More than 5000 patients with metastatic melanoma in Europe per year do not have access to recommended first-line innovative treatments

Combined therapy of dabrafenib and an anti-HER2 antibody-drug conjugate for advanced BRAF-mutant melanoma

BACKGROUND

Melanoma is the most lethal skin cancer characterized by its high metastatic potential. In the past decade, targeted and immunotherapy have brought revolutionary survival benefits to patients with advanced and metastatic melanoma, but these treatment responses are also heterogeneous and/or do not achieve durable responses. Therefore, novel therapeutic strategies for improving outcomes remain an unmet clinical need. The aim of this study was to evaluate the therapeutic potential and underlying molecular mechanisms of RC48, a novel HER2-target antibody drug conjugate, either alone or in combination with dabrafenib, a V600-mutant BRAF inhibitor, for the treatment of advanced BRAF-mutant cutaneous melanoma.

METHODS

We evaluated the therapeutic efficacy of RC48, alone or in combination with dabrafenib, in BRAF-mutant cutaneous melanoma cell lines and cell-derived xenograft (CDX) models. We also conducted signaling pathways analysis and global mRNA sequencing to explore mechanisms underlying the synergistic effect of the combination therapy.

RESULTS

Our results revealed the expression of membrane-localized HER2 in melanoma cells. RC48 effectively targeted and inhibited the growth of HER2-positive human melanoma cell lines and corresponding CDX models. When used RC48 and dabrafenib synergically induced tumor regression together in human BRAF-mutant melanoma cell lines and CDX models. Mechanically, our results demonstrated that the combination therapy induced apoptosis and cell cycle arrest while suppressing cell motility in vitro. Furthermore, global RNA sequencing analysis demonstrated that the combination treatment led to the downregulation of several key signaling pathways, including the PI3K-AKT pathway, MAPK pathway, AMPK pathway, and FOXO pathway.

CONCLUSION

These findings establish a preclinical foundation for the combined use of an anti-HER2 drug conjugate and a BRAF inhibitor in the treatment of BRAF-mutant cutaneous melanoma.

Melanoma epidemiology in Europe: what is new?

Every year in Europe over 150,000 new cases of melanoma are reported and over 25,000 lives are lost to this tumor. Incidence has been rising rapidly, faster than for any other cancer, and it is expected to continue to do so in most regions. Mortality also crept up, decades-long, with only few very recent exceptions. Thus, melanoma remains a public health problem that will not go away soon, nor easy. Some notable progress has been made in the last decade in the fight against this tumor. Registration and reporting for skin cancers improved across Europe. Incidence trends have begun to plateau or even to descend in younger age groups, in some countries, and there are encouraging signs that mortality might do the same, after the recent therapeutic breakthroughs. Survival rates are on average above 80% at 5 years for European patients, while diagnosis trends toward ever thinner tumors. Yet this progress is far from uniform across the continent, with many Southern-and Eastern European countries still struggling with sub-optimal cancer reporting, delayed access to innovative treatments, late detection and insufficient healthcare funding, that push survival rates down to harrowing 50%. This article aims to give an updated overview of the epidemiological situation of melanoma in Europe, highlighting the progress but also the persisting disparities in tumor burden, prognosis and access to quality cancer care and surveillance between European countries, as a reminder that relentless efforts must continue in order to tackle this aggressive tumor in an effective and equitable manner.

Improving care of melanoma patients through efficient, integrated cellular-molecular pathology workflows using tissue samples with low tumour nuclear content

AIMS

The aim of this quality improvement project was to improve the turnaround time of B-raf proto-oncogene (BRAF) mutation testing in patients with malignant melanoma to support oncologists in making timely treatment decisions.

METHODS

This is a prospective in-house verification of the Idylla BRAF test as compared with DNA panel next-generation sequencing (NGS) performed at an external laboratory.

RESULTS

The Idylla BRAF test had an overall concordance of 95% compared with NGS. This was considered sufficiently good for use in patients with a poor performance status who were at risk of rapid clinical deterioration. Reliable results can be generated using the Idylla BRAF test in tissue sections with tumour neoplastic cell content below 50%. We present a multidisciplinary clinical care algorithm to support dual testing.

CONCLUSIONS

The Idylla BRAF test has the potential to make a significant positive impact on progression-free survival of malignant melanoma patients due to its rapid turnaround time. The Idylla BRAF test can be used as an adjunct to NGS for timely management of patients, particularly those with a poor performance status at presentation.

Nischarin expression may have differing roles in male and female melanoma patients

Due to the development of resistance to previously effective therapies, there is a constant need for novel treatment modalities for metastatic melanoma. Nischarin (NISCH) is a druggable scaffolding protein reported as a tumor suppressor and a positive prognostic marker in breast and ovarian cancers through regulation of cancer cell survival, motility and invasion. The aim of this study was to examine the expression and potential role of nischarin in melanoma. We found that nischarin expression was decreased in melanoma tissues compared to the uninvolved skin, and this was attributed to the presence of microdeletions and hyper-methylation of the NISCH promoter in the tumor tissue. In addition to the previously reported cytoplasmic and membranous localization, we observed nischarin in the nuclei in melanoma patients' tissues. NISCH expression in primary melanoma had favorable prognostic value for female patients, but, unexpectedly, high NISCH expression predicted worse prognosis for males. Gene set enrichment analysis suggested significant sex-related disparities in predicted association of NISCH with several signaling pathways, as well as with different tumor immune infiltrate composition in male and female patients. Taken together, our results imply that nischarin may have a role in melanoma progression, but that fine-tuning of the pathways it regulates is sex-dependent. KEY MESSAGES: Nischarin is a tumor suppressor whose role has not been investigated in melanoma. Nischarin expression was downregulated in melanoma tissue compared to the normal skin. Nischarin had the opposite prognostic value in male and female melanoma patients. Nischarin association with signaling pathways differed in females and males. Our findings challenge the current view of nischarin as a universal tumor suppressor.

A Descriptive Study of Repeated Hospitalizations and Survival of Patients with Metastatic Melanoma in the Northern Italian Region during 2004-2019

BACKGROUND

Survival rates for metastatic melanoma (MM) patients have improved in recent years, leading to major expenses and health resource use. We conducted a non-concurrent prospective study to describe the burden of hospitalization in a real-world setting for patients with MM.

METHODS

Patients were tracked throughout all hospital stays in 2004-2019 by means of hospital discharges. The number of hospitalizations, the rehospitalization rate, the average time spent in the hospital and the time span between consecutive admissions were evaluated. Relative survival was also calculated.

RESULTS

Overall, 1570 patients were identified at the first stay (56.5% in 2004-2011 and 43.7% in 2012-2019). A total of 8583 admissions were retrieved. The overall rehospitalization rate was 1.78 per patient/year (95%CI = 1.68-1.89); it increased significantly with the period of first stay (1.51, 95%CI = 1.40-1.64 in 2004-2011 and 2.11, 95%CI = 1.94-2.29 thereafter). The median time span between hospitalizations was lower for patients hospitalized after 2011 (16 vs. 26 months). An improvement in survival for males was highlighted.

CONCLUSIONS

The hospitalization rate of patients with MM was higher in the last years of the study. Compared with a shorter length of stay, patients were admitted to hospitals with a higher frequency. Knowledge of the burden of MM is essential for planning the allocation of healthcare resources.

Melanoma Mortality Trends in 28 European Countries: A Retrospective Analysis for the Years 1960-2020

BACKGROUND

In 2020, in 27 European Union (EU) Member States, melanoma accounted for 4% of all new cancer cases and 1.3% of all cancer deaths, making melanoma the fifth most common malignancy and placing it in the 15 most frequent causes of cancer deaths in the EU-27. The main aim of our study was to investigate melanoma mortality trends in 25 EU Member States and three non-EU countries (Norway, Russia, and Switzerland) in a broad time perspective (1960-2020) in a younger (45-74 years old) vs. older age group (75+).

METHODS

We identified melanoma deaths defined by ICD-10 codes C-43 for individuals aged 45-74 and 75+ years old between 1960-2020 in 25 EU Member States (excluding Iceland, Luxembourg, and Malta) and in 3 non-EU countries-Norway, Russia, and Switzerland. Age-standardized melanoma mortality rates (ASR) were computed using the direct age-standardization for Segi's World Standard Population. To determine melanoma-mortality trends with 95% confidence intervals (CI), Joinpoint regression was applied. Our analysis used the Join-point Regression Program, version 4.3.1.0 (National Cancer Institute, Bethesda, MD, USA).

RESULTS

Regardless of the considered age groups, in all investigated countries, in general, melanoma standardized mortality rates were higher for men than women. Considering the age group 45-74, the highest number of countries was characterized by decreasing melanoma-mortality trends in both sexes-14 countries. Contrarily, the highest representation of countries in the age group 75+ was connected with increasing melanoma-mortality trends in both sexes-26 countries. Moreover, considering the older age group-75+-there was no country with a decreasing melanoma mortality in both sexes.

CONCLUSIONS

Investigated melanoma-mortality trends vary in individual countries and age groups; however, a highly concerning phenomenon-increasing melanoma-mortality rates in both sexes-was observed in 7 countries for the younger age group and in as many as 26 countries for the older age group. There is a need for coordinated public-health actions to address this issue.

How Can the EU Beating Cancer Plan Help in Tackling Lung Cancer, Colorectal Cancer, Breast Cancer and Melanoma?

Cancer is the second leading cause of mortality in EU countries, and the needs to tackle cancer are obvious. New scientific understanding, techniques and methodologies are opening up horizons for significant improvements in diagnosis and care. However, take-up is uneven, research needs and potential outstrip currently available resources, manifestly beneficial practices—such as population-level screening for lung cancer—are still not generalised, and the quality of life of patients and survivors is only beginning to be given attention it merits. This paper, mainly based on a series of multistakeholder expert workshops organised by the European Alliance for Personalised Medicine (EAPM), looks at some of those specifics in the interest of planning a way forward. Part of this exercise also involves taking account of the specific nature of Europe and its constituent countries, where the complexities of planning a way forward are redoubled by the wide variations in national and regional approaches to cancer, local epidemiology and the wide disparities in health systems. Despite all the differences between cancers and national and regional resources and approaches to cancer care, there is a common objective in pursuing broader and more equal access to the best available care for all European citizens.

Income loss after a cancer diagnosis in Germany: An analysis based on the socio-economic panel survey

BACKGROUND AND AIMS

Cancer treatments often require intensive use of healthcare services and limit patients' ability to work, potentially causing them to become financially vulnerable. The present study is the first attempt to measure, on the German national level, the magnitude of absolute income loss after a cancer diagnosis.

METHODS

This study analyzes data from the Socio-Economic Panel (SOEP) survey, one of the largest and most comprehensive household surveys in Germany, consisting of approximately 20,000 individuals, who are traced annually. The empirical strategy consists of ordinary least squares (OLS) and multinomial logistic estimators to measure changes in job income, work status, working hours, and pension as a result of reporting a cancer diagnosis for the period between 2009 and 2015. Sample consistency checks were conducted to limit measurement error biases.

RESULTS

Our results show that job incomes dropped between 26% and 28% within the year a cancer diagnosis was reported. The effect persisted for two years after the diagnosis and was no longer observable after four years. The finding was linked to an increased likelihood of unemployment and a reduction of working hours by 24%. Pension levels, on the other hand, were not affected by a cancer diagnosis.

CONCLUSIONS

These findings suggest that many cancer patients are exposed to financial hardship in Germany, particularly when the cancer diagnosis occurs during their working age and before requirements to obtain a pension are met. Further research seems warranted to identify particularly vulnerable patient groups.

Cutaneous melanoma: cost of illness under Brazilian health system perspectives

BACKGROUND

The landscape of cutaneous melanoma (CM) diagnosis, staging, prognosis, and treatment has undergone fundamental changes in the past decade. While the benefits of new health resources are recognized, there is a distinct lack of accurate cost-of-illness information to aid healthcare decision makers.

METHODS

The cost-of-illness study for CM was conducted from the perspective of two health systems in Brazil: the public health system (Unified Health System, SUS) and the private health system (Health Management Organization, HMO). The study considered the direct medical cost in a bottom-up analysis, using melanoma incidence, knowledge of the disease's progression, and the overall survival rates. The executional costs for the complete healthcare delivery cycle were investigated considering different disease stages and possible clinical course variations. The structural cost was assessed qualitatively considering the health value chain in Brazil.

RESULTS

CM represents a critical financial burden in Brazil, and the cost of illness varied according to the health system and by stage at diagnosis. HMO patient costs are approximately 10-fold and 90-fold more than a SUS patient in the early-stage and advanced disease, respectively. Overall, spending on advanced disease patients can be up to 34-fold (SUS) or 270-fold (HMO) higher than that required for the early-stage disease. Given the massive amount of resources spent by the SUS and HMO, significant efforts must be made to improve the health value chain to deliver the right mix of medical care goods and services using available resources.

CONCLUSION

The cost-of-illness study for CM has the potential to inform policymakers and decision-makers regarding the economic burden that melanoma impose on a society in terms of the use of health care services, assisting them in making projections of future health care costs and resource allocation decisions. We believe that cost-of-illness analysis from a strategic perspective could be of help in assessing executional costs and be used to support the change in structural costs required for long-term strategies related to the health value chain.

Access to innovation through the national early access program and clinical trials for patients with malignant melanoma

Background

The arrival of immunotherapies and targeted therapies challenged the authorities to make them available as soon as possible. France has effective tools, such as clinical trials (CTs) and a national early access program (temporary authorizations for use [ATUs] and temporary recommendations for use [RTUs]), allowing the use of innovative drugs, whether or not they have been authorized or used off‐label, for cases that have reached a therapeutic impasse.

Methods

The methodology involved real‐time data collection from ATUs, RTUs (between September 1, 2009 and September 1, 2019), and CT authorizations (from December 1, 2017 to September 1, 2019) that were filed and reviewed by the French National Agency for Medicines for metastatic melanoma (MM).

Results

In total, 45 CTs were authorized for MM (51% early phase trials and 44% phase 2 and 3 trials), mainly for the metastatic line (86%) and with an industrial sponsor (73%). Immunotherapies and targeted therapies (63% and 24%, respectively) mostly were used in combination. Three RTUs were authorized for the adjuvant treatment of MM, whereas 13 drugs were available through nominal ATUs (nATUs), of which 5 were awarded a cohort ATU (cATU). This enabled the treatment of 6538 patients (28% through nATUs and 72% through cATUs). All of these drugs were granted marketing authorization and were included in the reimbursement list.

Conclusions

Thanks to CTs and the national early access program, patients in France have been able to benefit from innovative MM treatments.

Lay Summary

Several tools allow the use of innovative drugs in France, even if they are not yet authorized or used off‐label.

From December 1, 2017 to September 1, 2019, 45 clinical trials have been authorized for metastatic melanoma, mostly using immunotherapy (63%) and targeted therapy (24%) at an early phase (51%).

Since 2010, the national early access program has treated 6538 patients, including 28% under nominative temporary authorizations for use and 72% under cohort temporary authorizations for use.

Fourteen drugs are available through nominative temporary authorizations for use, and 5 are available through cohort temporary authorizations for use, and all of these drugs were granted marketing authorization.

France has effective tools, such as clinical trials and a national early access program (temporary authorizations for use and temporary recommendations for use), allowing the use of innovative drugs that either are not authorized or are used off‐label in cases at a therapeutic impasse. Thanks to these tools, patients with malignant melanoma have early access to innovative treatments.

Circulating tumor DNA (ctDNA) detection is associated with shorter progression-free survival in advanced melanoma patients

BRAF, NRAS and TERT mutations occur in more than 2/3 of melanomas. Its detection in patient's blood, as circulating tumor DNA (ctDNA), represents a possibility for identification and monitoring of metastatic disease. We proposed to standardize a liquid biopsy platform to identify hotspot mutations in BRAF, NRAS and TERT in plasma samples from advanced melanoma patients and investigate whether it was associated to clinical outcome. Firstly, we performed digital polymerase chain reaction using tumor cell lines for validation and determination of limit of detection (LOD) of each assay and screened plasma samples from healthy individuals to determine the limit of blank (LOB). Then, we selected 19 stage III and IV patients and determined the somatic mutations status in tumor tissue and track them in patients' plasma. We established a specific and sensitive methodology with a LOD ranging from 0.13 to 0.37%, and LOB ranging from of 0 to 5.201 copies/reaction. Somatic mutations occurred in 17/19 (89%) patients, of whom seven (41%) had ctDNA detectable their paired plasma. ctDNA detection was associated with shorter progression free survival (p = 0.01). In conclusion, our data support the use of ctDNA as prognosis biomarker, suggesting that patients with detectable levels have an unfavorable outcome.

Malignant melanoma metastasis in the gallbladder. A case report of an unusual metastatic site

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Malignant melanoma metastasis into the gallbladder is a rare issue.

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Surgical treatment in a metastasized situation has to be carefully evaluated.

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Prevention of possible biliary complications is of significant importance.

Introduction

Malignant melanoma is a neoplasia with the ability to metastasize to all organs. Most frequently, metastases derives from a skin primary. A solitary metastasis in the gallbladder is rarely mentioned in current literature.

Presentation of case

We present the case of a 62-year-old female patient with the unusual metastatic spread of malignant melanoma into the gallbladder. The lesion was detected during routine follow up appointment six years after the initial surgical and radio-chemotherapeutic treatment of a malignant melanoma on the back. Following multidisciplinary team meeting, it was decided to perform a laparoscopic cholecystectomy to remove the gallbladder metastasis.

Discussion

New occurrence of a melanoma metastasis in the gallbladder is extremely rare, especially in stable disease. The therapeutical concept must be discussed extensively in the present of this metastasized tumor.

Conclusion

In otherwise stable disease, palliative surgery for metastasis in the gallbladder is a possible option to prevent biliary complications. In a palliative setting always weigh up the risks and benefits while maintaining the quality of life.

The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV and Task Forces, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force

BACKGROUND

The incidence of skin cancers has been increasing steadily over the last decades. Although there have been significant breakthroughs in the management of skin cancers with the introduction of novel diagnostic tools and innovative therapies, skin cancer mortality, morbidity and costs heavily burden the society.

OBJECTIVE

Members of the European Association of Dermato-Oncology, European Academy of Dermatology and Venereology, International Dermoscopy Society, European Dermatology Forum, European Board of Dermatovenereology of the European Union of Medical Specialists and EORTC Cutaneous Lymphoma Task Force have joined this effort to emphasize the fundamental role that the specialist in Dermatology-Venereology has in the diagnosis and management of different types of skin cancer. We review the role of dermatologists in the prevention, diagnosis, treatment and follow-up of patients with melanoma, non-melanoma skin cancers and cutaneous lymphomas, and discuss approaches to optimize their involvement in effectively addressing the current needs and priorities of dermato-oncology.

DISCUSSION

Dermatologists play a crucial role in virtually all aspects of skin cancer management including the implementation of primary and secondary prevention, the formation of standardized pathways of care for patients, the establishment of specialized skin cancer treatment centres, the coordination of an efficient multidisciplinary team and the setting up of specific follow-up plans for patients.

CONCLUSION

Skin cancers represent an important health issue for modern societies. The role of dermatologists is central to improving patient care and outcomes. In view of the emerging diagnostic methods and treatments for early and advanced skin cancer, and considering the increasingly diverse skills, knowledge and expertise needed for managing this heterogeneous group of diseases, dermato-oncology should be considered as a specific subspecialty of Dermatology-Venereology.

Melanoma Epidemiology and Early Detection in Europe: Diversity and Disparities

Melanoma claims annually more than 20,000 lives in Europe and is an important public health burden through its continuously increasing incidence and with its high mortality, costs, and complexity of care in advanced stages. Epidemiological surveillance is indispensable for the research into its causes, new prognostic markers, and innovative therapies, as well as for the building of efficient cancer control plans. However, important differences in the sources and availability of accurate epidemiological data exist among European countries and regions, contributing to a heterogeneous picture with 20-fold differences in the reported national melanoma incidence rates, divergent mortality trends, and solid disparities in survival across the Continent. Countries in the eastern half of Europe report the lowest incidence rates, but high case fatality, persisting and increasing mortality, a higher proportion of thicker tumors and late diagnosis, and lower survival rates. They are the least well equipped with quality cancer registration and reporting, and they lag behind in efficient cancer control plans implementation. This review highlights the main differences in melanoma epidemiology across Europe, together with an insight into their underlying causes in the areas of melanoma registration, early diagnosis, and prevention. These differences should be acknowledged and understood by physicians, researchers, and all stakeholders involved in improving melanoma care and outcomes, as no one-size-fits-all solution can tackle the melanoma problem in Europe. Instead, there is a need for nuanced strategies, adapted to the heterogeneous national and regional contexts, that would build on European diversity to eliminate the outcome disparities.

PD-1/PD-L1 Based Combinational Cancer Therapy: Icing on the Cake

Cancer has been a major global health problem due to its high morbidity and mortality. While many chemotherapy agents have been studied and applied in clinical trials or in clinic, their application is limited due to its toxic side effects and poor tolerability. Monoclonal antibodies specific to the PD-1 and PD-L1 immune checkpoints have been approved for the treatment of various tumors. However, the application of PD-1/PD-L1 inhibitors remains suboptimal and thus another strategy comes in to our sight involving the combination of checkpoint inhibitors with other agents, enhancing the therapeutic efficacy. Various novel promising approaches are now in clinical trials, just as icing on the cake. This review summarizes relevant investigations on combinatorial therapeutics based on PD-1/PD-L1 inhibition.

Trends in malignant melanoma mortality in 31 countries from 1985 to 2015

BACKGROUND

Malignant melanoma (MM) causes the highest absolute number of deaths among skin cancers. An up-to-date analysis of international MM mortality trends is required for assessing the burden of disease, and may support the assessment of the effectiveness of new diagnostic, therapeutic and preventative strategies.

OBJECTIVES

To report MM mortality trends between 1985 and 2015 using the World Health Organization (WHO) Mortality Database.

MATERIALS AND METHODS

We used country-level MM mortality data from the WHO Mortality Database for all countries with high usability death registration data. Mortality trends were described using Joinpoint regression modelling.

RESULTS

Thirty-one countries met the inclusion criteria. All countries, except the Czech Republic, demonstrated increased age-standardized death rates (ASDRs) in males over the observation period. More countries exhibited decreased or stable MM mortality in females. The median mortality rate for 2013-2015 was 2·57 deaths per 100 000 for males and 1·55 per 100 000 for females. Australia and Norway had the highest ASDRs for males (5·72 per 100 000 and 4·55 per 100 000, respectively). Norway and Slovenia had the highest ASDRs for females (3·02 per 100 000 and 2·58 per 100 000, respectively). MM mortality was greater for males than females in all countries, with sex disparity increasing across the period. Disparity in mortality between older and younger cohorts in several countries was also found.

CONCLUSIONS

An overall increase in MM mortality over the past 30 years was observed. However, there was notable variation in mortality trends between countries, as well as between males and females, and between different age groups.

Is single versus combination therapy problematic in the treatment of cutaneous melanoma?

Introduction: The development of immunotherapies and targeted therapies has changed the treatment approach in resectable, nonresectable, and metastatic melanoma. Because of their different pharmacological profiles, immunotherapies and/or targeted therapies have been studied in various combinations. Areas covered: We reviewed PubMed for most important clinical trials investigating efficacy and tolerability of combinatorial and single-agent approaches for the treatment of melanoma that were published up to June 2019. We discuss the most promising therapy approaches and highlight challenges of melanoma treatment. Expert opinion: Combinatorial approaches seem to be very promising in the treatment of resectable and advanced melanoma. Currently, dual immune checkpoint inhibition (ICI) with nivolumab and ipilimumab offers the best first-line treatment option for patients with BRAF-wt and -mutated, advanced melanoma. It is therapy of choice in younger patients with good ECOG performance status and poor prognostic features, whereas ICI monotherapy should be preferred in elderly patients with advanced melanoma. Benefit-risk ratio, patient's QoL and expectations, as well as treatment costs have to be considered in the choice of treatment. However, to elucidate mechanisms of resistance, biomarkers of response and to better define personalized strategies in the treatment of cutaneous melanoma, larger clinical trials comparing combined versus sequential therapies are necessary.

Does the time interval between sentinel lymph node biopsy and completion lymph node dissection affect outcome in malignant melanoma? A retrospective cohort study

Nodal clearance was recommended after positive sentinel lymph node biopsy (SLNB) despite further metastases to the regional lymph node basin being found in only 6-21% in the literature. This retrospective study was conducted to determine the role of the time interval between excision of primary melanoma and confirmed metastasis in the sentinel lymph node biopsy as well as the one between positive sentinel lymph node biopsy (SLNB-positive patients) and subsequent completion lymph node dissection (CLND) on the presence of metastases. The monocentric analysis included 121 patients with a history of completion lymph node dissection after positive SLNB from January 2005 to October 2013. Additional metastases in the regional lymph node basin (non-sentinels) were found in 14.05% (n = 17). Significant risk factors for the presence of metastases in CLND were the time between confirmed primary tumour to metastasis in sentinel lymph nodes (SLN) (p = 0.0034), N-category of TNM-classification (p = 0.0066) and independent of thickness of primary tumour (p = 0.11). If SLNB was performed up to forty-three days after confirmed primary melanoma, subsequent lymph node dissection was positive in less than 9.1%. When SLNB was performed with a delay of more than 80 days, all patients had metastases in the CLND specimens. Our data analysis suggests that delays in subsequent procedures of SLNB after diagnosis of primary melanoma may have a greater impact on positivity of non-sentinel lymph nodes than previously assumed. Our retrospective analysis may indicate the reconsideration of time schedule in the management of primary melanoma to potentially avoid local relapse in the draining lymph node region after positive SLNB.

Transferability of Economic Evaluations of Treatments for Advanced Melanoma

BACKGROUND

Differing methodological requirements and decision-making criteria are recognised as barriers to transferability of cost-effectiveness analysis (CEA) across jurisdictions.

OBJECTIVE

We assessed the generic and specific transferability of published CEAs of systemic treatments for advanced melanoma to the Irish setting.

METHODS

CEAs of treatments for melanoma were identified by systematic review. Transferability to the Irish setting was assessed using the EUnetHTA transferability tool for Economic Evaluation. We present a narrative discussion comparing the differences in key parameter inputs and the likely impact of these differences on the model outcomes and the reimbursement recommendation. Transferability is considered within the context of the Irish cost-effectiveness threshold, using the net monetary benefit (NMB) framework.

RESULTS

No published CEAs (n = 15) aligned with the Irish reference case for CEA. Changes to key parameters were unlikely to change the conclusions of the CEA when the cost-effectiveness threshold was considered. Ten studies (19 pairwise comparisons) were compared with findings by the National Centre for Pharmacoeconomics (NCPE) using NMB. Without accounting for differences in the cost-effectiveness threshold, there was alignment between the study conclusions and NCPE recommendations in 73.7% cases. When the Irish cost-effectiveness threshold was applied in the estimation of NMB, there was agreement in 89.5% of cases.

CONCLUSIONS

Alignment in methodological requirements for CEA is important to facilitate joint health technology assessment (HTA) by regional collaborations in Europe. When parameter inputs are not exactly aligned, conclusions may still be comparable across jurisdictions. For international joint procurement initiatives, determining and implementing joint decision rules may be more important than trying to align rules regarding methodological and parameter inputs.

Economic Evaluation of Systemic Treatments for Advanced Melanoma: A Systematic Review

BACKGROUND

Many high cost treatments for advanced melanoma have become available in recent years. National health technology assessment agencies have raised concerns regarding uncertainty in their clinical and cost-effectiveness.

OBJECTIVE

The aim of this systematic review is to identify economic evaluations of treatments for advanced melanoma and review model assumptions, outcomes, and quality as preparation for a health technology assessment.

METHODS

A search of Embase, MEDLINE, EconLit, and the Cochrane Database was conducted. Only studies using decision-analytic models were included. Two authors independently completed full-text review and data extraction.

RESULTS

Fifteen studies were identified. There were major differences in the structural assumptions underpinning the models. There was general agreement in study conclusions, although the predicted costs and quality-adjusted life years for each treatment varied. BRAF monotherapy (vemurafenib, dabrafenib) or BRAF/MEK combination therapy (BRAF monotherapy with cobimetinib or trametinib) has not been shown to be cost-effective in any jurisdiction. PD-1 inhibitors (pembrolizumab, nivolumab) are consistently found to be cost-effective compared with ipilimumab, although their cost-effectiveness compared with chemotherapy is not established. Combination therapy with nivolumab and ipilimumab is unlikely to be cost-effective in any setting. One study including all agents found that none of the new treatments were cost-effective relative to chemotherapy. Publication of the study in a health economics journal is associated with better reporting of and higher-quality assessment than those published in clinical journals.

CONCLUSION

Despite differences in model structures and assumptions, the conclusions of most included studies were consistent. Health technology assessment has a key role in maximizing value from high-cost innovative treatments. Consideration should be given to divestment from BRAF/MEK inhibitors and ipilimumab in favor of reimbursement of PD-1 inhibitors.

Achieving equal and timely access to innovative anticancer drugs in the European Union (EU): summary of a multidisciplinary CECOG-driven roundtable discussion with a focus on Eastern and South-Eastern EU countries

The Central European Cooperative Oncology Group (CECOG) and ‘ESMO Open—Cancer Horizons’ roundtable discussion brought together stakeholders from several European Union (EU) countries involved in drug development, drug authorisation and reimbursement or otherwise affected by delayed and unequal access to innovative anticancer drugs. The approval process of drugs is well established and access delays can be caused directly or indirectly by national or regional decision-making processes on reimbursement. The two key aspects for those involved in reimbursement decisions are first the level of evidence required to decide and second pricing, which can be challenging for some innovative oncology compounds, especially in Eastern and South-Eastern European countries. Other important factors include: available healthcare budget; the structure and sophistication of healthcare authorities and health technology assessment processes; societal context and political will. From the point of view of the pharmaceutical industry, better alignment between stakeholders in the process and adaptive pathway initiatives is desirable. Key aspects for patients are improved access to clinical trials, preapproval availability and reports on real-world evidence. Restricted access limits oncologists’ daily work in Eastern and South-Eastern EU countries. The roundtable discussion suggested considering the sequencing of regulatory approval and reimbursement decisions together with more flexible contracting as a possible way forward. The panel concluded that early and regular dialogue between all stakeholders including regulators, payers, patient stakeholders and industry is required to improve the situation.

The European Cancer Patient Coalition and its central role in connecting stakeholders to advance patient-centric solutions in the mission on cancer

There is an urgent need for solutions to the economic and social inequalities in cancer care that still exist in many European countries. Patient preferences, ‘big data’, mobile digital technology and molecular and genomic profiling are among the innovative research topics that connect cancer patients to comprehensive cancer centres, and link translational research to cancer diagnosis, treatment and care. The question is whether Europe can deliver the complex infrastructure needed for universal coverage and equitable access to cancer care. The European Cancer Patient Coalition (ECPC), the leading ‘umbrella’ cancer patient organisation in Europe, has a central role in bringing the unmet needs of patients with cancer to the forefront of cancer policy, care and research. The ECPC is a respected and reliable partner in the oncology community and has effectively collaborated with institutional stakeholders and organisations, as well as with the European Commission, on cancer research projects and in the development of tools to advance health care and cancer policies at the European and national level. The ECPC believes that innovation cannot emerge and grow without patient involvement and is fully committed to increasing patient education and contribution in cancer research through its active participation in various European cancer research programmes and educational resources. The ECPC is expected to play a major role in the mission on cancer, given its previous achievements in policy and research to help overcome the inequalities in cancer prevention, treatment, rehabilitation and survivorship care. The mission on cancer will be facilitated by active collaboration between patient organisations and scientists, clinicians, politicians and industry, with the aim of identifying important research questions regarding quality of life and social issues for cancer patients of all ages.

Quality assurance in melanoma care: The EU-MELACARE study

BACKGROUND

A significant disparity regarding survival outcome for melanoma among European regions is well recognized and access to high quality care for European melanoma patients needs to be improved. There is an unmet need for the implementation of minimal standard of care within defined clinical pathways and Quality Assurance (QA) indicators.

OBJECTIVE

The EU-MELACARE study aims to identify shared variables for cutaneous melanoma cases recorded in melanoma registries across Europe.

MATERIAL AND METHODS

Opinion leaders involved in melanoma data registration and care quality analysis in 34 European countries were invited to respond to an expert survey covering questions regarding the melanoma registration practice in their countries and the characteristics, coverage and variables collected by the relevant melanoma registries.

RESULTS

Data regarding 13 melanoma registries from 11 European countries contributed to the study. The majority (61,5%) were population based registries and more than half (62%) had national coverage. The included registries collected a median of 38 variables (Interquartile Range, IRQ 21-76). We identified 24 shared variables available in >70% of registries.

CONCLUSIONS

This study provides valuable specific information on information recorded for melanoma cases are registered within Europe. A core of shared variables has been identified, which will constitute the basis for a standardized set of QA indicators for assessing and monitoring melanoma care across European countries.

Access to innovative medicines for metastatic melanoma worldwide: Melanoma World Society and European Association of Dermato-oncology survey in 34 countries

According to data from recent studies from Europe, a large percentage of patients have restricted access to innovative medicines for metastatic melanoma. Melanoma World Society and European Association of Dermato-oncology conducted a Web-based survey on access to first-line recommended treatments for metastatic melanoma by current guidelines (National Comprehensive Center Network, European Society for Medical Oncology [ESMO] and European Organization for Research and Treatment of Cancer/European Association of Dermato-oncology/European dermatology Forum) among melanoma experts from 27 European countries, USA, China, Australia, Argentina, Brazil, Chile and Mexico from September 1st, 2017 to July 1st, 2018. Data on licencing and reimbursement of medicines and the number of patient treated were correlated with the data on health expenditure per capita (HEPC), Mackenbach score of health policy performance, health technology assessment (HTA), ASCO and ESMO Magnitude of clinical benefit scale (ESMO MCBS) scores of clinical benefit and market price of medicines. Regression analysis for evaluation of correlation between the parameters was carried out using SPSS software. The estimated number of patients without access in surveyed countries was 13768. The recommended BRAFi + MEKi combination and anti-PD1 immunotherapy were fully reimbursed/covered in 19 of 34 (55.8%) and 17 of 34 (50%) countries, and combination anti-CTLA4+anti-PD1 in was fully covered in 6 of 34 (17.6%) countries. Median delay in reimbursement was 991 days, and it was in significant correlation with ESMO MCBS (p = 0.02), median market price (p = 0.001), HEPC and Mackenbach scores (p < 0.01). Price negotiations or managed entry agreements (MEAs) with national authorities were necessary for reimbursement. In conclusion, great discrepancy exists in metastatic melanoma treatment globally. Access to innovative medicines is in correlation with economic parameters as well as with healthcare system performance parameters. Patient-oriented drug development, market access and reimbursement pathways must be urgently found.

Melanoma

Cutaneous melanoma causes 55 500 deaths annually. The incidence and mortality rates of the disease differ widely across the globe depending on access to early detection and primary care. Once melanoma has spread, this type of cancer rapidly becomes life-threatening. For more than 40 years, few treatment options were available, and clinical trials during that time were all unsuccessful. Over the past 10 years, increased biological understanding and access to innovative therapeutic substances have transformed advanced melanoma into a new oncological model for treating solid cancers. Treatments that target B-Raf proto-oncogene serine/threonine-kinase (BRAF)V600 (Val600) mutations using selected BRAF inhibitors combined with mitogen-activated protein kinase inhibitors have significantly improved response and overall survival. Furthermore, advanced cutaneous melanoma has developed into a prototype for testing checkpoint-modulating agents, which has increased hope for long-term tumour containment and a potential cure. These expectations have been sustained by clinical success with targeted agents and antibodies that block programmed cell-death protein 1 in locoregional disease, which induces prolongation of relapse-free, distant-metastasis-free, and overall survival times.

Highlights from the 2018 WIN Symposium, 25-26 June 2018, Paris: designing the future of precision oncology

The Worldwide Innovative Networking (WIN) Symposium is the annual gathering of WIN consortium members from across the globe, representing academic institutions, pharmaceutical partners, technology companies and charitable organisations, to discuss ongoing research and the latest developments in precision oncology. The symposium held in Paris, France on 25-26 June was structured into five plenary sessions, two open forums and poster presentations. This year marked the 10th anniversary of the consortium, and the programme anchored itself with retrospectives of recent breakthroughs in personalised medicine, programme sessions reviewing the iterative design of trials in precision oncology at present, and the future of implementing personalised medicine initiatives in US and EU healthcare systems for the maximum patient benefit. This year was also marked by the absence of Dr John Mendelsohn, who has stepped down as chairman, and co-founder Professor Tomas Tursz, who passed away in April this year. The latter was given a brief memorial session at the conclusion of the symposium.

An Overview of the Reimbursement Decision-Making Processes in Bulgaria As a Reference Country for the Middle-Income European Countries

Background

Policy makers face a lot of challenges in the process of drug reimbursement decision-making, especially in the context of entering the market of more and more innovative medicinal products (MPs). The aim of the current study is to make an overview of the reimbursement system development and to evaluate the access of innovative medicines, which have entered the EU-market in the period 2015-2017, in Bulgaria as reference example for middle-income European country.

Methods

A literature and a legislative systematic review regarding the Bulgarian reimbursement system as well as a defining the number of available innovative reimbursed MPs in 2017 in Bulgaria was made.

Results

The reimbursement legislation in Bulgaria is quite unstable due to constant changes, which have been made, especially in the recent years. Despite this fact, the reimbursement process in Bulgaria is in accordance with the Transparency Directive. Bulgarian patients have a relatively delayed access to innovative medicines as only 5% of centrally authorized MPs in 2017 are available in the positive drug list (PDL), 16% of all in 2016 and 18%-in 2015. This could be explained by the long procedure for their appraisal in Bulgaria: the first step is issuing an opinion by the HTA Committee, followed by negotiation of discounts between the marketing authorization holder and the National Health Insurance Fund and making a final decision by the National Council on Prices and Reimbursement (NCPR) for the inclusion into the PDL.

Conclusion

Optimization of the procedure for issuing reimbursement status for innovative MPs is needed, such as improvements in the process of conducting HTA reports and their appraisal, incorporation of adequate systems for following the effectiveness and safety of MPs in the real-world conditions, value-based pricing implementation, and increasing the financial control over the health insurance system.

ECCO essential requirements for quality cancer care: Melanoma

BACKGROUND

ECCO essential requirements for quality cancer care (ERQCC) are explanations and descriptions of challenges, organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe.

MELANOMA

ESSENTIAL REQUIREMENTS FOR QUALITY CARE: CONCLUSION: Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality service for melanoma. The ERQCC expert group is aware that it is not possible to propose a 'one size fits all' system for all countries, but urges that access to multidisciplinary teams and specialised treatments is guaranteed to all patients with melanoma.

Review of cancer treatment with immune checkpoint inhibitors : Current concepts, expectations, limitations and pitfalls

Immunotherapy by checkpoint inhibition is about to profoundly change cancer therapy. The number of indications are growing at an unprecedented speed. Clinical studies have demonstrated efficacy in a variety of solid tumors and in hematologic malignancies, although some clinical trials have produced negative results. Thus, it is fair to assume that there are obvious limitations and pitfalls in immunotherapy. Future concepts for combination treatment of immune checkpoint inhibitors have to be developed, but there is also urgent need for better and standardized biomarkers to identify those cancer patients who will benefit from treatment by checkpoint inhibition. The current overview summarizes current knowledge on immune checkpoint inhibitor treatment in malignancies, its outlook and limitations, diagnostic means and, finally, side effect management.

Initial experience of anti-PD1 therapy with nivolumab in advanced hepatocellular carcinoma

Purpose

To evaluate efficacy and safety of anti-PD1 therapy with nivolumab for treatment of advanced hepatocellular carcinoma (HCC).

Methods

From Jan 2016 to Jan 2017, eleven cases of HCC (average age of 51.8-year), 4 at stage B and 7 at stage C, according to Barcelona Clinic Liver Cancer staging, were treated with nivolumab. There were 4 patients with lung metastasis, 1 with portal vein tumor thrombus, 1 with abdominal metastasis and 1 with bone metastasis. The protocol was nivolumab, 3 mg/kg, on day 1, q3w. All patients were treated for more than 4 cycles. During anti-PD1 treatment period, 6 patients also received sorafenib and 1 patient received cytokine-induced killer cell therapy. Objective response and clinical adverse events were evaluated retrospectively.

Results

Patients underwent a total of 80 cycles of nivolumab therapy, ranging between 4 and 18 cycles per patient. Nivolumab was associated with a disease control rate of 81.8%, with an objective response of 63.6% (Modified Response Evaluation Criteria in Solid Tumors). No adverse effects related to nivolumab were noted.

Conclusion

Our experience shows that nivolumab could achieve acceptable outcome in HCC patients and may serve as an optional treatment, especially for patients who failed to gain a benefit from routine treatments.