4 days with a nonsignificant P value of .33 and 95% CIs overlapping with zero difference. As of May 2024, the main study is ongoing. CONCLUSIONS A protocol is presented for a national whole-of-patient-population retrospective cohort study designed to describe the safety and effectiveness of erlotinib and gefitinib during their first decade of routine use in NZ for treating EGFR mutation-positive lung cancer. The validation substudy demonstrated the feasibility and validity of using national electronic health databases and the methods for determining patient eligibility and identifying the study outcomes and variables proposed in the study protocol. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12615000998549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368928. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51381.
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Affiliation(s)
- Phyu Sin Aye
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Joanne Barnes
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - George Laking
- Te Aka Mātauranga Matepukupuku Centre for Cancer Research, University of Auckland, Auckland, New Zealand
| | - Laird Cameron
- Department of Medical Oncology, Te Pūriri o Te Ora Regional Cancer and Blood Service, Te Whatu Ora Health New Zealand, Auckland City Hospital, Auckland, New Zealand
| | - Malcolm Anderson
- Department of Medical Oncology, Te Whatu Ora Health New Zealand Te Pae Hauuora o Ruahine o Tararua, Palmerston North Hospital, Palmerston North, New Zealand
| | - Brendan Luey
- Wellington Blood and Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast and Hutt Valley, Wellington Hospital, Wellington, New Zealand
| | - Stephen Delany
- Department of Oncology, Te Whatu Ora Health New Zealand Nelson Marlborough, Nelson Hospital, Nelson, New Zealand
| | - Dean Harris
- Oncology Service, Te Whatu Ora - Waitaha Canterbury, Christchurch Hospital, Christchurch, New Zealand
| | - Blair McLaren
- Southern Blood and Cancer Service, Te Whatu Ora Southern, Dunedin Hospital, Dunedin, New Zealand
| | - Elliott Brenman
- Cancer and Haematology Services, Te Whatu Ora Health New Zealand Haora a Toi Bay of Plenty, Tauranga Hospital, Tauranga, New Zealand
| | - Jayden Wong
- Cancer Services, Te Whatu Ora Health New Zealand Waikato, Waikato Hospital, Hamilton, New Zealand
| | - Ross Lawrenson
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Michael Arendse
- Department of Pathology, Te Whatu Ora Health New Zealand Waikato, Waikato Hospital, Hamilton, New Zealand
| | - Sandar Tin Tin
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Mark Elwood
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Philip Hope
- Lung Foundation New Zealand, Manukau, Auckland, New Zealand
| | - Mark James McKeage
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
- Department of Medical Oncology, Te Pūriri o Te Ora Regional Cancer and Blood Service, Te Whatu Ora Health New Zealand, Auckland City Hospital, Auckland, New Zealand
- Auckland Cancer Society Research Centre, University of Auckland, Auckland, New Zealand
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Brenner DR, O'Sullivan DE, Jarada TN, Yusuf A, Boyne DJ, Mather CA, Box A, Morris DG, Cheung WY, Mirza I. The impact of population-based EGFR testing in non-squamous metastatic non-small cell lung cancer in Alberta, Canada. Lung Cancer 2023; 175:60-67. [PMID: 36463730 DOI: 10.1016/j.lungcan.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES While Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase Inhibitors have been shown to be effective in phase III randomized trials, the value of targeted therapies has been challenging to evaluate at the population-level. We examined the impact of population-level EGFR testing and treatment on survival outcomes among non-squamous metastatic Non-Small Cell Lung Cancer (NSCLC) patients. MATERIALS AND METHODS Real-world, population-level data were collected from all de novo non-squamous metastatic NSCLC patients in Alberta, Canada from 2004 to 2020. EGFR testing data were collected through Alberta Precision Laboratories. Differences in survival rates and overall survival (OS) pre (2004-2012) and post initiation (post) (2013-2019) testing periods were evaluated using interrupted time series analyses. The impact of testing and subsequent treatment was evaluated using multivariable Cox Proportional Hazards models. RESULTS In total, 4,578 non-squamous metastatic NSCLC patients were diagnosed pre-EGFR testing and 4,457 patients were diagnosed post-EGFR testing (2013-2019). Among patients diagnosed in the pre-EGFR testing period, the 6-month, 1-year, and 2-year survival probabilities were 0.39 (95 % CI: 0.38-0.41), 0.22 (95 % CI: 0.21-0.23), and 0.09 (95 % CI: 0.08-0.10), while the survival probabilities for patients diagnosed in the post-EGFR testing period were 0.45 (95 % CI: 0.43-0.46), 0.29 (95 % CI: 0.27-0.30), and 0.16 (95 % CI: 0.15-0.17), respectively. After adjusting for baseline patient and clinical characteristics, OS in the post-EGFR period was significantly improved compared to the pre-EGFR period (HR: 0.81; 95 % CI: 0.78-0.85). Among patients who were treated with systemic therapy, those tested for an EGFR mutation had significantly greater survival than patients who were not tested HR of 0.81 (95 % CI: 0.70-0.95). CONCLUSION These results show the considerable impact of population-based molecular testing and subsequent targeted therapies on survival among metastatic NSCLC patients. The estimates here can be used in future studies to evaluate the population-level cost-effectiveness of testing and treatment.
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Affiliation(s)
- Darren R Brenner
- Department of Oncology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Oncology Outcomes Initiative, University of Calgary, AB, Canada.
| | - Dylan E O'Sullivan
- Department of Oncology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Oncology Outcomes Initiative, University of Calgary, AB, Canada
| | - Tamer N Jarada
- Department of Oncology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Oncology Outcomes Initiative, University of Calgary, AB, Canada
| | - Amman Yusuf
- Oncology Outcomes Initiative, University of Calgary, AB, Canada
| | - Devon J Boyne
- Department of Oncology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Oncology Outcomes Initiative, University of Calgary, AB, Canada
| | | | - Adrian Box
- Alberta Precision Laboratories, AB, Canada
| | - Donald G Morris
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Winson Y Cheung
- Department of Oncology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Oncology Outcomes Initiative, University of Calgary, AB, Canada
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O’Sullivan DE, Jarada TN, Yusuf A, Hu L(XY, Gogna P, Brenner DR, Abbie E, Rose JB, Eaton K, Elia-Pacitti J, Ewara EM, Pabani A, Cheung WY, Boyne DJ. Prevalence, Treatment Patterns, and Outcomes of Individuals with EGFR Positive Metastatic Non-Small Cell Lung Cancer in a Canadian Real-World Setting: A Comparison of Exon 19 Deletion, L858R, and Exon 20 Insertion EGFR Mutation Carriers. Curr Oncol 2022; 29:7198-7208. [PMID: 36290844 PMCID: PMC9600059 DOI: 10.3390/curroncol29100567] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Real-world evidence surrounding EGFR positive NSCLC patients in Canada is limited. Administrative databases in Alberta, Canada were used to evaluate EGFR testing and mutation prevalence in de novo metastatic NSCLC, as well as the characteristics, treatment patterns, and outcomes of individuals with Exon 19, L858R and Exon20ins mutations. Between 2013-2019, 2974 individuals underwent EGFR testing, of which 451 (15.2%) were EGFR positive. Among EGFR positive individuals, 221 (49.0%) had an Exon 19 mutation, 159 (35.3%) had an L858R mutation, and 18 (4%) had an Exon20ins mutation. The proportion of individuals who initiated 1L systemic therapy was 89.1% for Exon19, 85.5% for L858R, and 72.2% for Exon20ins carriers. The primary front-line systemic therapy was gefitinib or afatinib monotherapy for individuals with Exon 19 (93.4%) and L858R (94.1%) mutations versus platinum combination therapy for individuals with Exon20ins mutations (61.5%). The Exon20ins cohort had worse median overall survival from initiation of 1L systemic therapy (10.5 months [95% CI: 8.0-not estimable]) than the Exon19 (20.6 months [95% CI: 18.4-24.9]), and L858R cohorts (19.1 months [95% CI: 14.5-23.1]). These findings highlight that Exon20ins mutations represent a rare subset of NSCLC in which treatment options are limited and survival outcomes are worse relative to individuals with more common types of EGFR mutations.
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Affiliation(s)
- Dylan E. O’Sullivan
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Tamer N. Jarada
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Amman Yusuf
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Leo (Xun Yang) Hu
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Priyanka Gogna
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
- Public Health Sciences, Queen’s University, Kingston, Toronto, ON K7L 3N6, Canada
| | - Darren R. Brenner
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
| | | | | | | | | | | | - Aliyah Pabani
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Winson Y. Cheung
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Devon J. Boyne
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Oncology Outcomes Initiative, University of Calgary, Calgary, AB T2N 4N2, Canada
- Correspondence:
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Aye PS, McKeage MJ, Tin Tin S, Khwaounjoo P, Elwood JM. Population-based incidence rates and increased risk of EGFR mutated non-small cell lung cancer in Māori and Pacifica in New Zealand. PLoS One 2021; 16:e0251357. [PMID: 33961689 PMCID: PMC8104366 DOI: 10.1371/journal.pone.0251357] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/26/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Non-squamous non-small cell lung cancer (NSCLC) patients with Epidermal Growth Factor Receptor (EGFR) mutation benefit from targeted treatments. Previous studies reported EGFR mutation-positive proportions among tested non-squamous NSCLC patients. However, incidence rates and population risk of EGFR mutation-positive and EGFR mutation-negative non-squamous NSCLC have not been assessed. This study therefore aimed to estimate the population-based incidence rates of EGFR mutation-positive and EGFR mutation-negative non-squamous NSCLC in different population groups defined by sex, ethnic group and smoking status. METHODS This study included data from all non-squamous NSCLC patients diagnosed in northern New Zealand between 1/02/2010 and 31/07/2017 (N = 3815), obtained from a population-based cancer registry. Age-specific incidence rates, WHO age-standardised rates (ASRs) and rates adjusted for incomplete testing were calculated for EGFR mutation-positive and EGFR mutation-negative diseases for the study cohort as a whole and subgroups of patients. RESULTS Among 3815 patients, 45% were tested for EGFR mutations; 22.5% of those tested were EGFR mutation-positive. The ASR of EGFR mutation-positive NSCLC was 5.05 (95%CI 4.71-5.39) per 100,000 person-years. ASRs for EGFR mutation-positive NSCLC were higher for females than males: standardised incidence ratio (SIR) 1.50 (1.31-1.73); higher for Pacifica, Asians and Māori compared with New Zealand Europeans: SIRs 3.47 (2.48-4.85), 3.35 (2.62-4.28), and 2.02 (1.43-2.87), respectively; and, only slightly increased in ever-smokers compared with never-smokers: SIR 1.25 (1.02-1.53). In contrast, the ASR of EGFR mutation-negative NSCLC was 17.39 (16.75-18.02) per 100,000 person-years, showing a strong association with smoking; was higher for men; highest for Māori, followed by Pacifica and then New Zealand Europeans, and lowest for Asians. When corrected for incomplete testing, SIRs by sex, ethnicity and smoking, for both diseases, remained similar to those based on tested patients. CONCLUSION The population risk of EGFR mutation-positive NSCLC was significantly higher for Māori and Pacifica compared with New Zealand Europeans.
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Affiliation(s)
- Phyu Sin Aye
- Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Mark James McKeage
- Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
- Auckland Cancer Society Research Centre, University of Auckland, Auckland, New Zealand
| | - Sandar Tin Tin
- Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | | | - J Mark Elwood
- Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
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McKeage MJ, Tin Tin S, Khwaounjoo P, Sheath K, Dixon-McIver A, Ng D, Sullivan R, Cameron L, Shepherd P, Laking GR, Kingston N, Strauss M, Lewis C, Elwood M, Love DR. Screening for anaplastic lymphoma kinase (ALK) gene rearrangements in non-small-cell lung cancer in New Zealand. Intern Med J 2021; 50:716-725. [PMID: 31318119 DOI: 10.1111/imj.14435] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/21/2019] [Accepted: 07/09/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lung cancer is a major cause of death in New Zealand. In recent years, targeted therapies have improved outcomes. AIM To determine the uptake of anaplastic lymphoma kinase (ALK) testing, and the prevalence, demographic profile and outcomes of ALK-positive non-small-cell lung cancer (NSCLC), in New Zealand, where no national ALK-testing guidelines or subsidised ALK tyrosine kinase inhibitor (TKI) therapies are available. METHODS A population-based observational study reviewed databases to identify patients presenting with non-squamous NSCLC over 6.5 years in northern New Zealand. We report the proportion tested for ALK gene rearrangements and the results. NSCLC samples tested by fluorescence in situ hybridisation were retested by next generation sequencing and ALK immunohistochemistry. A survival analysis compared ALK-positive patients treated or not treated with ALK TKI therapy. RESULTS From a total of 3130 patients diagnosed with non-squamous NSCLC, 407 (13%) were tested for ALK gene rearrangements, and patient selection was variable and inequitable. Among those tested, 34 (8.4%) had ALK-positive NSCLC. ALK-positive disease was more prevalent in younger versus older patients, non-smokers versus smokers and in Māori, Pacific or Asian ethnic groups than in New Zealand Europeans. Fluorescence in situ hybridisation, ALK immunohistochemistry and next generation sequencing showed broad concordance for detecting ALK-positive disease under local testing conditions. Among patients with ALK-positive metastatic NSCLC, those treated with ALK TKI survived markedly longer than those not treated with ALK TKI (median overall survival 5.12 vs 0.55 years). CONCLUSION Lung cancer outcomes in New Zealand may be improved by providing national guidelines and funding policy for ALK testing and access to subsidised ALK TKI therapy.
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Affiliation(s)
- Mark J McKeage
- Department of Pharmacology and Clinical Pharmacology and the Auckland Cancer Society Research Centre Auckland, University of Auckland, Auckland, New Zealand.,Medical Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Sandar Tin Tin
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Prashannata Khwaounjoo
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Karen Sheath
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | | | | | | | - Laird Cameron
- Medical Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Philip Shepherd
- School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - George R Laking
- Medical Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Nicola Kingston
- Anatomical Pathology, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Magreet Strauss
- Anatomical Pathology, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | | | - Mark Elwood
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Donald R Love
- Diagnostic Genetics, LabPLUS, Auckland City Hospital, Auckland, New Zealand.,Pathology Genetics, Sidra Medicine, Doha, Qatar
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Dragojlovic N, Kopac N, Borle K, Tandun R, Salmasi S, Ellis U, Birch P, Adam S, Friedman JM, Elliott AM, Lynd LD. Utilization and uptake of clinical genetics services in high-income countries: A scoping review. Health Policy 2021; 125:877-887. [PMID: 33962789 DOI: 10.1016/j.healthpol.2021.04.010] [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: 06/10/2020] [Revised: 02/11/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022]
Abstract
Ongoing rapid growth in the need for genetic services has the potential to severely strain the capacity of the clinical genetics workforce to deliver this care. Unfortunately, assessments of the scale of this health policy challenge and potential solutions are hampered by the lack of a consolidated evidence base on the growth in genetic service utilization. To enable health policy research and strategic planning by health systems in this area, we conducted a scoping review of the literature on the utilization and uptake of clinical genetics services in high-income countries published between 2010 and 2018. One-hundred-and-ninety-five unique studies were included in the review. Most focused on cancer (85/195; 44%) and prenatal care (50/195; 26%), which are consistently the two areas with the greatest volume of genetic service utilization in both the United States and other high-income countries. Utilization and uptake rates varied considerably and were influenced by contextual factors including health system characteristics, provider knowledge, and patient preferences. Moreover, growth in genetic service utilization appears to be driven to a significant degree by technological advances and the integration of new tests into clinical care. Our review highlights both the policy challenge posed by the rapid growth in the utilization of genetic services and the variability in this trend across clinical indications and health systems.
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Affiliation(s)
- Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Nicola Kopac
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Kennedy Borle
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Rachel Tandun
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Shahrzad Salmasi
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Ursula Ellis
- Woodward Library, University of British Columbia, 2198 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Patricia Birch
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Shelin Adam
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Jan M Friedman
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | | | - Alison M Elliott
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada; BC Women's Hospital Research Institute, H214 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, 588-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z 1Y6.
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Utilisation and Determinants of Epidermal Growth Factor Receptor Mutation Testing in Patients with Non-small Cell Lung Cancer in Routine Clinical Practice: A Global Systematic Review. Target Oncol 2021; 15:279-299. [PMID: 32445082 DOI: 10.1007/s11523-020-00718-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) mutation testing is recommended for selecting patients with non-squamous non-small cell lung cancer (NSCLC) for EGFR tyrosine kinase inhibitor drug treatment. OBJECTIVE The objective of this article was to systematically review available evidence on the utilisation and determinants of EGFR mutation testing of patients with NSCLC in routine clinical practice. PATIENTS AND METHODS Searches were made of five electronic databases (Web of Science, MEDLINE [Ovid], Science Direct, EMBASE and Scopus), bibliographies of relevant articles, studies that cited included studies and relevant cancer websites. Studies were included if they: (1) reported the rate of uptake of EGFR testing in patients with NSCLC; (2) were conducted in routine clinical practice settings; (3) were published in English prior to July 2017; and (4) had full text available. Studies were appraised using the STROBE and the National Institutes of Health (National Heart, Lung and Blood Institute) checklists. RESULTS Eighteen eligible studies were identified for this systematic review, published between 2011 and 2017, from the USA (n = 7), Canada (n = 2), Republic of Korea (n = 2), Norway (n = 1), Sweden (n = 1), Germany (n = 1), Spain (n = 1), New Zealand (n = 1), China (n = 1) and multiple countries from the Asia-Pacific region (n = 1). Overall, testing for EGFR mutations was undertaken in 16,146 of 52,257 study patients (31%), although testing rates varied widely between different studies (from 7.8% to 78.3%). Single institution retrospective audits reported higher rates of testing (median 65.7%, range 31.3-78.3%) than population-based retrospective cohort analyses (median 23%, range 11-69%) and multi-institutional cross-sectional practitioner surveys (median 19.8%, range 7.8-31.8%). Nine studies reported increasing rates of testing over the study period but maximum testing rates remained less than 75% in most studies. Factors associated with higher testing uptake rates included: female sex; younger age; former/no smoking; advanced stage of lung cancer; adenocarcinoma histology; better mobility; radiation therapy; available tissue specimen; and private insurance. Among 16,146 tested patients, EGFR mutations were detected in 4328 patients (26.8%). However, estimates of mutation prevalence were biased by incomplete and selective testing in many studies. CONCLUSIONS The uptake of EGFR mutation testing of patients with NSCLC is suboptimal in many parts of the world. Incomplete uptake of testing is fuelled by selective testing referral practices, sample limitations, and funding constraints.
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Aye PS, McKeage MJ, Tin Tin S, Khwaounjoo P, Elwood JM. Factors associated with overall survival in a population-based cohort of non- squamous NSCLC patients from northern New Zealand: A comparative analysis by EGFR mutation status. Cancer Epidemiol 2020; 69:101847. [PMID: 33126040 DOI: 10.1016/j.canep.2020.101847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/02/2020] [Accepted: 10/17/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Previous studies have reported inconsistent results regarding the effect of epidermal growth factor receptor (EGFR) mutations on overall survival in patients with non-squamous non-small-cell lung cancer (NSCLC). This study assesses the effect of EGFR mutation on overall survival, and how the effects of other survival predictors differ by EGFR mutation status. METHODS The study used a population- based cohort of 1534 non-squamous NSCLC patients diagnosed in northern New Zealand between 1st February 2010 and 31st July 2017. Cox regression survival analyses were used to explore the associations between clinicopathological factors and overall survival by EGFR mutation status. The factors included were age at diagnosis, sex, ethnicity, smoking status, performance status, metastasis status and tumour site. RESULTS In this cohort, 20% had anEGFR mutation. The median overall survival times were 0.8 years and 2.79 years in EGFR-mutation-negative and -positive groups, respectively (p < 0.0001). Metastasis at diagnosis showed large effects on overall survival in both EGFR-mutation- negative (hazard ratio (HR) = 3.6) and mutation-positive (HR = 3.3) groups. In subgroup analyses by mutation status and metastasis, females had lower survival only if they were mutation-positive; Māori had lower survival (than European New Zealanders) only if the disease was metastatic, and tumour site had significant effects only in patients without metastasis. Age, performance status and smoking status showed consistent effects in all subgroups. CONCLUSION EGFR mutation status and metastasis are the main predictors for overall survival in non-squamous NSCLC patients. The effects of sex, ethnicity and tumour site vary depending on EGFR mutation and metastasis status.
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Affiliation(s)
- Phyu Sin Aye
- Epidemiology and Biostatistics, University of Auckland, New Zealand.
| | - Mark James McKeage
- Pharmacology and Clinical Pharmacology, University of Auckland, New Zealand; Auckland Cancer Society Research Centre, University of Auckland, New Zealand
| | - Sandar Tin Tin
- Epidemiology and Biostatistics, University of Auckland, New Zealand
| | | | - J Mark Elwood
- Epidemiology and Biostatistics, University of Auckland, New Zealand
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Aye PS, Tin Tin S, McKeage MJ, Khwaounjoo P, Cavadino A, Elwood JM. Development and validation of a predictive model for estimating EGFR mutation probabilities in patients with non-squamous non-small cell lung cancer in New Zealand. BMC Cancer 2020; 20:658. [PMID: 32664868 PMCID: PMC7362551 DOI: 10.1186/s12885-020-07162-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 07/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Targeted treatment with Epidermal Growth Factor Receptor (EGFR) tyrosine kinase inhibitors (TKIs) is superior to systemic chemotherapy in non-small cell lung cancer (NSCLC) patients with EGFR gene mutations. Detection of EGFR mutations is a challenge in many patients due to the lack of suitable tumour specimens for molecular testing or for other reasons. EGFR mutations are more common in female, Asian and never smoking NSCLC patients. METHODS Patients were from a population-based retrospective cohort of 3556 patients diagnosed with non-squamous non-small cell lung cancer in northern New Zealand between 1 Feb 2010 and 31 July 2017. A total of 1694 patients were tested for EGFR mutations, of which information on 1665 patients was available for model development and validation. A multivariable logistic regression model was developed based on 1176 tested patients, and validated in 489 tested patients. Among 1862 patients not tested for EGFR mutations, 129 patients were treated with EGFR-TKIs. Their EGFR mutation probabilities were calculated using the model, and their duration of benefit and overall survival from the start of EGFR-TKI were compared among the three predicted probability groups: < 0.2, 0.2-0.6, and > 0.6. RESULTS The model has three predictors: sex, ethnicity and smoking status, and is presented as a nomogram to calculate EGFR mutation probabilities. The model performed well in the validation group (AUC = 0.75). The probability cut-point of 0.2 corresponds 68% sensitivity and 78% specificity. The model predictions were related to outcome in a group of TKI-treated patients with no biopsy testing available (n = 129); in subgroups with predicted probabilities of < 0.2, 0.2-0.6, and > 0.6, median overall survival times from starting EGFR-TKI were 4.0, 5.5 and 18.3 months (p = 0.02); and median times remaining on EGFR-TKI treatment were 2.0, 4.2, and 14.0 months, respectively (p < 0.001). CONCLUSION Our model may assist clinical decision making for patients in whom tissue-based mutation testing is difficult or as a supplement to mutation testing.
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Affiliation(s)
- Phyu Sin Aye
- Epidemiology and Biostatistics, University of Auckland, B507, 22-30 Park Ave, Grafton, Auckland, 1072, New Zealand.
| | - Sandar Tin Tin
- Epidemiology and Biostatistics, University of Auckland, B507, 22-30 Park Ave, Grafton, Auckland, 1072, New Zealand
| | - Mark James McKeage
- Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
- Auckland Cancer Society Research Centre, University of Auckland, Auckland, New Zealand
| | | | - Alana Cavadino
- Epidemiology and Biostatistics, University of Auckland, B507, 22-30 Park Ave, Grafton, Auckland, 1072, New Zealand
| | - J Mark Elwood
- Epidemiology and Biostatistics, University of Auckland, B507, 22-30 Park Ave, Grafton, Auckland, 1072, New Zealand
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