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Zhong L, Tran AT, Tomasino T, Nugent E, Smith JA. Cost-Effectiveness of Niraparib and Olaparib as Maintenance Therapy for Patients with Platinum-Sensitive Recurrent Ovarian Cancer. J Manag Care Spec Pharm 2018; 24:1219-1228. [PMID: 30479195 PMCID: PMC10397875 DOI: 10.18553/jmcp.2018.24.12.1219] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The recent approval of olaparib and niraparib as maintenance therapy can significantly affect the management of ovarian cancer. Clinical benefits, however, come with trade-offs in adverse events and costs. OBJECTIVE To evaluate the cost-effectiveness of new ovarian cancer poly-ADP ribose polymerase (PARP) inhibitor therapies, olaparib and niraparib, as maintenance therapy for patients with platinum-sensitive recurrent ovarian cancer. METHODS A decision tree model was constructed to evaluate the costs and effectiveness of olaparib and niraparib compared with placebo from a U.S. health care sector perspective. Costs included drug costs and costs of disease monitoring and management of adverse events throughout the treatment course. Costs were estimated from RED BOOK, Medicare reimbursement rates, and the literature and reported in 2017 U.S. dollars. Clinical effectiveness was measured in progression-free survival (PFS) life-years based on clinical trial results (NCT00753545, NCT01874353, and NCT01847274). The incremental cost-effectiveness ratio (ICER) was computed by dividing the incremental cost by the incremental effectiveness. RESULTS At base case, niraparib was the more effective treatment option with slightly higher PFS, followed by olaparib. The ICERs for niraparib and olaparib compared with common baseline placebo were $235K and $287K per PFS life-year, respectively, with olaparib extended-dominated by niraparib. Both drugs were associated with lower ICERs in patients with a gBRCA mutation than in patients without a gBRCA mutation. One-way sensitivity analysis suggested that drug prices and PFS could affect ICERs significantly, but the ICERs remained above $100K per PFS life-year within the plausible ranges of all parameters. Probabilistic sensitivity analysis suggested that niraparib was associated with higher net benefits compared with placebo only when willingness-to-pay (WTP) values were above $210K per PFS life-year thresholds. CONCLUSIONS PARP inhibitors niraparib and olaparib will extend PFS in platinum-sensitive recurrent ovarian cancer patients but are also associated with high drug acquisition costs. The base case ICERs were around or above $250K per PFS life-year in this model. No formal cost-effectiveness WTP threshold for health technology assessment exists in the United States. At a reference WTP of $100K per PFS life-year, the PARP inhibitors may not be cost-effective options. DISCLOSURES This study was unfunded. The authors have nothing to disclose.
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Affiliation(s)
- Lixian Zhong
- Irma Lerma Rangel College of Pharmacy, Texas A&M University, College Station
| | - Anh Thu Tran
- Irma Lerma Rangel College of Pharmacy, Texas A&M University, College Station
| | - Taylor Tomasino
- Irma Lerma Rangel College of Pharmacy, Texas A&M University, College Station
| | - Elizabeth Nugent
- Department of Obstetrics, Gynecology and Predictive Sciences, The University of Texas Health Science Center at Houston
| | - Judith A. Smith
- Department of Obstetrics, Gynecology and Predictive Sciences, The University of Texas Health Science Center at Houston
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Coleman RL, Oza AM, Lorusso D, Aghajanian C, Oaknin A, Dean A, Colombo N, Weberpals JI, Clamp A, Scambia G, Leary A, Holloway RW, Gancedo MA, Fong PC, Goh JC, O'Malley DM, Armstrong DK, Garcia-Donas J, Swisher EM, Floquet A, Konecny GE, McNeish IA, Scott CL, Cameron T, Maloney L, Isaacson J, Goble S, Grace C, Harding TC, Raponi M, Sun J, Lin KK, Giordano H, Ledermann JA. Rucaparib maintenance treatment for recurrent ovarian carcinoma after response to platinum therapy (ARIEL3): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2017; 390:1949-1961. [PMID: 28916367 PMCID: PMC5901715 DOI: 10.1016/s0140-6736(17)32440-6] [Citation(s) in RCA: 1201] [Impact Index Per Article: 171.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 08/24/2017] [Accepted: 08/29/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Rucaparib, a poly(ADP-ribose) polymerase inhibitor, has anticancer activity in recurrent ovarian carcinoma harbouring a BRCA mutation or high percentage of genome-wide loss of heterozygosity. In this trial we assessed rucaparib versus placebo after response to second-line or later platinum-based chemotherapy in patients with high-grade, recurrent, platinum-sensitive ovarian carcinoma. METHODS In this randomised, double-blind, placebo-controlled, phase 3 trial, we recruited patients from 87 hospitals and cancer centres across 11 countries. Eligible patients were aged 18 years or older, had a platinum-sensitive, high-grade serous or endometrioid ovarian, primary peritoneal, or fallopian tube carcinoma, had received at least two previous platinum-based chemotherapy regimens, had achieved complete or partial response to their last platinum-based regimen, had a cancer antigen 125 concentration of less than the upper limit of normal, had a performance status of 0-1, and had adequate organ function. Patients were ineligible if they had symptomatic or untreated central nervous system metastases, had received anticancer therapy 14 days or fewer before starting the study, or had received previous treatment with a poly(ADP-ribose) polymerase inhibitor. We randomly allocated patients 2:1 to receive oral rucaparib 600 mg twice daily or placebo in 28 day cycles using a computer-generated sequence (block size of six, stratified by homologous recombination repair gene mutation status, progression-free interval after the penultimate platinum-based regimen, and best response to the most recent platinum-based regimen). Patients, investigators, site staff, assessors, and the funder were masked to assignments. The primary outcome was investigator-assessed progression-free survival evaluated with use of an ordered step-down procedure for three nested cohorts: patients with BRCA mutations (carcinoma associated with deleterious germline or somatic BRCA mutations), patients with homologous recombination deficiencies (BRCA mutant or BRCA wild-type and high loss of heterozygosity), and the intention-to-treat population, assessed at screening and every 12 weeks thereafter. This trial is registered with ClinicalTrials.gov, number NCT01968213; enrolment is complete. FINDINGS Between April 7, 2014, and July 19, 2016, we randomly allocated 564 patients: 375 (66%) to rucaparib and 189 (34%) to placebo. Median progression-free survival in patients with a BRCA-mutant carcinoma was 16·6 months (95% CI 13·4-22·9; 130 [35%] patients) in the rucaparib group versus 5·4 months (3·4-6·7; 66 [35%] patients) in the placebo group (hazard ratio 0·23 [95% CI 0·16-0·34]; p<0·0001). In patients with a homologous recombination deficient carcinoma (236 [63%] vs 118 [62%]), it was 13·6 months (10·9-16·2) versus 5·4 months (5·1-5·6; 0·32 [0·24-0·42]; p<0·0001). In the intention-to-treat population, it was 10·8 months (8·3-11·4) versus 5·4 months (5·3-5·5; 0·36 [0·30-0·45]; p<0·0001). Treatment-emergent adverse events of grade 3 or higher in the safety population (372 [99%] patients in the rucaparib group vs 189 [100%] in the placebo group) were reported in 209 (56%) patients in the rucaparib group versus 28 (15%) in the placebo group, the most common of which were anaemia or decreased haemoglobin concentration (70 [19%] vs one [1%]) and increased alanine or aspartate aminotransferase concentration (39 [10%] vs none). INTERPRETATION Across all primary analysis groups, rucaparib significantly improved progression-free survival in patients with platinum-sensitive ovarian cancer who had achieved a response to platinum-based chemotherapy. ARIEL3 provides further evidence that use of a poly(ADP-ribose) polymerase inhibitor in the maintenance treatment setting versus placebo could be considered a new standard of care for women with platinum-sensitive ovarian cancer following a complete or partial response to second-line or later platinum-based chemotherapy. FUNDING Clovis Oncology.
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Affiliation(s)
- Robert L Coleman
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Amit M Oza
- Department of Medicine, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Domenica Lorusso
- Multicentre Italian Trials in Ovarian Cancer and Gynecologic Malignancies and Gynecologic Oncology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| | - Carol Aghajanian
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ana Oaknin
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Andrew Dean
- Department of Oncology, St John of God Subiaco Hospital, Subiaco, WA, Australia
| | - Nicoletta Colombo
- Gynecologic Cancer Program, European Institute of Oncology and University of Milan-Bicocca, Milan, Italy
| | | | - Andrew Clamp
- Department of Medical Oncology, Christie National Health Service Foundation Trust and University of Manchester, Manchester, UK
| | | | - Alexandra Leary
- Group d'Investigateurs Nationaux pour l'Étude des Cancers Ovariens et du sein and Gynecological Unit, Department of Medicine, Gustave Roussy Cancer Center and Institut National de la Santé et de la Recherche Médicale U981, Villejuif, France
| | - Robert W Holloway
- Department of Gynecologic Oncology, Florida Hospital Cancer Institute, Orlando, FL, USA
| | | | - Peter C Fong
- Medical Oncology Department, Auckland City Hospital, Grafton, Auckland, New Zealand
| | - Jeffrey C Goh
- Department of Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - David M O'Malley
- Gynecologic Oncology, Ohio State University, James Cancer Center, Columbus, OH, USA
| | - Deborah K Armstrong
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Jesus Garcia-Donas
- HM Hospitales-Centro Integral Oncológico Hospital de Madrid Clara Campal, Madrid, Spain
| | - Elizabeth M Swisher
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Anne Floquet
- Groupe d'Investigateurs Nationaux pour l'Étude des Cancers Ovariens et du sein and Institut Bergonié, Bordeaux, France
| | - Gottfried E Konecny
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Iain A McNeish
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | | | | | | | | | | | | | | | - James Sun
- Foundation Medicine, Cambridge, MA, USA
| | | | | | - Jonathan A Ledermann
- University College London Cancer Institute and University College London Hospitals, London, UK
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Lorusso D, Pietragalla A, Mainenti S, Masciullo V, Di Vagno G, Scambia G. Review role of topotecan in gynaecological cancers: current indications and perspectives. Crit Rev Oncol Hematol 2009; 74:163-74. [PMID: 19766512 DOI: 10.1016/j.critrevonc.2009.08.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 07/09/2009] [Accepted: 08/11/2009] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Ovarian cancer is the fourth cause of death from gynaecological cancer and cervical cancer is the first in women <45 years old in developing countries. The aim of this article is to review the role of topotecan (Hycamtin), a semi-synthetic alkaloid derivative of camptothecin, in ovarian and cervical cancer in monotherapy and in combination. METHODS This article reviews the mechanism of action, pharmacokinetics, toxicity and efficacy of topotecan. The paper also reports the principal phases II and III studies of topotecan in advanced or recurrent ovarian and cervical cancer. RESULTS Topotecan (Hycamtin), currently indicated for the treatment of relapsed ovarian cancer, has demonstrated activity both in platinum-sensitive and in platinum-resistant disease. The combination cisplatin-topotecan for the treatment of advanced and recurrent cervical cancer has demonstrated a clinical benefit in terms of response rate, overall survival and progression free survival. Haematological toxicity of topotecan also is easy to manage and not cumulative, especially with the weekly scheduled recently introduced in clinical practice. CONCLUSION Topotecan (Hycamtin) will continue to play a role in the treatment of advanced ovarian and cervical cancer, in monotherapy or in combination with other cytotoxic agents.
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Affiliation(s)
- Domenica Lorusso
- Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, IT-00168 Rome, Italy.
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Pectasides D, Xiros N, Papaxoinis G, Aravantinos G, Sykiotis C, Pectasides E, Psyrri A, Koumarianou A, Gaglia A, Gouveris P, Economopoulos T. Gemcitabine and pegylated liposomal doxorubicin alternating with cisplatin plus cyclophosphamide in platinum refractory/resistant, paclitaxel-pretreated, ovarian carcinoma. Gynecol Oncol 2007; 108:47-52. [PMID: 17915300 DOI: 10.1016/j.ygyno.2007.08.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 08/14/2007] [Accepted: 08/17/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This phase II study conducted to investigate the efficacy and toxicity of the combination of gemcitabine (GEM) and pegylated liposomal doxorubicin (LDOX) alternating with cisplatin (CDDP) and cyclophosphamide (CTX) in platinum-resistant/refractory, paclitaxel pretreated epithelial ovarian cancer (EOC). PATIENTS AND METHODS Forty-eight patients with CDDP-resistant/refractory and paclitaxel pretreated patients were treated with 8 cycles of GEM 800 mg/m2 days 1 and 8 and LDOX 30 mg/m2 day 1, alternating with CDDP 60 mg/m2 and CTX 600 mg/m2 every 3 weeks. RESULTS Objective responses were observed in 37.5% of patients (4 complete and 11 partial responses) with measurable disease (n=40). CA125 response occurred in 30 (71.4%) of patients with elevated CA125 (n=42). After a median follow-up of 23 months, the median progression-free survival (PFS) was 6.9 months (95% confidence interval, CI: 5.2-8.5), while the median overall survival (OS) was 18.2 months (95% CI: 12.7-23.6). A progression-free interval (PFI) of 0-3 months was associated with lower objective responses (10% versus 46.6%, p=0.06). Chemotherapy was well tolerated. The most frequent toxicities were myelosuppression, neurotoxicity, nephrotoxicity, nausea/vomiting, fatigue and palmar-plantar erythrodysesthesia (PPE). Overall 31 (65%) patients received G-CSF and 13 (27%) antibiotics because of neutropenia and/or febrile neutropenia. CONCLUSION This alternating combination chemotherapy is feasible for patients with platinum-resistant EOC and is associated with encouraging outcomes and a favorable toxicity profile.
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Affiliation(s)
- Dimitrios Pectasides
- 2nd Department of Internal Medicine, Propaedeutic, Oncology Section, University of Athens, Attikon University Hospital, Haidari, 1 Rimini, Athens, Greece.
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Raspollini MR, Amunni G, Villanucci A, Baroni G, Boddi V, Rossi Degl'innocenti D, Taddei GL. Microvessel density in ovarian carcinoma: computer image analysis in patients with shorter and longer survival. Int J Gynecol Cancer 2005; 15:844-9. [PMID: 16174234 DOI: 10.1111/j.1525-1438.2005.00146.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We previously reported that tumor microvessel density (MVD) may have prognostic significance in ovarian carcinoma. The aim of this study was to compare the intratumoral microvessels using a computer-aided image analysis system between FIGO stage IIIC, serous, G3, ovarian carcinomas obtained from living patients who had no evident disease 5 years after primary treatment and ovarian carcinomas, matched for stage, histopathology, grade of differentiation, and treatment, obtained from patients who had died of progression of disease no later than 1 year after primary treatment. We observed that MVD is statistically correlated, according to the logistic regression in univariate and multivariate ways, with the survival (P= 0.03 and P= 0.05, respectively) and with the progression of the disease during first-line chemotherapy (P= 0.009 and P= 0.012, respectively). In the past years, the modulation of first-line chemotherapeutic treatment has been a question of discussion, because the oncologist observes extremely unpredictable behaviors with surprisingly long survivals and also short survivals. Pathologists may give clinicians some additional prognostic information useful in the management of ovarian carcinoma patients. The results of this study support the hypothesis that the evaluation of MVD with computer image analysis can help clinicians in the choice of the tailored treatment of the single case.
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Affiliation(s)
- M R Raspollini
- Department of Human Pathology and Oncology, University of Florence, School of Medicine, Florence, Italy.
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