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Olivier T, Haslam A, Burke P, Boutron I, Naudet F, Ioannidis JPA, Prasad V. A novel framework to assess haematology and oncology registration trials: The THEOREMM project. Eur J Clin Invest 2024:e14267. [PMID: 38934596 DOI: 10.1111/eci.14267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Methodological limitations affect a significant number of oncology and haematology trials, raising concerns about the applicability of their results. For example, a suboptimal control arm or limited access to best care upon progression may skew the trial results toward a benefit in the experimental arm. Beyond the fact that such limitations do not prevent drugs reaching the market, other assessment tools, such as those developed by professional societies-ESMO-MCBS and ASCO Value Framework-do not integrate these important shortcomings. METHODS We propose creating a novel framework with the scope of assessing registration cancer clinical trials in haematology and oncology (randomized or single arm)-that is trials leading to a marketing authorization. The main steps of the methods are (1) assembling a scientific board; (2) defining the scope, goal and methods through pre-specified, pre-registered and protocolized methodology; (3) preregistration of the protocol; (4) conducting a scoping review of limitations and biases affecting oncology trials and assessing existing scores or methods; (5) developing a list of features to be included and assessed within the framework; (6) assessing each feature through a questionnaire sent to highly cited haematologists and oncologists involved in clinical trials; and (7) finalizing the first version of framework. RESULTS Not applicable. CONCLUSIONS Our proposal emerged in response to the lack of consideration for key limitations in current trial assessments. The goal is to create a framework specifically designed to assess single trials leading to marketing authorization in the field of oncology and haematogy.
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Affiliation(s)
- Timothée Olivier
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | - Isabelle Boutron
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAe, Centre for Research in Epidemiology and Statistics (CRESS), Paris, France
- Centre d'Épidémiologie Clinique, Hôpital Hôtel Dieu, Paris, France
- Cochrane France, Paris, France
| | - Florian Naudet
- Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes 1 University, Rennes, France
- Inserm, Irset (Institut de recherche en santé, environnement et travail), Rennes 1 University, Rennes, France
- Institut Universitaire de France, Paris, France
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Tibau A, Hwang TJ, Molto C, Avorn J, Kesselheim AS. Clinical Value of Molecular Targets and FDA-Approved Genome-Targeted Cancer Therapies. JAMA Oncol 2024; 10:634-641. [PMID: 38573645 PMCID: PMC11099684 DOI: 10.1001/jamaoncol.2024.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/03/2023] [Indexed: 04/05/2024]
Abstract
Importance The number of new genome-targeted cancer drugs has increased, offering the possibility of personalized therapy, often at a very high cost. Objective To assess the validity of molecular targets and therapeutic benefits of US Food and Drug Administration-approved genome-targeted cancer drugs based on the outcomes of their corresponding pivotal clinical trials. Design and Settings In this cohort study, all genome-targeted cancer drugs that were FDA-approved between January 1, 2015, and December 31, 2022, were analyzed. From FDA drug labels and trial reports, key characteristics of pivotal trials were extracted, including the outcomes assessed. Main Outcomes and Measures The strength of evidence supporting molecular targetability was assessed using the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT). Clinical benefit for their approved indications was evaluated using the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS). Substantial clinical benefit was defined as a grade of A or B for curative intent and 4 or 5 for noncurative intent. Molecular targets qualifying for ESCAT category level I-A and I-B associated with substantial clinical benefit by ESMO-MCBS were rated as high-benefit genomic-based cancer treatments. Results A total of 50 molecular-targeted drugs covering 84 indications were analyzed. Forty-five indications (54%) were approved based on phase 1 or phase 2 pivotal trials, 45 (54%) were supported by single-arm pivotal trials, and 48 (57%) were approved on the basis of subgroup analyses. By each indication, 46 of 84 primary end points (55%) were overall response rate (median [IQR] overall response rate, 57% [40%-69%]; median [IQR] duration of response, 11.1 [9.2-19.8] months). Among the 84 pivotal trials supporting these 84 indications, 38 trials (45%) had I-A ESCAT targetability, and 32 (38%) had I-B targetability. Overall, 24 of 84 trials (29%) demonstrated substantial clinical benefit via ESMO-MCBS. Combining these ratings, 24 of 84 indications (29%) were associated with high-benefit genomic-based cancer treatments. Conclusions and Relevance The results of this cohort study demonstrate that among recently approved molecular-targeted cancer therapies, fewer than one-third demonstrated substantial patient benefits at approval. Benefit frameworks such as ESMO-MCBS and ESCAT can help physicians, patients, and payers identify therapies with the greatest clinical potential.
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Affiliation(s)
- Ariadna Tibau
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Consolacion Molto
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Nieto-Gómez P, Castaño-Amores C, Rodríguez-Delgado A, Álvarez-Sánchez R. Analysis of oncological drugs authorised in Spain in the last decade: association between clinical benefit and reimbursement. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:257-267. [PMID: 36995531 DOI: 10.1007/s10198-023-01584-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Our study aimed to assess whether there was a relationship between clinical benefits and reimbursement decisions as well as the inclusion of economic evaluations in therapeutic positioning reports (IPTs) and to explore factors influencing reimbursement decisions. MATERIALS AND METHODS We analysed all anti-cancer drugs approved in Spain from 2010 to September 2022. The clinical benefit of each drug were evaluated using the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) 1.1. The characteristics of these drugs were obtained from the Spanish Agency of Medicines and Medical Devices. Reimbursement status information was obtained using BIFIMED, a web resource available in Spanish and consulted the agreements of the Interministerial Committee on Pricing of Medicines (CIPM). RESULTS In total, 73 drugs were included involving 197 indications. Almost half of the indications had substantial clinical benefit (49.8% yes vs. 50.3% no). Of the 153 indications with a reimbursement decision, 61 (56.5%) reimbursed indications had substantial clinical benefit compared to 14 (31.1%) of the non-reimbursed (p < 0.01). The median gain of overall survival was 4.9 months (2.8-11.2) for reimbursed indications and 2.9 months (1.7-5) in non-reimbursed (p < 0.05). Only six (3%) indications had an economic evaluation in the IPT. CONCLUSION Our study revealed that there is a relationship between substantial clinical benefit and the reimbursement decision in Spain. However, we also found that the overall survival gain was modest, and a significant proportion of the reimbursed indications had no substantial clinical benefit. Economic evaluations in IPTs are infrequent and cost-effectiveness analysis is not provided by CIPM.
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Affiliation(s)
- P Nieto-Gómez
- Pharmacy Unit, Hospital Santa Bárbara, Street Malagón S/N, 13500, Puertollano, Spain.
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Vallano A, Pontes C, Agustí A. The challenges of access to innovative medicines with limited evidence in the European Union. Front Pharmacol 2023; 14:1215431. [PMID: 37719853 PMCID: PMC10500193 DOI: 10.3389/fphar.2023.1215431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023] Open
Abstract
The European Medicines Agency (EMA) fosters access to innovative medicines through accelerated procedures and flexibility in the authorization requirements for diseases with unmet medical needs, such as many rare diseases as well as oncological diseases. However, the resulting increase of medicines being marketed with conditional authorizations and in exceptional circumstances has lead to higher clinical uncertainty about their efficacy and safety than when the standard authorizations are applied. This uncertainty has significant implications for clinical practice and the negotiation of pricing and reimbursement, particularly as high prices are based on assumptions of high value, supported by regulatory prioritization. The burden of clinical development is often shifted towards public healthcare systems, resulting in increased spending budgets and opportunity costs. Effective management of uncertainty, through appropriate testing and evaluation, and fair reflection of costs and risks in prices, is crucial. However, it is important not to sacrifice essential elements of evidence-based healthcare for the sake of access to new treatments. Balancing sensitive and rational access to new treatments, ensuring their safety, efficacy, and affordability to healthcare systems requires thoughtful decision-making. Ultimately, a responsible approach to timely access to innovative medicines that balances the needs of patients with healthcare systems' concerns is necessary. This approach emphasizes the importance of evidence-based decision-making and fair pricing and reimbursement.
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Affiliation(s)
- Antonio Vallano
- Medicines Department, Catalan Healthcare Service, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Healthcare Management of Hospitals, Catalan Institute of Health, Barcelona, Spain
| | - Caridad Pontes
- Medicines Department, Catalan Healthcare Service, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System DS3-IDIBEL, L’Hospitalet de Llobregat, Spain
| | - Antònia Agustí
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Clinical Pharmacology Service, Vall d’Hebron University Hospital, Barcelona, Spain
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Post H, Schutte T, van Oijen M, van Laarhoven H, Hollak C. Time to reimbursement of novel anticancer drugs in Europe: a case study of seven European countries. ESMO Open 2023; 8:101208. [PMID: 37030113 PMCID: PMC10163159 DOI: 10.1016/j.esmoop.2023.101208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Time to reimbursement (TTR) of new anticancer medicines differs between countries and contributes to unequal access. We aimed to investigate TTR of new anticancer medicines and explore factors influencing the reimbursement process in seven high-income European countries. MATERIALS AND METHODS We carried out a retrospective case study of anticancer medicines with European Union Market Access (EU-MA) and a positive Committee for Medicinal Products for Human Use opinion from 2016 until 2021 with subsequent national reimbursement approval (NRA). The National Health Technology Assessment (HTA) and reimbursement websites of Germany, France, UK, the Netherlands, Belgium, Norway and Switzerland were used to identify TTR, defined as time from EU-MA to NRA. Additionally, we investigated medication-, country-, indication- and pharma-related factors potentially influencing TTR. RESULTS Thirty-five medicines were identified for which TTR ranged from -81 days to 2320 days (median 407 days). At data cut-off, 16 (46%) were reimbursed in all seven countries. Overall, the shortest TTR was in Germany (median 3 days, all medicines reimbursed <5 days). The time limit for reimbursement of 180 days stated by the Council of European Communities after the EU-MA (EU Transparency Directive) was met for 100% of included medicines in Germany, 51% in France, 29% in the UK and the Netherlands, 14% in Switzerland, 6% in Norway and 3% in Belgium. The TTR was significantly different between countries (P < 0.001). In multivariate analysis, factors associated with shorter TTR were higher gross domestic product (GDP), absence of a pre-assessment procedure and submission by a big pharmaceutical company. CONCLUSIONS TTR of anticancer medicines varies significantly between seven high-income European countries and leads to inequality in access. Among explored medication-, country-, indication- and pharma-related factors we found that a high GDP, the absence of a pre-assessment procedure and submission by big pharmaceutical companies were associated with shorter TTR.
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Ollila E, Kataja V, Sailas L. A David and Goliath set-up: a qualitative study of the challenges of ensuring the introduction of cost-effective new cancer medicines in Finland. J Pharm Policy Pract 2022; 15:52. [PMID: 36038900 PMCID: PMC9422122 DOI: 10.1186/s40545-022-00449-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background To combat the global challenge of cancer, priority has been placed on the research and development of new cancer medicines (NCMs). NCMs are often approved for marketing in accelerated processes. Despite significant advances in treating cancer, the overall added value and high prices of NCMs has been questioned. While market authorisations for NCMs are granted at the EU level, the assessment of added value, price negotiations and purchase or reimbursement decisions are made by member states. This article explores the practices in Finland for assessing and deciding on purchasing or reimbursing NCMs. Methods Semi-structured interviews were conducted with 26 civil servants, hospital employees, scientists, and representatives of cancer NGOs and of the pharmaceutical industry in 2019 and 2020. The transcribed interviews were coded inductively using Atlas.ti software and analysed thematically under 3 major themes and 11 sub-themes.
Results The clinical value of NCMs is considered to be high, especially regarding NCMs for certain types of cancer. Proper patient selection is important but difficult and not all NCMs can be considered as adding value. The prices are considered to often be very high, leading to concerns about the sustainability and equity of health systems. Equity concerns among cancer patients are raised concerning differences in the availability of NCMs between hospital districts and cost differences for patients between those receiving outpatient and inpatient treatment. The systems and processes in Finland for deciding on the introduction of NCMs are fragmentary, involving separate approaches for outpatient care and hospital medicines by under-resourced evaluation bodies. The scientific evidence available is often limited for evidence-based decisions on introduction. Individual hospital districts sometimes introduce NCMs without assessment by national bodies. This can hamper the proper assessment of some NCMs before their uptake and lead to unequal access to NCMs by hospitals. There is an increasing lack of transparency about pricing, due to the rapid increase of market entry agreements. Lack of transparency on information on prices poses a challenge for authorities responsible for equitable access to cost-effective care within the available resources.
Conclusions Robust reform of the national introductory systems is needed. Internationally, efforts are needed to increase price transparency, to revise incentives within the system of market approval and to accumulate and assess evidence of comparable value and cost-effectiveness after the market approval of NCMs.
Supplementary Information The online version contains supplementary material available at 10.1186/s40545-022-00449-5.
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Affiliation(s)
- Eeva Ollila
- Cancer Society of Finland, P.O. Box 238, 00131, Helsinki, Finland. .,Faculty of Social Sciences, University of Tampere, Tampere, Finland.
| | - Vesa Kataja
- Kaiku Health, Part of ELEKTA, Helsinki, Finland.,University of Eastern Finland, Jyväskylä, Finland
| | - Liisa Sailas
- Cancer Center, Joint Municipal Authority for North Karelia Social and Health Care Services (SiunSote), Joensuu, Finland
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Adam R, Tibau A, Molto Valiente C, Šeruga B, Ocaña A, Amir E, Templeton AJ. Clinical benefit of cancer drugs approved in Switzerland 2010–2019. PLoS One 2022; 17:e0268545. [PMID: 35687539 PMCID: PMC9187080 DOI: 10.1371/journal.pone.0268545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 05/03/2022] [Indexed: 11/19/2022] Open
Abstract
Background
It is unknown to what extent cancer drugs approved in Switzerland by the Swissmedic fulfil criteria of clinical benefit according to the European Society of Medical Oncology Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS), the American Society of Clinical Oncology Value Framework version 2 (ASCO-VF) and the Swiss OLUtool v2 (OLUtool).
Patients and methods
An electronic search identified studies that led to marketing authorisations in Switzerland 2010–2019. Studies were evaluated according to ESMO-MCBS, ASCO-VF and OLUtool. Substantial benefit for ESMO-MCBS, was defined as a grade A or B for (neo)adjuvant intent and 4 or 5 for palliative intent. For ASCO-VF and OLUtool clinical benefit was defined as score ≥45 and A or B, respectively. Concordance between the frameworks was calculated with Cohen’s Kappa (κ). Factors associated with clinical benefit were evaluated by logistic regression.
Results
In the study period, 48 drugs were approved for 92 evaluable indications, based on 100 studies. Ratings for ESMO-MCBS, ASCO-VF and OLUtool could be performed for 100, 86, and 97 studies, respectively. Overall, 39 (39%), 44 (51%), 45 (46%) of the studies showed substantial clinical benefit according to ESMO-MCBS v1.1, ASCO-VF, OLUtool criteria, respectively. There was fair concordance between ESMO-MCBS and ASCO-VF in the palliative setting (κ = 0.31, P = 0.004) and moderate concordance between ESMO-MCBS and OLUtool (κ = 0.41, P<0.001). There was no significant concordance between ASCO-VF and OLUtool (κ = 0.18, P = 0.12). Factors associated with substantial clinical benefit in multivariable analysis were HRQoL benefit reported as secondary outcome for ESMO-MCBS and the ASCO-VF and blinded studies for OLUtool.
Conclusions
At the time of approval, only around half of the trials supporting marketing authorisation of recently approved cancer drugs in Switzerland meet the criteria for substantial clinical benefit when evaluated with ESMO-MCBS, ASCO-VF or OLUtool. There was at best only moderate concordance between the grading systems.
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Affiliation(s)
- Roman Adam
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ariadna Tibau
- Oncology Department, Departament de Medicina de la Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Consolación Molto Valiente
- Oncology Department, Departament de Medicina de la Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Boštjan Šeruga
- Institute of Oncology Ljubljana and Faculty of Medicine, Department of Medical Oncology, University of Ljubljana, Ljubljana, Slovenia
| | - Alberto Ocaña
- Experimental Therapeutics Unit, Medical Oncology Department, Hospital Clínico Universitario San Carlos and IdISSC, Madrid, Spain
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center and the University of Toronto, Toronto, ON, Canada
| | - Arnoud J. Templeton
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Medical Oncology, St. Claraspital, Basel, Switzerland
- St. Clara Research Ltd., Basel, Switzerland
- * E-mail:
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Korn EL, Allegra CJ, Freidlin B. Clinical Benefit Scales and Trial Design: Some Statistical Issues. J Natl Cancer Inst 2022; 114:1222-1227. [PMID: 35583264 DOI: 10.1093/jnci/djac099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 11/14/2022] Open
Abstract
Recently developed clinical-benefit outcome scales by the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) allow standardized objective evaluation of outcomes of randomized clinical trials. However, incorporation of clinical-benefit outcome scales into trial designs highlights a number of statistical issues: the relationship between minimal clinical benefit and the target treatment-effect alternative used in the trial design, designing trials to assess long-term benefit, potential problems with using a trial endpoint that is not overall survival, and how to incorporate subgroup analyses into the trial design. Using the ESMO Magnitude of Clinical Benefit Scale as a basis for discussion, we review what these issues are and how they can guide the choice of trial-design target effects, appropriate endpoints, and pre-specified subgroup analyses to increase the chances that the resulting trial outcomes can be appropriately evaluated for clinical benefit.
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Affiliation(s)
- Edward L Korn
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Carmen J Allegra
- Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA.,Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Boris Freidlin
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
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Schnog JJB, Samson MJ, Gans ROB, Duits AJ. An urgent call to raise the bar in oncology. Br J Cancer 2021; 125:1477-1485. [PMID: 34400802 PMCID: PMC8365561 DOI: 10.1038/s41416-021-01495-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/09/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023] Open
Abstract
Important breakthroughs in medical treatments have improved outcomes for patients suffering from several types of cancer. However, many oncological treatments approved by regulatory agencies are of low value and do not contribute significantly to cancer mortality reduction, but lead to unrealistic patient expectations and push even affluent societies to unsustainable health care costs. Several factors that contribute to approvals of low-value oncology treatments are addressed, including issues with clinical trials, bias in reporting, regulatory agency shortcomings and drug pricing. With the COVID-19 pandemic enforcing the elimination of low-value interventions in all fields of medicine, efforts should urgently be made by all involved in cancer care to select only high-value and sustainable interventions. Transformation of medical education, improvement in clinical trial design, quality, conduct and reporting, strict adherence to scientific norms by regulatory agencies and use of value-based scales can all contribute to raising the bar for oncology drug approvals and influence drug pricing and availability.
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Affiliation(s)
- John-John B. Schnog
- Department of Hematology-Medical Oncology, Curaçao Medical Center, Willemstad, Curaçao ,Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao
| | - Michael J. Samson
- Department of Radiation Oncology, Curaçao Medical Center, Willemstad, Curaçao
| | - Rijk O. B. Gans
- grid.4494.d0000 0000 9558 4598Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ashley J. Duits
- Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao ,grid.4494.d0000 0000 9558 4598Institute for Medical Education, University Medical Center Groningen, Groningen, The Netherlands ,Red Cross Blood Bank Foundation, Willemstad, Curaçao
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Fundytus A, Sengar M, Lombe D, Hopman W, Jalink M, Gyawali B, Trapani D, Roitberg F, De Vries EGE, Moja L, Ilbawi A, Sullivan R, Booth CM. Access to cancer medicines deemed essential by oncologists in 82 countries: an international, cross-sectional survey. Lancet Oncol 2021; 22:1367-1377. [PMID: 34560006 PMCID: PMC8476341 DOI: 10.1016/s1470-2045(21)00463-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The WHO Essential Medicines List (EML) identifies priority medicines that are most important to public health. Over time, the EML has included an increasing number of cancer medicines. We aimed to investigate whether the cancer medicines in the EML are aligned with the priority medicines of frontline oncologists worldwide, and the extent to which these medicines are accessible in routine clinical practice. METHODS This international, cross-sectional survey was developed by investigators from a range of clinical practice settings across low-income to high-income countries, including members of the WHO Essential Medicines Cancer Working Group. A 28-question electronic survey was developed and disseminated to a global network of oncologists in 89 countries and regions by use of a hierarchical snowball method; each primary contact distributed the survey through their national and regional oncology associations or personal networks. The survey was open from Oct 15 to Dec 7, 2020. Fully qualified physicians who prescribe systemic anticancer therapy to adults were eligible to participate in the survey. The primary question asked respondents to select the ten cancer medicines that would provide the greatest public health benefit to their country; subsequent questions explored availability and cost of cancer medicines. Descriptive statistics were used to compare access to medicines between low-income and lower-middle-income countries, upper-middle-income countries, and high-income countries. FINDINGS 87 country-level contacts and two regional networks were invited to participate in the survey; 46 (52%) accepted the invitation and distributed the survey. 1697 respondents opened the survey link; 423 were excluded as they did not answer the primary study question and 326 were excluded because of ineligibility. 948 eligible oncologists from 82 countries completed the survey (165 [17%] in low-income and lower-middle-income countries, 165 [17%] in upper-middle-income countries, and 618 [65%] in high-income countries). The most commonly selected medicines were doxorubicin (by 499 [53%] of 948 respondents), cisplatin (by 470 [50%]), paclitaxel (by 423 [45%]), pembrolizumab (by 414 [44%]), trastuzumab (by 402 [42%]), carboplatin (by 390 [41%]), and 5-fluorouracil (by 386 [41%]). Of the 20 most frequently selected high-priority cancer medicines, 19 (95%) are currently on the WHO EML; 12 (60%) were cytotoxic agents and 13 (65%) were granted US Food and Drug Administration regulatory approval before 2000. The proportion of respondents indicating universal availability of each top 20 medication was 9-54% in low-income and lower-middle-income countries, 13-90% in upper-middle-income countries, and 68-94% in high-income countries. The risk of catastrophic expenditure (spending >40% of total consumption net of spending on food) was more common in low-income and lower-middle-income countries, with 13-68% of respondents indicating a substantial risk of catastrophic expenditures for each of the top 20 medications in lower-middle-income countries versus 2-41% of respondents in upper-middle-income countries and 0-9% in high-income countries. INTERPRETATION These data demonstrate major barriers in access to core cancer medicines worldwide. These findings challenge the feasibility of adding additional expensive cancer medicines to the EML. There is an urgent need for global and country-level policy action to ensure patients with cancer globally have access to high priority medicines. FUNDING None.
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Affiliation(s)
- Adam Fundytus
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada; Departments of Oncology, Queen's University, Kingston, ON, Canada
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | | | - Wilma Hopman
- Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Matthew Jalink
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada; Departments of Oncology, Queen's University, Kingston, ON, Canada; Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | - Felipe Roitberg
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Elisabeth G E De Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Lorenzo Moja
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - André Ilbawi
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | | | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada; Departments of Oncology, Queen's University, Kingston, ON, Canada; Public Health Sciences, Queen's University, Kingston, ON, Canada.
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11
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Farina A, Moro F, Fasslrinner F, Sedghi A, Bromley M, Siepmann T. Strength of clinical evidence leading to approval of novel cancer medicines in Europe: A systematic review and data synthesis. Pharmacol Res Perspect 2021; 9:e00816. [PMID: 34232554 PMCID: PMC8262606 DOI: 10.1002/prp2.816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/27/2021] [Indexed: 11/06/2022] Open
Abstract
We aimed to evaluate the quality of clinical evidence that substantiated approval of cancer medicines by the European Medicines Agency (EMA) in the last decade. We performed a systematic review and data synthesis of EMA documents in agreement with PRISMA guidelines. We included the European Public Assessment Reports, Summaries of Product Characteristics, and published randomized controlled trials (RCTs) on anti-cancer drugs approved by EMA from 2010 to 2019, and excluded drugs not indicated for targeting solid or hematological tumors and non-innovative treatments. We synthesized frequencies of approvals differentiating between unblinded and blinded RCTs with and without overall survival (OS) as a predefined primary outcome measure. We assessed the frequency of post-approval RCTs for indications without at least one RCT at the time of approval. Of 199 approvals, 159 (80%) were supported by at least one RCT, 63 (32%) by at least one RCT having OS as the primary or co-primary endpoint, 74 (37%) by at least one blinded RCT, and 30 (15%) by at least one blinded RCT having OS as the primary or co-primary endpoint. Whereas 40 approvals (20%) were not supported by any RCT and, of those, 9 (22%) were followed by a post-approval RCT. While the majority of approvals of cancer medicines approved by EMA was supported by at least one RCT, we noted substantial methodological heterogeneity of the studies. Clinical trial registration: PROSPERO registration number CRD42020206669.
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Affiliation(s)
- Alberto Farina
- Division of Healthcare Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany.,Medical Affairs Department, Celltrion Healthcare Italy srl, Milan, Italy
| | - Federico Moro
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Frederick Fasslrinner
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annahita Sedghi
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Miluska Bromley
- Division of Healthcare Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany.,Universidad Cientifica del Sur, Lima, Peru
| | - Timo Siepmann
- Division of Healthcare Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany.,Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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12
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Twelve years of European cancer drug approval-a systematic investigation of the 'magnitude of clinical benefit'. ESMO Open 2021; 6:100166. [PMID: 34087744 PMCID: PMC8182388 DOI: 10.1016/j.esmoop.2021.100166] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/24/2022] Open
Abstract
Background The magnitude of clinical benefit of solid cancer drugs can be standardly assessed via the Magnitude of Clinical Benefit Scale (MCBS) developed by the European Society for Medical Oncology (ESMO). We applied two ESMO-MCBS versions to the last 12 years of European cancer drug approval and compared two predefined marketing authorisation timeframes to identify potential score changes over time. Material and methods Originator solid cancer drugs and indication extensions that were approved between 1 January 2009 and 31 October 2020 by the European Medicines Agency (EMA) were included in our analyses. To evaluate the clinical benefit of these cancer indications, the original ESMO-MCBS (v 1.1) and a locally adapted ESMO-MCBS version were applied to the study sample. Thus, two ESMO-MCBS versions were compared, and an additional analysis was conducted to identify potential score differences between two approval timeframes 2009-2014 versus 2015-2020. Results A total of 144 cancer indications intended as curative (n = 9) or non-curative (n = 135) treatment options were eligible for an ESMO-MCBS assessment. Solely a minority of the assessed cancer indications met the meaningful clinical benefit (MCB) criteria independent of the applied version of the scale and treatment intention (original: n = 48/144, 33.3% versus adapted: n = 27/144, 18.8%). Comparing the two EMA approval timeframes, a growing number of approved cancer indications could be observed: 2009-2014: n = 9/year versus 2015-2020: n = 14/year. In addition, almost no difference in the proportion of cancer indications that have met the MCB criteria was detectable when comparing the predefined authorisation timeframes (MCB increase original: +4.1% and adapted: +3.9%). Conclusion Applying both versions of the ESMO-MCBS can help to identify potentially beneficial cancer indications, but also those with rather uncertain or low clinical benefit and thus, support the fair allocation of limited health care resources. A total of 158 solid cancer indications were approved by the European Medicines Agency (EMA) in the last 12 years. A minority of these indications were deemed to be clinically meaningful after applying two versions of the ESMO-MCBS. Comparing two EMA approval timeframes, no difference in the highest possible ESMO-MCBS grades could be observed. The ESMO-MCBS supports the identification of beneficial as well as rather uncertain or low clinical benefit cancer drugs. Evidenced-based decision making and the allocation of limited health care resources can be facilitated by the ESMO-MCBS.
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Thomson S, Witzke N, Gyawali B, Delos Santos S, Udayakumar S, Cardone C, Cheung MC, Chan KKW. Assessing the benefit of cancer drugs approved by the European Medicines Agency using the European Society for Medical Oncology Magnitude of Clinical Benefit Scale over time. Eur J Cancer 2021; 150:203-210. [PMID: 33932727 DOI: 10.1016/j.ejca.2021.03.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Increasingly, cancer drugs are being approved based on surrogate measurements of efficacy. Clinically meaningful data, such as overall survival (OS) and quality of life, are often only presented in subsequent publications. We examined if the clinical benefit of cancer drugs, as measured by the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS), improves post-European Medicines Agency (EMA) approval as more data emerges. METHODS Cancer drug indications approved by the EMA from January 2006 to December 2016 were reviewed and trials cited for efficacy were identified. Primary and subsequent publications (up to December 2019) of scorable trials were included. Changes in benefit over time were measured using ESMO-MCBS thresholds for non-curative (≥4 for substantial, =3 for intermediate and ≤2 for low benefit) and curative intent (A or B for major benefit) scoring. RESULTS Fifty-five non-curative and two curative intent trials were included. At approval, 29.1% of non-curative trials were substantial, 45.5% intermediate and 25.5% low benefit. For curative intent trials, one displayed major benefit and one displayed no major benefit. We identified 82 subsequent publications for reassessment. A change in ESMO-MCBS classification was seen in 34.5% of non-curative trials (11 raised and 8 lowered). At 3-year reassessment, 36.4% of non-curative trials were substantial, 34.5% intermediate and 29.1% low benefit. Both curative trials showed no major benefit at reassessment. CONCLUSION As over a third of trials changed classification, in either direction, reassessing the ESMO-MCBS score of approved cancer drugs may help to inform patients and ensure ongoing relevance of regulatory and reimbursement decisions.
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Affiliation(s)
- Sasha Thomson
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Noah Witzke
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bishal Gyawali
- Department of Oncology, Department of Public Health Sciences and Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Seanthel Delos Santos
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Suji Udayakumar
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Claudia Cardone
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Matthew C Cheung
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada.
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14
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Del Paggio JC, Fundytus AM, Hopman WM, Pater JL, Chen BE, Brundage MD, Hay AE, Booth CM. Application of Value Frameworks to the Design of Clinical Trials: the Canadian Cancer Trials Group Experience. J Natl Cancer Inst 2021; 113:1422-1428. [PMID: 33760057 DOI: 10.1093/jnci/djab051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Use of value framework thresholds in the design of clinical trials may increase the proportion of randomized controlled trials (RCTs) that identify clinically meaningful advances for patients. Existing frameworks have not been applied to the research output of a cooperative cancer trials group. We apply value frameworks to the RCT output of the Canadian Cancer Trials Group (CCTG). METHODS Statistical design, study characteristics, and results of all published phase III trials of CCTG were abstracted. We applied the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) and American Society of Clinical Oncology Net Health Benefit (ASCO-NHB) to study results and the statistical power calculations to identify the proportion of all trials that were designed to detect a substantial clinical benefit. RESULTS During 1979-2017, CCTG published 113 phase III trials; 52.2% (59 of 113) of these trials were positive. Half (50.4%, 57 of 113) of trials were conducted in the palliative setting. In 37.2% (42 of 113) of trials the primary endpoint was overall survival; DFS or PFS was used in 38.9% (44 of 113) of trials. The ESMO-MCBS could be applied to the power calculation for 69 trials; 73.9% (51 of 69) of these trials were designed to detect an effect size that could meet ESMO-MCBS thresholds for substantial benefit. Among the 51 positive trials for which the ESMO-MCBS could be applied, 41.1% (21 of 51) met thresholds for substantial benefit. CONCLUSIONS Most CCTG phase III trials were designed to detect clinically meaningful differences in outcome, although less than half of positive trials met the threshold for substantial benefit. Application of value frameworks to the design of clinical trials is practical and may improve research efficiency and treatment options for patients.
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Affiliation(s)
- Joseph C Del Paggio
- Department of Medical Oncology, Thunder Bay Regional Health Sciences Centre and Northern Ontario School of Medicine, Thunder Bay, Canada
| | - Adam M Fundytus
- Department of Oncology, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Kingston General Hospital Research Institute, Kingston, ON, Canada
| | - Joseph L Pater
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Bingshu E Chen
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Michael D Brundage
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Annette E Hay
- Department of Medicine, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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15
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The use of ‘added benefit’ to determine the price of new anti-cancer drugs in France, 2004–2017. Eur J Cancer 2021; 145:11-18. [DOI: 10.1016/j.ejca.2020.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 01/28/2023]
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16
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Rodriguez A, Esposito F, Oliveres H, Torres F, Maurel J. Are Quality of Randomized Clinical Trials and ESMO-Magnitude of Clinical Benefit Scale Two Sides of the Same Coin, to Grade Recommendations for Drug Approval? J Clin Med 2021; 10:746. [PMID: 33668473 PMCID: PMC7918206 DOI: 10.3390/jcm10040746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 12/20/2022] Open
Abstract
The approval of a new drug for cancer treatment by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) is based on positive, well-designed randomized phase III clinical trials (RCTs). However, not all of them are analyzed to support the recommendations. For this reason, there are different scales to quantify and evaluate the quality of RCTs and the magnitude of the clinical benefits of new drugs for treating solid tumors. In this review, we discuss the value of the progression-free survival (PFS) as an endpoint in RCTs and the concordance between it and the overall survival (OS) as a measure of the quality of clinical trial designs. We summarize and analyze the different scales to evaluate the clinical benefits of new drugs such as the The American Society of Clinical Oncology value framework (ASCO-VF-NHB16) and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) and the concordance between them, focusing on metastatic colorectal cancer (mCRC). We propose several definitions that would help to evaluate the quality of RCT, the magnitude of clinical benefit and the appropriate approval of new drugs in oncology.
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Affiliation(s)
- Adela Rodriguez
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
| | - Francis Esposito
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
| | - Helena Oliveres
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
| | - Ferran Torres
- Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona, 08036 Barcelona, Spain
| | - Joan Maurel
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
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Galeone C, Bruzzi P, Jommi C. Key drivers of innovativeness appraisal for medicines: the Italian experience after the adoption of the new ranking system. BMJ Open 2021; 11:e041259. [PMID: 33441356 PMCID: PMC7812109 DOI: 10.1136/bmjopen-2020-041259] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE In 2017, the Italian Medicines Agency (Agenzia Italiana del Farmaco, AIFA) introduced a standardised process to appraise innovativeness of medicines. Innovative medicines are provided speeder market access and dedicated funds. Innovativeness criteria are: unmet therapeutic need, added therapeutic value and quality of the evidence (Grading of Recommendations Assessment, Development and Evaluation method). We investigated the role played by these three criteria on the final decision aimed to understand how the new Italian innovativeness appraisal framework was implemented. DESIGN A desk research gathered AIFA's appraisal reports on innovativeness and data analyses were conducted. No patients were directly involved in this study. SETTING AND PARTICIPANTS We scrutinised all 77 appraisal reports available on AIFA's website (2017-2020). PRIMARY AND SECONDARY OUTCOME MEASURES The impact of the three domains on final decision was investigated through a series of univariate analyses. RESULTS Among 77 appraisal reports on innovativeness available, 49 (64%) and 28 (36%) were for oncology and non-oncology medicines, respectively. The appraisals were equally distributed among 'fully innovative' (36%), 'conditionally innovative' (30%) and 'not innovative' (34%). Added therapeutic value was the most important driver on innovativeness decision, followed by quality of the evidence. Drugs for rare diseases and with paediatric/mixed indications were appraised 'innovative' by a larger proportion, but no statistical significance was found. CONCLUSIONS Despite some limitations, including the moderate number of appraisals, this paper provides an insight into the determinants of innovativeness appraisals for medicines in Italy and the accuracy of the appraisal process. This has important implications in terms of transparency and accountability in the prioritisation process applied to innovative medicines.
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Affiliation(s)
- Carlotta Galeone
- Bicocca Applied Statistics Center (B-ASC), Università degli Studi di Milano-Bicocca, Milano, Lombardia, Italy
- Biostatistics & Outcome Research, Statinfo, Renate, Lombardia, Italy
| | - Paolo Bruzzi
- Department of Clinical Epidemiology, IRCCS AOU San Martino, Genova, Liguria, Italy
| | - Claudio Jommi
- CERGAS (Centre for Research on Health and Social Care Management), SDA Bocconi School of Management, Bocconi University, Milano, Lombardia, Italy
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18
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Azam F, Vazquez A. Trends in Phase II Trials for Cancer Therapies. Cancers (Basel) 2021; 13:E178. [PMID: 33430223 PMCID: PMC7825663 DOI: 10.3390/cancers13020178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 12/27/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Drug combinations are the standard of care in cancer treatment. Identifying effective cancer drug combinations has become more challenging because of the increasing number of drugs. However, a substantial number of cancer drugs stumble at Phase III clinical trials despite exhibiting favourable efficacy in the earlier Phase. Methods: We analysed recent Phase II cancer trials comprising 2165 response rates to uncover trends in cancer therapies and used a null model of non-interacting agents to infer synergistic and antagonistic drug combinations. We compared our latest efficacy dataset with a previous dataset to assess the progress of cancer therapy. Results: Targeted therapies reach higher response rates when used in combination with cytotoxic drugs. We identify four synergistic and 10 antagonistic combinations based on the observed and expected response rates. We demonstrate that recent targeted agents have not significantly increased the response rates. Conclusions: We conclude that either we are not making progress or response rate measured by tumour shrinkage is not a reliable surrogate endpoint for the targeted agents.
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Affiliation(s)
- Faruque Azam
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1QH, UK;
| | - Alexei Vazquez
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1QH, UK;
- Cancer Research UK Beatson Institute, Switchback Road, Bearsden, Glasgow G61 1BD, UK
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19
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“Magnitude of clinical benefit” of solid tumour drugs and their real-world application in the Austrian health care setting. J Cancer Policy 2020. [DOI: 10.1016/j.jcpo.2020.100235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Liang F, Zhang S, Wang Q, Li W. Clinical benefit of immune checkpoint inhibitors approved by US Food and Drug Administration. BMC Cancer 2020; 20:823. [PMID: 32867707 PMCID: PMC7457752 DOI: 10.1186/s12885-020-07313-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/18/2020] [Indexed: 12/17/2022] Open
Abstract
Background We describe the clinical benefit of immune checkpoint inhibitors using the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) and ASCO VF. Methods We identify all approved indications of immune checkpoint inhibitors based on RCTs between January 1, 2011 and September 30, 2018 by FDA. Information including medians and HR of OS (PFS or DFS) and 95% CI, grade 3 or 4 toxicities in each arm, QOL data, survival probability at fixed time were extracted. Results Immune checkpoint inhibitors were approved for 18 indications based on RCTs. All the indications meet the ESMO-MCBS 1.1 threshold for meaningful benefit. By the updated ASCO-VF, the median Net Health Benefit (NHB) of these agents was 55.3 (range 17.4–77.1). Two third of the indication gained the bonus points for durable survival benefits by updated ASCO VF. When updated results were incorporated in the assessment, clinical benefit of most approved immune checkpoint inhibitors increased with a median improvement of NHB of 10 (range 2–20). Conclusions Approved immune checkpoint inhibitors provided clinical meaningful benefit by ESMO-MCBS 1.1, and most of these agents reach the threshold for bonus points for durable survival in the updated ASCO VF.
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Affiliation(s)
- Fei Liang
- Medical Oncology, Shanghai Cancer Center, Fudan University, 270 Dongan Road, Shanghai, 200032, China.,Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Sheng Zhang
- Medical Oncology, Shanghai Cancer Center, Fudan University, 270 Dongan Road, Shanghai, 200032, China.
| | - Qin Wang
- Shanghai University of Engineering Science, Shanghai, China.
| | - Wenfeng Li
- Department of Medical oncology, the affiliated hospital of Qingdao University, Qingdao, China.
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Pantziarka P, Verbaanderd C, Meheus L. Biased by design? Clinical trials and patient benefit in oncology. Future Oncol 2020; 16:4419-4423. [DOI: 10.2217/fon-2019-0763] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Pan Pantziarka
- The Anticancer Fund, 1853 Strombeek-Bever, Brussels, Belgium
- The George Pantziarka TP53 Trust, London, UK
| | - Ciska Verbaanderd
- The Anticancer Fund, 1853 Strombeek-Bever, Brussels, Belgium
- Clinical Pharmacology & Pharmacotherapy, Department of Pharmaceutical & Pharmacological Sciences, KU Leuven, Belgium
| | - Lydie Meheus
- The Anticancer Fund, 1853 Strombeek-Bever, Brussels, Belgium
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Schuster Bruce C, Brhlikova P, Heath J, McGettigan P. The use of validated and nonvalidated surrogate endpoints in two European Medicines Agency expedited approval pathways: A cross-sectional study of products authorised 2011-2018. PLoS Med 2019; 16:e1002873. [PMID: 31504034 PMCID: PMC6736244 DOI: 10.1371/journal.pmed.1002873] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/07/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In situations of unmet medical need or in the interests of public health, expedited approval pathways, including conditional marketing authorisation (CMA) and accelerated assessment (AA), speed up European Medicines Agency (EMA) marketing authorisation recommendations for medicinal products. CMAs are based on incomplete benefit-risk assessment data and authorisation remains conditional until regulator-imposed confirmatory postmarketing measures are fulfilled. For products undergoing AA, complete safety and efficacy data should be available, and postauthorisation measures may include only standard requirements of risk management and pharmacovigilance plans. In the pivotal trials supporting products assessed by expedited pathways, surrogate endpoints reduce drug development time compared with waiting for the intended clinical outcomes. Whether surrogate endpoints supporting products authorised through CMA and AA pathways reliably predict clinical benefits of therapy has not been studied systematically. Our objectives were to determine the extent to which surrogate endpoints are used and to assess whether their validity had been confirmed according to published hierarchies. METHODS AND FINDINGS We used European Public Assessment Reports (EPARs) to identify the primary endpoints in the pivotal trials supporting products authorised through CMA or AA pathways during January 1, 2011 to December 31, 2018. We excluded products that were vaccines, topical, reversal, or bleeding prophylactic agents or withdrawn within the study time frame. Where pivotal trials reported surrogate endpoints, we conducted PubMed searches for evidence of validity for predicting clinical outcomes. We used 2 published hierarchies to assess validity level. Surrogates with randomised controlled trials supporting the surrogate-clinical outcome relationship were rated as 'validated'. Fifty-one products met the inclusion criteria; 26 underwent CMAs, and 25 underwent AAs. Overall, 26 products were for oncology indications, 10 for infections, 8 for genetic disorders, and 7 for other systems disorders. Five products (10%), all AAs, were authorised based on pivotal trials reporting clinical outcomes, and 46 (90%) were authorised based on surrogate endpoints. No studies were identified that validated the surrogate endpoints. Among a total of 49 products with surrogate endpoints reported, most were rated according to the published hierarchies as being 'reasonably likely' (n = 30; 61%) or of having 'biological plausibility' (n = 46; 94%) to predict clinical outcomes. EPARs did not consistently explain the nature of the pivotal trial endpoints supporting authorisations, whether surrogate endpoints were validated or not, or describe the endpoints to be reported in the confirmatory postmarketing studies. Our study has limitations: we may have overlooked relevant validation studies; the findings apply to 2 expedited pathways and may not be generalisable to products authorised through the standard assessment pathway. CONCLUSIONS The pivotal trial evidence supporting marketing authorisations for products granted CMA or AA was based dominantly on nonvalidated surrogate endpoints. EPARs and summary product characteristic documents, including patient information leaflets, need to state consistently the nature and limitations of endpoints in pivotal trials supporting expedited authorisations so that prescribers and patients appreciate shortcomings in the evidence about actual clinical benefit. For products supported by nonvalidated surrogate endpoints, postauthorisation measures to confirm clinical benefit need to be imposed by the regulator on the marketing authorisation holders.
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Affiliation(s)
- Catherine Schuster Bruce
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Petra Brhlikova
- The Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Joseph Heath
- Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, United Kingdom
| | - Patricia McGettigan
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, United Kingdom
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Le Saux O, Lardy-Cleaud A, Frank S, Debled M, Cottu PH, Pistilli B, Vanlemmens L, Leheurteur M, Lévy C, Laborde L, Uwer L, D'hondt V, Berchery D, Lorgis V, Ferrero JM, Perrocheau G, Courtinard C, Mouret-Reynier MA, Velten M, Breton M, Parent D, Chabaud S, Robain M, Bachelot T. Assessment of the efficacy of successive endocrine therapies in hormone receptor-positive and HER2-negative metastatic breast cancer: a real-life multicentre national study. Eur J Cancer 2019; 118:131-141. [PMID: 31330488 DOI: 10.1016/j.ejca.2019.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/12/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND For luminal metastatic breast cancer (MBC), endocrine therapy (ET) is the recommended initial treatment before chemotherapy. Our objective was to evaluate the efficacy of multiple ET lines in a real-life study. METHODS The Breast Cancer Epidemiological Strategy and Medical Economics (ESME) project analysed data from all patients with systemic treatment for MBC initiated between 2008 and 2014 in one of the 18 French Comprehensive Cancer Centres. The primary end-point was the successive progression-free survival (PFS) evaluation. RESULTS The ESME research programme included 9921 patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2 (HER2) negative (HER2-) MBC. Before any chemotherapy, 4195 (43.4%), 1252 (29.8%) and 279 (6.6%) patients received one, two or three ET ± targeted therapy, respectively. The median PFS for first-, second- and third-line ET ± targeted therapy was 11.5 (95% confidence interval [CI], 10.8-12.1), 5.8 (95% CI, 5.3-6.1) and 5.5 (95% CI, 4.6-6.3) months, respectively. In a multivariate analysis, time from diagnosis to metastatic recurrence (P < 0.0001), presence of symptoms at metastatic relapse (P = 0.01), number of metastatic sites (P = 0.0003) and their localisation (P < 0.0001) were prognostic factors for PFS1. Duration of previous PFS was the only prognostic factor for subsequent PFS (10% threshold). Ten percent of the patients showed long-term response to ET, with a total treatment duration before chemotherapy ≥43.6 months. CONCLUSIONS Median PFS in our HR+/HER2- real-life cohort is similar to median first-line PFS reported in clinical trials, regardless of ET used as second- and third-line treatment. Despite the international consensus on early initiation of ET, the latter is not prescribed in most of the cases. Patients with a low tumour burden may achieve prolonged response on ET.
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Affiliation(s)
- Olivia Le Saux
- Department of Medical Oncology, Léon Bérard Centre, Lyon, France.
| | | | - Sophie Frank
- Department of Medical Oncology, Curie Institute, Paris, France
| | - Marc Debled
- Department of Medical Oncology, Bergonié Institute, Bordeaux, France
| | - Paul H Cottu
- Department of Medical Oncology, Curie Institute, Paris, France
| | | | | | | | - Christelle Lévy
- Cancers & Preventions, François Baclesse Centre, Caen, France
| | - Lilian Laborde
- Data Management and Analysis Center, Paoli-Calmettes Institute, Marseille, France
| | - Lionel Uwer
- Department of Medical Oncology, Alexis-Vautrin Cancer Institute of Lorraine, Vandœuvre-lès-Nancy, France
| | - Veronique D'hondt
- Department of Medical Oncology, Montpellier Regional Cancer Institute, Montpellier, France
| | - Delphine Berchery
- Department of Medical Information, Claudius Regaud Institute, Toulouse, France
| | - Veronique Lorgis
- Department of Medical Oncology, Georges-François-Leclerc Centre, Dijon, France
| | - Jean-Marc Ferrero
- Department of Medical Oncology, Antoine Lacassagne Cancer Center, Nice, France
| | | | | | | | - Michel Velten
- Department of Epidemiology and Biostatistics, Centre Paul Strauss, Strasbourg, France
| | - Mathias Breton
- Medical Information Department, Centre Eugéne Marquis, Rennes, France
| | - Damien Parent
- Department of Pharmacy, Institut de Cancérologie Jean-Godinot, Reims, France
| | - Sylvie Chabaud
- Department of Medical Oncology, Léon Bérard Centre, Lyon, France
| | - Mathieu Robain
- Department of Research and Development, R&D Unicancer, Paris, France
| | - Thomas Bachelot
- Department of Medical Oncology, Léon Bérard Centre, Lyon, France
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24
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Li J, Vivot A, Alter L, Durand-Zaleski I. Appraisal of cancer drugs: a comparison of the French health technology assessment with value frameworks of two oncology societies. Expert Rev Pharmacoecon Outcomes Res 2019; 20:405-409. [PMID: 31240965 DOI: 10.1080/14737167.2019.1635458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Our primary objective was to compare the grading of the value of cancer drugs ('Amélioration du Service Médical Rendu' [ASMR] level) by the French health technology assessment authority ('Haute Autorité de santé' [HAS]) with that by the American Society of Clinical Oncology Value Framework (ASCO-VF) and the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). Our secondary objective was to study the drivers of the French grading system. METHODS We included new drugs for solid tumors assessed by the HAS between 2010 and 2016 and compared their ASMR level to scores calculated by the 2016-updated ASCO-VF and 2015 ESMO-MCBS. RESULTS We investigated 27 new cancer drugs assessed by the French HAS between 2010 and 2016. Among the 17 drugs eligible for comparison, the correlation between ASMR levels and ASCO and ESMO scores was weak (r = 0.34 and r = 0.27, respectively). The agreement between the HAS and ESMO regarding the level of meaningful additional benefit was moderate (kappa = 0.43). We found no significant association between 12 potential variables and ASMR level of additional benefit of drugs. CONCLUSION Our findings show inconsistencies in cancer drug appraisals among the three appraisers.
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Affiliation(s)
- J Li
- Clinical Epidemiology Unit, Greater Paris University Hospitals (AP-HP) , Paris, France.,Judge Business School, University of Cambridge , Cambridge, UK.,Faculty of Medicine, Paris XII University , Créteil, France
| | - A Vivot
- Clinical Epidemiology Unit, Greater Paris University Hospitals (AP-HP) , Paris, France.,UMR1153 Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, University Paris Descartes , Paris, France
| | - L Alter
- Department is Oncology Business Unit, LILLY FRANCE , Neuilly-sur-Seine, France
| | - I Durand-Zaleski
- Faculty of Medicine, Paris XII University , Créteil, France.,URC Eco IdF, Greater Paris University Hospitals (AP-HP) , Paris, France
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25
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Fiorin de Vasconcellos V, Rcc Bonadio R, Avanço G, Negrão MV, Pimenta Riechelmann R. Inpatient palliative chemotherapy is associated with high mortality and aggressive end-of-life care in patients with advanced solid tumors and poor performance status. BMC Palliat Care 2019; 18:42. [PMID: 31109330 PMCID: PMC6528308 DOI: 10.1186/s12904-019-0427-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background The benefit of palliative chemotherapy (PC) in patients with advanced solid tumors and poor performance status (ECOG-PS) has not been prospectively validated, which makes treatment decision challenging. We aimed to evaluate the overall survival, factors associated with early mortality, and adoption of additional procedures in hospitalized patients with advanced cancer and poor ECOG-PS treated with PC. Methods We analyzed a retrospective cohort of patients with advanced cancer treated with PC during hospitalization at an academic cancer center in Brazil from 2014 to 2016. Eligibility criteria included: ECOG-PS 3–4 and start of first-line PC; or ECOG-PS ≥ 2 and start of second or subsequent lines. Primary endpoint was 30-day survival from start of PC. Kaplan-Meier method was used for survival estimates and Cox regression for factors associated with 30-day mortality. Results Two hundred twenty-eight patients were eligible. 21.9, 66.7 and 11.4% of patients had ECOG-PS 2, 3 and 4, respectively. 49.6% had gastrointestinal tumors. Median follow-up was 49 days (range 1–507). 98.2% of patients had died, 32% during the index hospitalization. The 30-day and 60-day survival rates were 55.7 and 38.5%, respectively. 30% of patients were admitted to the intensive care unit. In a multivariable analysis, ECOG-PS 3/4 (HR 2.01; P = 0.016), hypercalcemia (HR 2.19; P = 0.005), and elevated bilirubin (HR 3.17; P < 0.001) were significantly associated with 30-day mortality. Conclusions Patients with advanced cancer and poor ECOG-PS had short survival after treatment with inpatient PC. Inpatient PC was associated with aggressive end-of-life care. Prognostic markers such as ECOG-PS, hypercalcemia and elevated bilirubin can contribute to the decision-making process for these patients.
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Affiliation(s)
- Vitor Fiorin de Vasconcellos
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil.
| | - Renata Rcc Bonadio
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil
| | - Guilherme Avanço
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil
| | - Marcelo Vailati Negrão
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil.,Department of Thoracic/Head and Neck Medical Oncology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 432, Houston, TX, 77030, USA
| | - Rachel Pimenta Riechelmann
- Department of Clinical Oncology, AC Camargo Cancer Center, R. Prof. Antônio Prudente, 211 - Liberdade, São Paulo, SP, 01509-010, Brazil
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Gyawali B, Hwang TJ, Vokinger KN, Booth CM, Amir E, Tibau A. Patient-Centered Cancer Drug Development: Clinical Trials, Regulatory Approval, and Value Assessment. Am Soc Clin Oncol Educ Book 2019; 39:374-387. [PMID: 31099613 DOI: 10.1200/edbk_242229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Historically, patient experience, including symptomatic toxicities, physical function, and disease-related symptoms during treatment or their perspectives on clinical trials, has played a secondary role in cancer drug development. Regulatory criteria for drug approval require that drugs are safe and effective, and almost all drug approvals have been based only on efficacy endpoints rather than on quality-of-life (QoL) assessments. In contrast to Europe, information regarding the impact of drugs on patients' QoL is rarely included in oncology drug labeling in the United States. Until recently, patient input and preferences have not been incorporated into the design and conduct of clinical trials. In recent years, a more in-depth understanding of cancer biology, as well as regulatory changes focused on expediting cancer drug development and approval, has allowed earlier access to novel therapeutic agents. Understanding the implications of these expedited programs is important for oncologists and patients, given the rapid expansion of these programs. In this article, we provide an overview of the role of QoL in the regulatory drug-approval process, key issues regarding trial participation from the patient perspective, and the implications of key expedited approval programs that are increasingly being used by regulatory bodies for cancer care.
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Affiliation(s)
- Bishal Gyawali
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas J Hwang
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kerstin Noelle Vokinger
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,2 Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Christopher M Booth
- 3 Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,4 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Eitan Amir
- 5 Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 6 Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
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Jiang DM, Chan KKW, Jang RW, Booth C, Liu G, Amir E, Mason R, Everest L, Elimova E. Anticancer drugs approved by the Food and Drug Administration for gastrointestinal malignancies: Clinical benefit and price considerations. Cancer Med 2019; 8:1584-1593. [PMID: 30848108 PMCID: PMC6488126 DOI: 10.1002/cam4.2058] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The cost of new anticancer drugs is rising. We aimed to assess the clinical benefit and price of anti-cancer drugs approved by the US Food and Drug Administration (FDA) for advanced gastrointestinal cancers. METHODS Drugs approved between 2006 and 2017 for advanced GI malignancies were identified from FDA.gov, and their updated supporting trial data were searched. Incremental clinical benefit was quantified by using ESMO Magnitude of Clinical Benefit Scale version 1.1 (grade 0-5) and ASCO Value Framework version 2 (score range -20 to 180). Higher scores indicate larger net benefit, and substantial benefit was defined as score 4 or 5 by the European Society for Medical Oncology (ESMO). The Micromedex REDBOOK was used to estimate the monthly average wholesale price (AWP) and total drug price (TDP) over the median treatment duration per patient. Clinical benefit, AWP and TDP of each drug class were assessed. RESULTS In total, 16 GI cancer drugs received FDA approval for 24 indications, including five monoclonal antibodies (mAbs), five oral targeted therapies (TT), two immunotherapeutics (IO), three cytotoxic chemotherapies (CT), and one recombinant fusion protein (aflibercept). Most supporting trials (82%) reported overall survival benefit of less than 3 months and no significant improvement in quality of life. Only five agents (including one TT and one IO) with 21% the of approved indications met the ESMO's threshold of substantial clinical benefit. Median incremental benefit scores of TT and IO were comparable to other drug classes. However their median TDP was much higher at $153 402 and $98 208, respectively, compared to $30 330 USD per patient for CT. The estimated TDP did not correlate with clinical benefit scores. CONCLUSION Most FDA-approved gastrointestinal cancer drugs do not meet the ESMO threshold of substantial clinical benefit. TT and IO are estimated to carry significant drug costs, and further cost analysis of these drugs is urgently needed.
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Affiliation(s)
- Di Maria Jiang
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity Health Network, University of TorontoTorontoCanada
| | - Kelvin K. W. Chan
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
- Canadian Centre for Applied Research in Cancer ControlTorontoCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | - Raymond W. Jang
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity Health Network, University of TorontoTorontoCanada
| | - Christopher Booth
- Department of OncologyQueen’s UniversityKingstonOntarioCanada
- Division of Cancer Care and EpidemiologyQueen’s Cancer Research InstituteKingstonOntarioCanada
| | - Geoffrey Liu
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity Health Network, University of TorontoTorontoCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | - Eitan Amir
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity Health Network, University of TorontoTorontoCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | - Robert Mason
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
| | - Louis Everest
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
| | - Elena Elimova
- Division of Medical Oncology, Princess Margaret Cancer CentreUniversity Health Network, University of TorontoTorontoCanada
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28
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Grössmann N, Robausch M, Rosian K, Wild C, Simon J. Monitoring evidence on overall survival benefits of anticancer drugs approved by the European Medicines Agency between 2009 and 2015. Eur J Cancer 2019; 110:1-7. [DOI: 10.1016/j.ejca.2018.12.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 02/01/2023]
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29
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Grössmann N, Wolf S, Rosian K, Wild C. Pre-reimbursement: early assessment for coverage decisions. Wien Med Wochenschr 2019; 169:254-262. [PMID: 30725442 PMCID: PMC6713676 DOI: 10.1007/s10354-019-0683-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/15/2019] [Indexed: 12/21/2022]
Abstract
Background In the past decade, the Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) has introduced two programs: “Horizon Scanning in Oncology” (HSO) and extra medical services (“MELs”), which are to facilitate coverage decisions based on early assessments. This article aims to outline the general process and methods within these two programs. Methods A narrative-descriptive synthesis of the literature was performed to outline the general and LBI-HTA-specific processes and methods of early assessments. Results In total, 79 HSO assessments (2009–2018) and 95 MELs (2008–2018) have been conducted by the LBI-HTA. Recently, additional methods that contribute to European applicability have been introduced into these programs. Conclusions Overall, pre-coverage decisions based on early assessment reports are dependent on the existing evidence. However, the organisation of the health care system and the cross-linking between decision-makers and HTA institutions can have an impact.
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Affiliation(s)
- Nicole Grössmann
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090, Vienna, Austria. .,Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Sarah Wolf
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090, Vienna, Austria
| | - Katharina Rosian
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090, Vienna, Austria
| | - Claudia Wild
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090, Vienna, Austria
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30
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Lawrence NJ, Roncolato F, Martin A, Simes RJ, Stockler MR. Effect Sizes Hypothesized and Observed in Contemporary Phase III Trials of Targeted and Immunological Therapies for Advanced Cancer. JNCI Cancer Spectr 2018; 2:pky037. [PMID: 31360867 PMCID: PMC6649714 DOI: 10.1093/jncics/pky037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 05/05/2018] [Accepted: 07/13/2018] [Indexed: 12/22/2022] Open
Abstract
Background We sought to compare the effect sizes hypothesized in the trial design, observed in the trial results, and considered clinically meaningful by the American Society of Clinical Oncology (ASCO) 2014 recommendations, in phase III trials of targeted and immunological therapies. Methods We studied phase III, superiority trials of targeted and immunological therapies in advanced cancers published from 2005 to 2015. We recorded the characteristics, design parameters, and observed results for the primary endpoint of each trial. The effect sizes hypothesized in the trial design were compared with the ASCO 2014 recommendation that phase III trials be designed to detect overall survival (OS) benefits that are clinically meaningful (hazard ratio ≤0.8). Results All critical elements of the trial design (effect sizes hypothesized, estimated survival in the control group, power, and significance level) were identified in 165 of 213 included trials (77%). Of trials with a statistically significant result for the primary endpoint, 16 of 30 (53%) with a primary endpoint of OS and 20 of 53 (38%) with a primary endpoint of progression free survival (PFS) had an observed effect size less extreme than hypothesized; and 7 of 30 trials (23%) reported an observed effect size for OS that was statistically significant but not clinically meaningful (HR > 0.80) according to the ASCO 2014 recommendations. Conclusion Many trials were designed such that an observed benefit in OS or PFS that was not clinically meaningful would be statistically significant. Phase III trials should be designed to provide results that are statistically significant for observed effects that are clinically meaningful but not for observed results that are of dubious clinical importance.
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Affiliation(s)
- Nicola Jane Lawrence
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Felicia Roncolato
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.,Macarthur Cancer Therapy Centre, Campbelltown, New South Wales, Australia
| | - Andrew Martin
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Robert John Simes
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.,Concord Cancer Centre, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
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31
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Ladanie A, Speich B, Naudet F, Agarwal A, Pereira TV, Sclafani F, Martin-Liberal J, Schmid T, Ewald H, Ioannidis JPA, Bucher HC, Kasenda B, Hemkens LG. The Comparative Effectiveness of Innovative Treatments for Cancer (CEIT-Cancer) project: Rationale and design of the database and the collection of evidence available at approval of novel drugs. Trials 2018; 19:505. [PMID: 30231912 PMCID: PMC6146631 DOI: 10.1186/s13063-018-2877-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/24/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The available evidence on the benefits and harms of novel drugs and therapeutic biologics at the time of approval is reported in publicly available documents provided by the US Food and Drug Administration (FDA). We aimed to create a comprehensive database providing the relevant information required to systematically analyze and assess this early evidence in meta-epidemiological research. METHODS We designed a modular and flexible database of systematically collected data. We identified all novel cancer drugs and therapeutic biologics approved by the FDA between 2000 and 2016, recorded regulatory characteristics, acquired the corresponding FDA approval documents, identified all clinical trials reported therein, and extracted trial design characteristics and treatment effects. Herein, we describe the rationale and design of the data collection process, particularly the organization of the data capture, the identification and eligibility assessment of clinical trials, and the data extraction activities. DISCUSSION We established a comprehensive database on the comparative effects of drugs and therapeutic biologics approved by the FDA over a time period of 17 years for the treatment of cancer (solid tumors and hematological malignancies). The database provides information on the clinical trial evidence available at the time of approval of novel cancer treatments. The modular nature and structure of the database and the data collection processes allow updates, expansions, and adaption for a continuous meta-epidemiological analysis of novel drugs. The database allows us to systematically evaluate benefits and harms of novel drugs and therapeutic biologics. It provides a useful basis for meta-epidemiological research on the comparative effects of innovative cancer treatments and continuous evaluations of regulatory developments.
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Affiliation(s)
- Aviv Ladanie
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.,Swiss Tropical and Public Health Institute (Swiss TPH), Socinstrasse 57, Basel, 4002, Switzerland
| | - Benjamin Speich
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Florian Naudet
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], 22 rue Henri Le Guilloux, 35000, Rennes, France
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S 1A8, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, ON, Canada
| | - Tiago V Pereira
- Health Technology Assessment Unit, Institute of Education and Health Sciences, Oswaldo Cruz German Hospital, Rua João Julião, 245 1º andar, Bloco D, São Paulo, 01323-040, Brazil
| | - Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, Surrey, UK
| | - Juan Martin-Liberal
- Catalan Institute of Oncology (ICO) Hospitalet, Melanoma, Sarcoma and GU Tumors Unit, Av Gran Via de L'Hospitalet 199-203, Barcelona, 08908, Spain.,Vall d'Hebron Institute of Oncology (VHIO), Early Drug Development Unit (UITM), Pg Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Thomas Schmid
- St. Clara Hospital, Kleinriehenstrasse 30, Basel, 4058, Switzerland
| | - Hannah Ewald
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.,Swiss Tropical and Public Health Institute (Swiss TPH), Socinstrasse 57, Basel, 4002, Switzerland.,University Medical Library, University of Basel, Schönbeinstrasse 18-20, Basel, 4056, Switzerland
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Health Research and Policy, Stanford University School of Medicine, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Biomedical Data Science, Stanford University School of Medicine, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Statistics, Stanford University School of Humanities and Sciences, 1265 Welch Road, Stanford, 94305, CA, USA
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.,Medical Oncology, University Hospital and University of Basel, Petersgraben 4, Basel, 4031, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.
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Baldo P, Fornasier G, Ciolfi L, Sartor I, Francescon S. Pharmacovigilance in oncology. Int J Clin Pharm 2018; 40:832-841. [PMID: 30069667 PMCID: PMC6132974 DOI: 10.1007/s11096-018-0706-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/26/2018] [Indexed: 12/31/2022]
Abstract
Background Side effects of cancer therapy are one of the most important issues faced by cancer patients during their illness. Pharmacovigilance, namely the science and activities aimed at monitoring the safety of drugs, is particularly important in oncology, due to the intrinsic biologic toxicity of antineoplastic agents, their narrow therapeutic windows, and the high doses and rigid timing of treatment regimens. Aim of the review To identify the main issues in carrying out an effective pharmacovigilance activity in oncology. Method We searched PubMed for articles about pharmacovigilance in relation to chemotherapy, radiotherapy and targeted therapy for cancer, using MeSH terms and text words. We also searched Embase, CINAHL, Scopus, Micromedex, the Cochrane Library, two pharmacovigilance databases and the gray literature for articles published in 2012-2018. Overall, 137 articles were considered potentially relevant and were critically appraised independently by two authors, leading to the inclusion of 44 relevant studies, guidelines and reviews. Another 10 important research reports were included in the review. Results Eight critical issues of pharmacovigilance in oncology were identified. These issues pertain to: terminology; range of side effects; targeted therapy and immunotherapy; chemoradiotherapy; generic drugs and biosimilars; drug interactions, pharmacogenetics and polypharmacy; special patient categories; and under-reporting of ADRs. Conclusion The importance of pharmacovigilance in oncology must be highlighted with every effort, to improve safety and offer cancer patients every possible help to improve their quality of life during such a critical period of their lives.
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Affiliation(s)
- Paolo Baldo
- Pharmacy Unit, CRO Aviano IRCCS, National Cancer Institute, Aviano, Italy.
| | - Giulia Fornasier
- Pharmacy Unit, CRO Aviano IRCCS, National Cancer Institute, Aviano, Italy
| | - Laura Ciolfi
- Scientific and Patients' Library, CRO Aviano IRCCS, National Cancer Institute, Aviano, Italy
| | - Ivana Sartor
- Scientific Direction, Clinical Trial Office Unit, CRO Aviano IRCCS, National Cancer Institute, Aviano, Italy
| | - Sara Francescon
- Pharmacy Unit, CRO Aviano IRCCS, National Cancer Institute, Aviano, Italy
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Kempf E, Bogaerts J, Lacombe D, Liu L. ‘Mind the gap’ between the development of therapeutic innovations and the clinical practice in oncology: A proposal of the European Organisation for Research and Treatment of Cancer (EORTC) to optimise cancer clinical research. Eur J Cancer 2017; 86:143-149. [DOI: 10.1016/j.ejca.2017.08.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 12/29/2022]
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