1
|
Wilson BE, Sengar M, Tregear M, van der Graaf WTA, Luca Battisti NM, Csaba DL, Soto-Perez-de-Celis E, Gyawali B, Booth CM. Common Sense Oncology: Equity, Value, and Outcomes That Matter. Am Soc Clin Oncol Educ Book 2024; 44:e100039. [PMID: 38788178 DOI: 10.1200/edbk_100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
While some recent drug treatments have been transformative for patients with cancer, many treatments offer small benefits despite high clinical toxicity, time toxicity and financial toxicity. Moreover, treatments that do provide substantial clinical benefits are not available to many patients globally due to issues with availability and affordability. The Common Sense Oncology's vision is that patients will have access to treatments that provide meaningful improvements in outcomes that matter, regardless of where they live. In recognition of the growing challenges in the field of oncology, Common Sense Oncology seeks to achieve this vision by improving evidence generation, evidence interpretation and evidence communication.
Collapse
Affiliation(s)
- Brooke E Wilson
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
- School of Population Health, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Manju Sengar
- Tata Memorial Hospital, Affiliated to Homi Bhabha National Institute, Mumbai, India
| | | | - Winette T A van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Nicolò Matteo Luca Battisti
- Department of Medicine, Breast Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Inequalities Focused Topic Network, European Cancer Organisation, Brussels, Belgium
- International Society of Geriatric Oncology, Geneva, Switzerland
| | - Degi Laszlo Csaba
- Faculty of Sociology and Social Work, Babeş-Bolyai University, Cluj Napoca, Romania
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
| |
Collapse
|
2
|
Briercheck E, Pyle D, Adams C, Atun R, Booth C, Dent J, Garcia-Gonzalez P, Ilbawi A, Jazieh AR, Kerr D, Knaul F, Kobayashi E, Lim C, Maza M, Milner D, Navarro MF, O'Brien M, Rodriguez-Galindo C, Sullivan R, Torode J, Vokes E, Gralow J. Unification of Efforts to Improve Global Access to Cancer Therapeutics: Report From the 2022/2023 Access to Essential Cancer Medicines Stakeholder Summit. JCO Glob Oncol 2024; 10:e2300256. [PMID: 38781548 DOI: 10.1200/go.23.00256] [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: 07/25/2023] [Revised: 12/06/2023] [Accepted: 03/24/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE There is an urgent need to improve access to cancer therapy globally. Several independent initiatives have been undertaken to improve access to cancer medicines, and additional new initiatives are in development. Improved sharing of experiences and increased collaboration are needed to achieve substantial improvements in global access to essential oncology medicines. METHODS The inaugural Access to Essential Cancer Medicines Stakeholder Meeting was organized by ASCO and convened at the June 2022 ASCO Annual Meeting in Chicago, IL, with two subsequent meetings, Union for International Cancer Control World Cancer Congress held in Geneva, Switzerland, in October 2022 and at the ASCO Annual Meeting in June of 2023. Invited stakeholders included representatives from cancer institutes, physicians, researchers, professional societies, the pharmaceutical industry, patient advocacy organizations, funders, cancer organizations and foundations, policy makers, and regulatory bodies. The session was moderated by ASCO. Past efforts and current and upcoming initiatives were initially discussed (2022), updates on progress were provided (2023), and broad agreement on resulting action steps was achieved with participants. RESULTS Summit participants recognized that while much work was ongoing to enhance access to cancer therapeutics globally, communication and synergy across projects and organizations could be enhanced by providing a platform for collaboration and shared expertise. CONCLUSION The summit resulted in new cross-stakeholder insights and planned collaboration addressing barriers to accessing cancer medications. Specific actions and timelines for implementation and reporting were established.
Collapse
Affiliation(s)
- Edward Briercheck
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Doug Pyle
- American Society of Clinical Oncology, Alexandria, VA
| | - Cary Adams
- Union for International Cancer Control, Geneva, Switzerland
| | - Rifat Atun
- Department of Global Health and Population, Harvard University, Boston, MA
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
| | | | | | - Andre Ilbawi
- Cancer Programme, World Health Organization, Geneva, Switzerland
| | | | - David Kerr
- Nuffield Department of Clinical Laboratory Sciences, Oxford University, Oxford, United Kingdom
| | - Felicia Knaul
- Department of Public Health Sciences, University of Miami, Miami, FL
| | | | | | | | - Danny Milner
- Union for International Cancer Control, Geneva, Switzerland
| | | | | | | | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Julie Torode
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Everett Vokes
- Department of Medicine, University of Chicago, Chicago, IL
| | - Julie Gralow
- American Society of Clinical Oncology, Alexandria, VA
| |
Collapse
|
3
|
Lasala R, Romagnoli A, Santoleri F, Isgrò V, Confalonieri C, Costantini A, Enrico F, Russo G, Polidori P, Di Paolo A, Malorgio F, Beretta G, Musicco F. The lack of head-to-head randomised trials and the consequences for patients and national health service: The case of non-small cell lung cancer. Eur J Clin Pharmacol 2024; 80:519-527. [PMID: 38244052 DOI: 10.1007/s00228-024-03628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
INTRODUCTION To introduce a drug to the market, it's not mandatory for it to be more effective and safer than the current treatment for the same condition. Consequently, head-to-head studies between the two best treatments for the same condition are not required, and this could result in a lack of information for patients, clinicians, and decision-makers. This study aims to evaluate the presence of head-to-head studies among the drugs used for the treatment of non-small cell lung cancer (NSCLC). METHODS Taking into account the National Comprehensive Cancer Network (NCCN) guidelines updated to 2022, which list all available treatments for each NSCLC subtype, the search engine Pubmed and the platform clinicaltrials.gov were consulted to find all completed and ongoing head-to-head studies among various treatments for NSCLC. RESULTS Among the anti-EGFR (epidermal growth factor receptor) drugs, 7 studies were found, with 6 completed and 5 registrational for drug commercialisation. No completed study to date has compared osimertinib and afatinib. For anti-ALK (anaplastic lymphoma kinase) drugs, 7 studies were found, with 5 completed. Alectinib, brigatinib, and lorlatinib have no completed comparison studies, but all were compared with crizotinib. Among various immunotherapy-based regimens, 5 studies were found, with only 1 completed. Therapeutic regimens based on pembrolizumab, atezolizumab, or the combination of nivolumab/ipilimumab have not been compared in studies published to date. CONCLUSION There are few head-to-head studies comparing treatments for NSCLC; there are no such studies between the latest generation of drugs. Consequently, ambiguous areas exist due to the lack of comparative studies among the available evidence, preventing the clinician's choice of the most effective treatment and risking the patient receiving suboptimal therapy. Simultaneously, the price of the drug cannot be determined correctly, relying only on indirect evaluations from different trials. To dispel this uncertainty, it would be desirable to initiate a process that brings together the demands derived from clinical practice and clinical research to provide clinicians and patients with the best possible evidence.
Collapse
Affiliation(s)
- Ruggero Lasala
- Hospital Pharmacy of Corato, Local Health Unit of Bari, Corato, Italy.
| | - Alessia Romagnoli
- Territorial Pharmaceutical Service, Local Health Unit of Lanciano Vasto Chieti, Chieti, Italy
| | | | - Valentina Isgrò
- Hospital Pharmacy Complex Operational Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
| | - Corrado Confalonieri
- UOC Farmacia Ospedaliera, Direzione Tecnica Farmacia, AUSL Piacenza, Piacenza, Italy
| | | | - Fiorenza Enrico
- Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia - IRCCS, Candiolo, Italy
| | - Gianluca Russo
- Medical Oncology, Santo Spirito Hospital, Pescara, Italy
| | - Piera Polidori
- Hospital Pharmacy Complex Operational Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
| | | | | | | | - Felice Musicco
- Hospital Pharmacy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| |
Collapse
|
4
|
Yoon NR, Na YJ, Lee JH, Song I, Lee EK, Park MH. Evaluation of changes in the clinical benefits of oncology drugs over time following reimbursement using the ASCO-VF and the ESMO-MCBS. J Cancer Res Clin Oncol 2024; 150:113. [PMID: 38436796 PMCID: PMC10912263 DOI: 10.1007/s00432-023-05587-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 03/05/2024]
Abstract
PURPOSE This study aims to estimate changes in the value of oncology drugs over time from initial data of the reimbursement decisions to subsequent publications in Korea, using two value frameworks. METHODS We retrieved primary publications assessed for reimbursement between 2007 and July 2021 from the decision documents of Health Insurance Review and Assessment and subsequent publications made available following reimbursement decision from ClinicalTrials.Gov and PubMed databases. Changes in the clinical benefit scores were assessed using the American Society of Clinical Oncology Value Framework (ASCO-VF) and the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). A paired t test was performed to test whether there was a difference in the scores between primary and subsequent publications. RESULTS Of 73 anticancer product/indication pairs, 45 (61.6%) had subsequent publications, of which 62.5% were released within 1 year of reimbursement decision. The mean ESMO-MCBS and ASCO-VF Net Health Benefit scores increased from primary to subsequent publications, although the differences were not significant. The mean ASCO-VF bonus score significantly increased from 15.91 to 19.09 (p = 0.05). The ESMO-MCBS and bonus scores increased by 0.25 and 0.21, respectively, and the bonus score had a greater impact on the ESMO-MCBS score than the preliminary score did. CONCLUSION The value of drugs demonstrated in subsequent publications varies considerably among oncology drugs, depending on uncertainty associated with the initial evidence and the availability of updated evidence. As decision-making in the face of uncertainty becomes more prevalent, the value frameworks can serve as simple screening tools for re-evaluation in these cases.
Collapse
Affiliation(s)
- Na Ri Yoon
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeonggi-do, Republic of Korea
| | - Young Jin Na
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeonggi-do, Republic of Korea
| | - Jong Hwan Lee
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeonggi-do, Republic of Korea
| | - Inmyung Song
- College of Nursing and Health, Kongju National University, 56 Gongjudaehak-ro, Gongju, Republic of Korea
| | - Eui-Kyung Lee
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeonggi-do, Republic of Korea.
| | - Mi-Hai Park
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon-si, Gyeonggi-do, Republic of Korea.
| |
Collapse
|
5
|
Koole SN, Huisman AH, Timmers L, Westgeest HM, van Breugel E, Sonke GS, van Waalwijk van Doorn-Khosrovani SB. Lessons learned from postmarketing withdrawals of expedited approvals for oncology drug indications. Lancet Oncol 2024; 25:e126-e135. [PMID: 38423058 DOI: 10.1016/s1470-2045(23)00592-2] [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: 09/18/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 03/02/2024]
Abstract
In the past decade, there have been a record number of oncology therapy approvals by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Besides the EMA's conditional marketing authorisation programme and the FDA's Accelerated Approval Program, we observe a tendency towards fast approval for exploratory studies with non-randomised, uncontrolled designs and surrogate endpoints. This issue raises concerns about the robustness and effectiveness of accepted treatments, leaving patients and health-care professionals in a state of uncertainty. A substantial number of accelerated approvals have recently been withdrawn in the USA, with some still authorised in Europe, emphasising discrepancies in regulatory standards that affect both patients and society as a whole. We highlight examples of drugs, authorised on the basis of surrogate endpoints, that were later withdrawn due to an absence of overall survival benefit. Our findings address the challenges and consequences of accelerated approval pathways in oncology. In conclusion, this Policy Review calls for regulatory bodies to better align their procedures and insist on robust evidence, preferably through unbiased randomised controlled trials. Drug approval processes should prioritise patient benefit, overall survival, and quality of life to minimise risks and uncertainties for patients.
Collapse
Affiliation(s)
- Simone N Koole
- Medical Advisory Department, ONVZ Health Insurance, Houten, Netherlands.
| | | | - Lonneke Timmers
- Care Department, National Health Care Institute, Diemen, Netherlands
| | - Hans M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, Netherlands
| | - Edwin van Breugel
- Medical Advisory Department, VGZ Health Insurance, Arnhem, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | | |
Collapse
|
6
|
Brinkhuis F, Goettsch WG, Mantel-Teeuwisse AK, Bloem LT. Added benefit and revenues of oncology drugs approved by the European Medicines Agency between 1995 and 2020: retrospective cohort study. BMJ 2024; 384:e077391. [PMID: 38418086 PMCID: PMC10899806 DOI: 10.1136/bmj-2023-077391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVES To evaluate the added benefit and revenues of oncology drugs, explore their association, and investigate potential discrepancies between added benefit and revenues across different approval pathways of the European Medicines Agency (EMA). DESIGN Retrospective cohort study. SETTING Oncology drugs and their indications approved by the EMA between 1995 and 2020. MAIN OUTCOME MEASURES Added benefit was evaluated using ratings published by seven organisations: health technology assessment agencies from the United States, France, Germany, and Italy, two medical oncology societies, and a drug bulletin. All retrieved ratings were recategorised using a four point ranking scale to indicate negative or non-quantifiable, minor, substantial, or major added benefit. Revenue data were extracted from publicly available financial reports and compared with published estimates of research and development (R&D) costs. Finally, the association between added benefit and revenue was evaluated. All analyses were performed within the overall study cohort, and within subgroups based on the EMA approval pathway: standard marketing authorisation, conditional marketing authorisation, and authorisation under exceptional circumstances. RESULTS 131 oncology drugs with 166 indications were evaluated for their added benefit by at least one organisation within the required timeframe, yielding a total of 458 added benefit ratings; 189 (41%) were negative or non-quantifiable. The median time to offset the median R&D costs ($684m, £535m, €602m, adjusted to 2020 values) was three years; 50 of 55 (91%) drugs recovered these costs within eight years. Drugs with higher added benefit ratings generally had greater revenues. Negative or non-quantifiable added benefit ratings were more frequent for conditional marketing authorisations and authorisations under exceptional circumstances than for standard marketing authorisations (relative risk 1.53, 95% confidence interval 1.23 to 1.89). Conditional marketing authorisations generated lower revenues and took longer to offset R&D costs than standard marketing authorisations (four years compared with three years). CONCLUSIONS While revenues seem to align with added benefit, most oncology drugs recover R&D costs within a few years despite providing little added benefit. This is particularly true for drugs approved through conditional marketing authorisations, which inherently appear to lack comprehensive evidence. Policy makers should evaluate whether current regulatory and reimbursement incentives effectively promote development of the most effective drugs for patients with the greatest needs.
Collapse
Affiliation(s)
- Francine Brinkhuis
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- National Health Care Institute, Diemen, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Lourens T Bloem
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
7
|
Michaeli DT, Michaeli T. Launch and Post-Launch Prices of Injectable Cancer Drugs in the US: Clinical Benefit, Innovation, Epidemiology, and Competition. PHARMACOECONOMICS 2024; 42:117-131. [PMID: 37855850 DOI: 10.1007/s40273-023-01320-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Rising cancer drug prices adversely affect patients' adherence and survival. OBJECTIVE We aimed to identify and quantify factors associated with launch prices and post-launch price changes of injectable cancer drugs in the US from 2005 to 2023. DATA AND METHODS All anticancer drugs with US FDA approval between 2000 and 2022 were identified in the Drugs@FDA database. The sample was then restricted to cancer drugs covered under Medicare Part B (injectable drugs). Data characterizing each drug's clinical benefits, disease epidemiology, approved indications, competition, and price were obtained from FDA labels, the Global Burden of Disease study, and the Centers for Medicare and Medicaid Services. The association between launch/post-launch prices and collected variables was assessed in random-effects regressions. RESULTS Of 170 cancer drugs with FDA approval between 2000 and 2022, we identified 66 (39%) injectable cancer drugs with quarterly price data from 2005 to 2023. In 2023, mean prices amounted to $27,688 per month, with an average price increase of 94% from 2005 to 2023. Launch and post-launch price changes were significantly associated with the treated disease epidemiology. A 1% decline in disease incidence was associated with a 0.2511% (p = 0.008) increase in launch prices and a 0.0086% (p = 0.032) annual increase in post-launch prices. Accordingly, launch prices were 120% (p = 0.051) higher for orphan than non-orphan drugs, with 3% (p = 0.008) greater annual post-launch price increases. Post-launch prices declined by up to -2% annually as new supplemental indications were approved for the same drug. We found no consistent association between launch/post-launch prices and the drugs' clinical benefit in terms of overall survival, progression-free survival, and tumor response. The market entry of new competitors was not associated with price reductions. 28 of 33 drug pairs within the same class had positive correlation coefficients. Pearson correlation coefficients were high (>0.80) for PD-1/PD-L1 inhibitors, CD38 antibodies, CD20 antibodies, HER2 antibodies, and mTOR inhibitors. CONCLUSIONS Cancer drug prices regularly increase faster than inflation; however, there is no evidence that launch prices and post-launch price changes are aligned with the clinical benefit a drug offers to patients. In particular, patients with rare diseases experience greater price increases for their orphan drugs. There is no evidence that brand-brand competition results in drug price reductions.
Collapse
Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany.
| | - Thomas Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
8
|
Zhou J, Lan T, Lu H, Pan J. Price negotiation and pricing of anticancer drugs in China: An observational study. PLoS Med 2024; 21:e1004332. [PMID: 38166148 DOI: 10.1371/journal.pmed.1004332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/17/2024] [Accepted: 12/13/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND While China has implemented reimbursement-linked drug price negotiation annually since 2017, emphasizing value-based pricing to achieve a value-based strategic purchase of medical insurance, whether drug prices became better aligned with clinical value after price negotiation has not been sufficiently established. This study aimed to assess the changes in prices and their relationship with the clinical value of anticancer drugs after the implementation of price negotiations in China. METHODS AND FINDINGS In this observational study, anticancer drug indications that were negotiated successfully between 2017 and 2022 were identified through National Reimbursement Drug Lists (NRDL) of China. We excluded extensions of indications for drugs already listed in the NRDL, indications for pediatric use, and indications lacking corresponding clinical trials. We identified pivotal clinical trials for included indications by consulting review reports or drug labels issued by the Center for Drug Evaluation, National Medical Products Administration. We calculated treatment costs as outcome measures based on publicly available prices and collected data on clinical value including safety, survival, quality of life, and overall response rate (ORR) from publications of pivotal clinical trials. The associations between drug costs and clinical value, both before and after negotiation, were analyzed using regression analyses. We also examined whether price negotiation has led to a reduction in the variation of treatment costs for a given value. We included 103 anticancer drug indications, primarily for the treatment of blood cancer, lung cancer, and breast cancer, with 76 supported by randomized controlled trials and 27 supported by single-arm clinical trials. The median treatment costs over the entire sample have been reduced from US$34,460.72 (interquartile range (IQR): 19,990.49 to 55,441.66) to US$13,688.79 (IQR: 7,746.97 to 21,750.97) after price negotiation (P < 0.001). Before price negotiation, each additional month of survival gained was associated with an increase in treatment costs of 3.4% (95% confidence interval (CI) [2.1, 4.8], P < 0.001) for indications supported by randomized controlled trials, and a 10% increase in ORR was associated with a 6.0% (95% CI [1.6, 10.3], P = 0.009) increase in treatment costs for indications supported by single-arm clinical trials. After price negotiation, the associations between costs and clinical value may not have changed significantly, but the variation of drug costs for a given value was reduced. Study limitations include the lack of transparency in official data, missing data on clinical value, and a limited sample size. CONCLUSIONS In this study, we found that the implementation of price negotiation in China has led to drug pricing better aligned with clinical value for anticancer drugs even after substantial price reductions. The achievements made in China could shed light on the price regulation in other countries, particularly those with limited resources and increasing drug expenditures.
Collapse
Affiliation(s)
- Jing Zhou
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Tianjiao Lan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Hao Lu
- School of Public Health, Imperial College London, London, United Kingdom
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- School of Public Administration, Sichuan University, Chengdu, China
| |
Collapse
|
9
|
Gillett P, Mahar RK, Tran NR, Rosenthal M, IJzerman M. Developing and validating a multi-criteria decision analytic tool to assess the value of cancer clinical trials: evaluating cancer clinical trial value. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:87. [PMID: 37964269 PMCID: PMC10647033 DOI: 10.1186/s12962-023-00496-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/02/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Demonstrating safety and efficacy of new medical treatments requires clinical trials but clinical trials are costly and may not provide value proportionate to their costs. As most health systems have limited resources, it is therefore important to identify the trials with the highest value. Tools exist to assess elements of a clinical trial such as statistical validity but are not wholistic in their valuation of a clinical trial. This study aims to develop a measure of clinical trials value and provide an online tool for clinical trial prioritisation. METHODS A search of the academic and grey literature and stakeholder consultation was undertaken to identify a set of criteria to aid clinical trial valuation using multi-criteria decision analysis. Swing weighting and ranking exercises were used to calculate appropriate weights of each of the included criteria and to estimate the partial-value function for each underlying metric. The set of criteria and their respective weights were applied to the results of six different clinical trials to calculate their value. RESULTS Seven criteria were identified: 'unmet need', 'size of target population', 'eligible participants can access the trial', 'patient outcomes', 'total trial cost', 'academic impact' and 'use of trial results'. The survey had 80 complete sets of responses (51% response rate). A trial designed to address an 'Unmet Need' was most commonly ranked as the most important with a weight of 24.4%, followed by trials demonstrating improved 'Patient Outcomes' with a weight of 21.2%. The value calculated for each trial allowed for their clear delineation and thus a final value ranking for each of the six trials. CONCLUSION We confirmed that the use of the decision tool for valuing clinical trials is feasible and that the results are face valid based on the evaluation of six trials. A proof-of-concept applying this tool to a larger set of trials with an external validation is currently underway.
Collapse
Affiliation(s)
- Piers Gillett
- Cancer Health Services Research Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Robert K Mahar
- Cancer Health Services Research Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Biostatistics Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Nancy R Tran
- Cancer Health Services Research Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Mark Rosenthal
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Maarten IJzerman
- Cancer Health Services Research Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Melbourne, Australia.
| |
Collapse
|
10
|
Michaeli DT, Michaeli T. Cancer Drug Prices in the United States: Efficacy, Innovation, Clinical Trial Evidence, and Epidemiology. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1590-1600. [PMID: 37516196 DOI: 10.1016/j.jval.2023.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/24/2023] [Accepted: 06/29/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVES Rising cancer drug prices challenge patients and healthcare systems. Although prices are routinely assigned to original drug indications receiving US Food and Drug Administration (FDA) approval, the pricing of supplemental indication approvals remains uncertain. This study identifies and quantifies factors associated with cancer drug prices, distinctly analyzing original and supplemental indications. METHODS Clinical trial evidence and epidemiologic data supporting new indications' FDA approval (2003-2022) were collected from the Drugs@FDA database, ClinicalTrials.gov, and Global Burden of Disease study. Indication-specific monthly treatment costs were calculated for Medicare patients. The association between log-prices and collected variables were assessed in regression analyses. RESULTS We identified 145 drugs approved across 373 cancer indications. Drugs were priced at $24 444 per month on average (median = $16 013). For original indications, prices weakly correlated to improvements in overall survival (β = 0.28, P = .037) and progression-free survival (β = 0.16, P = .001). Original indications' prices were as follows: (1) negatively associated with disease incidence (β = -0.21, P < .001) and prevalence; (2) positively correlated with first-in-class drugs (26%, P = .057), gene and cell therapies (176%, P < .001), hematologic cancers (62%, P < .001), and severe diseases with substantial unmet needs (6% per disability-adjusted life-year, P < .001); and (3) negatively correlated to indications with randomized-controlled phase 3 trials. Prices were poorly associated with supplemental indications' efficacy, clinical evidence, and epidemiology. CONCLUSIONS Cancer drug prices are set based on the original indication's characteristics, thereby omitting the value of supplemental indications. Indication-specific pricing, coverage, and reimbursement policies considering each indication's safety, efficacy, innovativeness, and unmet needs are necessary to align a drug's value and price.
Collapse
Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Baden-Wuerttemberg, Germany; Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, North Rhine-Westphalia, Germany.
| | - Thomas Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, North Rhine-Westphalia, Germany; Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Baden-Wuerttemberg, Germany; Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg University, Heidelberg, Baden-Wuerttemberg, Germany; DKFZ-Hector Cancer Institute, University Medical Center Mannheim, Mannheim, Baden-Wuerttemberg, Germany
| |
Collapse
|
11
|
Booth CM, Sengar M, Goodman A, Wilson B, Aggarwal A, Berry S, Collingridge D, Denburg A, Eisenhauer EA, Ginsburg O, Goldstein D, Gunasekera S, Hammad N, Honda K, Jackson C, Karikios D, Knopf K, Koven R, Marini BL, Maskens D, Moraes FY, Mohyuddin GR, Poudyal BS, Pramesh CS, Roitberg F, Rubagumya F, Schott S, Sirohi B, Soto-Perez-de-Celis E, Sullivan R, Tannock IF, Trapani D, Tregear M, van der Graaf W, Vanderpuye V, Gyawali B. Common Sense Oncology: outcomes that matter. Lancet Oncol 2023; 24:833-835. [PMID: 37467768 DOI: 10.1016/s1470-2045(23)00319-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/21/2023]
Affiliation(s)
| | | | - Aaron Goodman
- University of California San Diego, San Diego, CA, USA
| | | | | | - Scott Berry
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | | | | | | | - Nazik Hammad
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | - Kevin Knopf
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian F Tannock
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | | | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology, and Nuclear Medicine, Accra, Ghana
| | | |
Collapse
|
12
|
Chauca Strand G, Johansson N, Jakobsson N, Bonander C, Svensson M. Cancer Drugs Reimbursed with Limited Evidence on Overall Survival and Quality of Life: Do Follow-Up Studies Confirm Patient Benefits? Clin Drug Investig 2023; 43:621-633. [PMID: 37505421 PMCID: PMC10480259 DOI: 10.1007/s40261-023-01285-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND OBJECTIVE Cancer drug costs have increased considerably within healthcare systems, but many drugs lack quality-of-life (QoL) and overall survival (OS) data at the time of reimbursement approval. This study aimed to review the extent of subsequent literature documenting improvements in OS and QoL for cancer drug indications where no such evidence existed at the time of reimbursement approval. METHODS Drug indications with claims of added therapeutical value but a lack of evidence on OS and QoL that were reimbursed between 2010 and 2020 in Sweden were included for review. Searches were conducted in PubMed and ClinicalTrial.gov for randomized controlled trials examining OS and QoL. RESULTS Of the 22 included drug indications, seven were found to have at least one trial with conclusive evidence of improvements in OS or QoL after a mean follow-up of 6.6 years. The remaining 15 drug indications either lacked subsequent randomized controlled trial data on OS or QoL (n = 6) or showed no statistically significant improvements (n = 9). Only one drug demonstrated evidence of improvement in both OS and QoL for its indication. CONCLUSIONS A considerable share of reimbursed cancer drug indications continue to lack evidence of improvement in both OS and QoL. With limited healthcare resources and an increasing cancer burden, third-party payers have strong incentives to require additional post-reimbursement data to confirm any improvements in OS and QoL.
Collapse
Affiliation(s)
- Gabriella Chauca Strand
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden.
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Medicinaregatan 18 A, PO Box 463, 405 30, Gothenburg, Västra Götalands Län, Sweden.
| | - Naimi Johansson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Örebro Län, Sweden
| | - Niklas Jakobsson
- Karlstad Business School, Faculty of Arts and Social Sciences, Karlstads Business School, Karlstad University, Karlstad, Värmlands Län, Sweden
| | - Carl Bonander
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden
- Centre for Societal Risk Management, Faculty of Arts and Social Sciences, Karlstad University, Karlstad, Värmlands Län, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Västra Götalands Län, Sweden
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
| |
Collapse
|
13
|
Sengar M, Hopman WM, Mohyuddin GR, Goodman AM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Sullivan R, Booth CM. Randomised controlled trials evaluating anticancer therapies in haematological cancers: an overview of global research activity. Ecancermedicalscience 2023; 17:1558. [PMID: 37396096 PMCID: PMC10310333 DOI: 10.3332/ecancer.2023.1558] [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: 12/18/2022] [Indexed: 07/04/2023] Open
Abstract
Background Design, results, and interpretation of oncology randomised controlled trials (RCTs) have changed substantially over the past decade. In this study, we describe all RCTs evaluating anticancer therapies in haematological cancers published globally during 2014-2017 with comparisons with solid tumours RCTs. Methods A PubMed literature search identified all phase 3 RCTs of anticancer therapy for haematological cancers and solid tumours published globally during 2014-2017. Descriptive statistics, chi-square tests and the Kruskal-Wallis test were used to compare RCT design results, and output between haematological cancers and solid tumours as well as for different haematological cancer subtypes. Results 694 RCTs were identified; 124 in haematological cancers and 570 in solid tumours. Overall survival (OS) was the primary endpoint in only 12% (15/124) of haematological cancer trials compared to 35% (200/570) in solid tumours (p < 0.001). Haematological cancer RCTs evaluated the systemic novel therapy more often than the solid tumour RCT (98% versus 84%, p = 0.002). Use of surrogate endpoints like progression-free survival (PFS) and time to treatment failure (TTF) were more common in haematological cancers than solid tumours (47% versus 31%, p < 0.001). Within haematological cancers, the use of PFS and TTF was more prevalent in chronic lymphocytic leukaemia and multiple myeloma as compared to others (80%-81% versus 0%-41%, p < 0.001). Seventy-eight percent of haematologic trials were funded by industry as compared to 70% of solid tumour trials. Only 4% (5/124) of haematologicalcancer trials were led by investigators in upper-middle and lower-middle-income countries as compared to the 9% of solid tumour trials. Conclusion The fact that only 12% of haematological cancer RCTs are designed to show improvements in OS is of grave concern for the field and the care of future patients. This is further compounded by the highly prevalent use of alternative primary endpoints that are rarely valid surrogates for OS in haematological cancers.
Collapse
Affiliation(s)
- Manju Sengar
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 400012, India
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Haematological Malignancies, University of Utah, Salt Lake City, UT 84112, USA
| | - Aaron M Goodman
- Division of Blood and Marrow Transplantation, University of California, San Diego, CA 92093, USA
| | - Bishal Gyawali
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
| | - Deborah Mukherji
- American University of Beirut Medical Center, Beirut 11-0236, Lebanon
| | - Nazik Hammad
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada
| | - CS Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 400012, India
| | - Ajay Aggarwal
- Institute of Cancer Policy, King’s College London, WC2R 2LS London, UK
- London School of Hygiene and Tropical Medicine, WC1E 7HT London, UK
| | - Richard Sullivan
- Institute of Cancer Policy, King’s College London, WC2R 2LS London, UK
| | - Christopher M Booth
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
| |
Collapse
|
14
|
Jenei K, Raymakers AJN, Bayle A, Berger-Thürmel K, Cherla A, Honda K, Jackson CCGA, Karikios D, Trapani D, Berry S, Gyawali B. Health technology assessment for cancer medicines across the G7 countries and Oceania: an international, cross-sectional study. Lancet Oncol 2023; 24:624-635. [PMID: 37269843 DOI: 10.1016/s1470-2045(23)00175-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/07/2023] [Accepted: 04/17/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Criticisms have emerged that cancer medicines offer modest benefits at increasingly high prices. Reimbursement decisions made by health technology assessment (HTA) agencies have become a complex endeavour for cancer medicines. Most high-income countries (HICs) use HTA criteria to identify high-value medicines for reimbursement under public drug coverage plans. We compared HTA criteria specific for cancer medicines in economically similar HICs, to understand how these criteria contribute to reimbursement decisions. METHODS We did an international, cross-sectional analysis in collaboration with author investigators across eight HICs, from the Group of Seven (known as G7; Canada, England, France, Germany, Italy, and Japan) and Oceania (Australia and New Zealand). Publicly available data from HTA agency reports and official documentation were extracted and analysed between Aug 15, 2021, and July 31, 2022. We collected data pertaining to the decision-making criteria used by the national HTA agency; HTA reimbursement status for 34 medicine-indication pairs corresponding to 15 unique US top-selling cancer medicines; and HTA reimbursement status for 18 cancer medicine-indication pairs (13 unique medicines) with minimal clinical benefit (score of 1 on the European Society of Medical Oncology Magnitude of Clinical Benefit Scale). Descriptive statistics were used to compare HTA decision criteria and drug reimbursement recommendations (or for Germany and Japan, final reimbursement status) across the eight countries. FINDINGS Therapeutic impact related to clinical outcomes of the new medicine was a uniform criterion across the eight countries, whereas quality of evidence (under the remit of therapeutic impact assessment) and equity were infrequently cited criteria. Only the German HTA agency mandated that surrogate endpoints be validated in therapeutic impact assessment. All countries except Germany included formal cost-effectiveness analyses within HTA reports. England and Japan were the only countries that specified a cost-effectiveness threshold. Of the 34 medicine-indication pairs corresponding to US top-selling cancer medicines, Germany reimbursed the maximum (34 [100%]), followed by Italy (32 [94%] recommended for reimbursement), Japan (28 [82%] reimbursed), Australia, Canada, England, and France (27 [79%] recommended for reimbursement), and New Zealand (12 [35%] recommended for reimbursement). Of the 18 cancer medicine-indication pairs with marginal clinical benefit, Germany reimbursed 15 (83%) and Japan reimbursed 12 (67%). France recommended nine (50%) for reimbursement, followed by Italy (seven [39%]), Canada (five [28%]), and Australia and England (three [17%] each). New Zealand did not recommend any medicine-indications with marginal clinical benefit for reimbursement. Considering the overall cumulative proportion across the eight countries, 58 (21%) of 272 indications for the US top-selling medicines and 90 (63%) of 144 marginally beneficial medicine-indications were not recommended for reimbursement or reimbursed. INTERPRETATION Our findings indicate discordance in public reimbursement decisions across economically similar countries, despite overlapping HTA decision criteria. This suggests a need for improved transparency around the nuances of the criteria to ensure improved access to high-value cancer medicines, and deprioritisation of low-value cancer medicines. Health systems have opportunities to improve their HTA decision-making processes by learning from the systems in other countries. FUNDING None.
Collapse
Affiliation(s)
- Kristina Jenei
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Adam J N Raymakers
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Arnaud Bayle
- Oncostat U1018, Inserm, Paris-Saclay University, Gustave Roussy, Villejuif, France
| | - Karin Berger-Thürmel
- Department of Hematology/Oncology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Avi Cherla
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Kazunori Honda
- Department of Clinical Oncology, Aichi Cancer Center, Nagoya, Japan
| | | | - Deme Karikios
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Dario Trapani
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Haematology, University of Milan, Milan, Italy
| | - Scott Berry
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, ON, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| |
Collapse
|
15
|
Michaeli T, Jürges H, Michaeli DT. FDA approval, clinical trial evidence, efficacy, epidemiology, and price for non-orphan and ultra-rare, rare, and common orphan cancer drug indications: cross sectional analysis. BMJ 2023; 381:e073242. [PMID: 37160306 PMCID: PMC10167557 DOI: 10.1136/bmj-2022-073242] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To analyze the US Food and Drug Administration (FDA) approval, trials, unmet needs, benefit, and pricing of ultra-rare (<6600 affected US citizens), rare (6600-200 000 citizens), and common (>200 000 citizens) orphan cancer drug indications and non-orphan cancer drug indications. DESIGN Cross sectional analysis. SETTING Data from Drugs@FDA, FDA labels, Global Burden of Disease study, and Medicare and Medicaid. POPULATION 170 FDA approved drugs across 455 cancer indications between 2000 and 2022. MAIN OUTCOME MEASURES Comparison of non-orphan and ultra-rare, rare, and common orphan indications regarding regulatory approval, trials, epidemiology, and price. Hazard ratios for overall survival and progression-free survival were meta-analyzed. RESULTS 161 non-orphan and 294 orphan cancer drug indications were identified, of which 25 were approved for ultra-rare diseases, 205 for rare diseases, and 64 for common diseases. Drugs for ultra-rare orphan indications were more frequently first in class (76% v 48% v 38% v 42%; P<0.001), monotherapies (88% v 69% v 72% v 55%; P=0.001), for hematologic cancers (76% v 66% v 0% v 0%; P<0.001), and supported by smaller trials (median 85 v 199 v 286 v 521 patients; P<0.001), of single arm (84% v 44% v 28% v 21%; P<0.001) phase 1/2 design (88% v 45% v 45% v 27%; P<0.001) compared with rare and common orphan indications and non-orphan indications. Drugs for common orphan indications were more often biomarker directed (69% v 26% v 12%; P<0.001), first line (77% v 39% v 20%; P<0.001), small molecules (80% v 62% v 48%; P<0.001) benefiting from quicker time to first FDA approval (median 5.7 v 7.1 v 8.9 years; P=0.02) than those for rare and ultra-rare orphan indications. Drugs for ultra-rare, rare, and common orphan indications offered a significantly greater progression-free survival benefit (hazard ratio 0.53 v 0.51 v 0.49 v 0.64; P<0.001), but not overall survival benefit (0.50 v 0.73 v 0.71 v 0.74; P=0.06), than non-orphans. In single arm trials, tumor response rates were greater for drugs for ultra-rare orphan indications than for rare or common orphan indications and non-orphan indications (objective response rate 57% v 48% v 55% v 33%; P<0.001). Disease incidence/prevalence, five year survival, and the number of available treatments were lower, whereas disability adjusted life years per patient were higher, for ultra-rare orphan indications compared with rare or common indications and non-orphan indications. For 147 on-patent drugs with available data in 2023, monthly prices were higher for ultra-rare orphan indications than for rare or common orphan indications and non-orphan indications ($70 128 (£55 971; €63 370) v $33 313 v $16 484 v $14 508; P<0.001). For 48 on-patent drugs with available longitudinal data from 2005 to 2023, prices increased by 94% for drugs for orphan indications and 50% for drugs for non-orphan indications on average. CONCLUSIONS The Orphan Drug Act of 1983 incentivizes development of drugs not only for rare diseases but also for ultra-rare diseases and subsets of common diseases. These orphan indications fill significant unmet needs, yet their approval is based on small, non-robust trials that could overestimate efficacy outcomes. A distinct ultra-orphan designation with greater financial incentives could encourage and expedite drug development for ultra-rare diseases.
Collapse
Affiliation(s)
- Thomas Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hendrik Jürges
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Daniel Tobias Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| |
Collapse
|
16
|
Dare AJ, Bayle A, Hatoqai A, Mungo C, Velilla DG, Soto-Perez-de-Celis E, Gnangnon FHR, Lim MSH, Ralefala T, Mushininga VD. Ensuring Global Access to Cancer Medicines: A Generational Call to Action. Cancer Discov 2023; 13:269-274. [PMID: 36734325 DOI: 10.1158/2159-8290.cd-22-1372] [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: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 02/04/2023]
Abstract
SUMMARY Essential cancer treatments are not accessible, affordable, or available to patients who need them in many parts of the world. A new Access to Oncology Medicines (ATOM) Coalition, using public-private partnerships, aims to bring essential cancer medicines and diagnostics to patients in low- and lower middle-income countries.
Collapse
Affiliation(s)
- Anna J Dare
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Arnauld Bayle
- Oncostat U1018, Inserm, Paris-Saclay University, Gustave Roussy, Villejuif, France
| | - Asma Hatoqai
- Cancer Control Office, King Hussein Cancer Center, Amman, Jordan
| | - Chemtai Mungo
- Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Diego Gimenez Velilla
- Departamento de Oncología Radiante, Instituto Nacional del Cáncer (INCAN), Capiatá, Paraguay
| | | | | | - Melissa Siaw Han Lim
- Department of Paraclinical Sciences, Faculty of Medicine and Health Sciences, University Malaysia Sarawak (UNIMAS), Sarawak, Malaysia
| | - Tlotlo Ralefala
- Princess Marina Hospital, Ministry of Health and Wellness, Gaborone, Botswana
| | | |
Collapse
|
17
|
Thawani R, Agrawal N, Taflin NF, Kardosh A, Chen EY. Application of Value Framework to Phase III Trials of Immune Checkpoint Inhibitors in Esophageal and Gastric Cancer. Oncologist 2023; 28:40-47. [PMID: 36130326 PMCID: PMC9847562 DOI: 10.1093/oncolo/oyac187] [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: 05/25/2022] [Accepted: 08/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent trials testing immune-checkpoint inhibitors in esophago-gastric malignancies have shown mixed results. We aim to assess key subgroups using the ASCO Net Health Benefit Score (NHBS) and ESMO Magnitude of Clinical Benefit Scale (MCBS). MATERIALS AND METHODS A search for phase III trials of FDA-approved anti-PD-1 or anti-PD-L1 drugs in esophago-gastric cancer trials was identified using www.clinicaltrials.gov. These published studies were scored using the ASCO NHBS and ESMO MCBS. The ASCO NHBS scores were compared by primary site of cancer (esophageal vs gastric) and PD-L1 expression using the Mann-Whitney test and the ESMO-MCBS grading, by Fisher's Exact test. RESULTS Fifteen of 45 clinical trials were included. Of them, 6 were primarily esophageal cancer trials, and 9 were primarily gastric cancer trials. Ten stratified their analysis based on PD-L1 expression. The ASCO NHBS score was higher (mean 40, range 20 to 56.6 vs. mean 12, range -1.1 to 18.4, P < .01) for esophageal cancer than gastric cancer. No difference was observed in survival and response endpoints between the 2 groups. Similarly, the ESMO MCBS scored higher for esophageal cancer group than gastric cancer (P < .05). Additionally, the scores were higher in those with high PD-L1 expression vs. low PD-L1 (mean 36, range 11.2-66.6 vs. mean 14, range -19.5 to 43.6, P < .05). CONCLUSION The ASCO NHB and ESMO scores were consistently higher among esophageal cancer trials than gastric cancer trials and in those with high PD-L1 expression than low expression. Histology and PD-L1 expression should be considered when discussing value of immunotherapy to patients.
Collapse
Affiliation(s)
- Rajat Thawani
- Knight Cancer Institute, Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Neha Agrawal
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Nicholas F Taflin
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Adel Kardosh
- Knight Cancer Institute, Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Emerson Y Chen
- Corresponding author: Emerson Y. Chen, MD, MCR, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR 97239, USA. Tel: +1 503 418 1297;
| |
Collapse
|
18
|
Luo J, Ou S, Wei H, Qin X, Peng R, Wang S, Jiang Q. Value assessment of NMPA-approved new cancer drugs for solid cancer in China, 2016-2020. Front Public Health 2023; 11:1109668. [PMID: 36908440 PMCID: PMC9998930 DOI: 10.3389/fpubh.2023.1109668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/09/2023] [Indexed: 02/26/2023] Open
Abstract
Background Whether the high cost of cancer drugs is commensurate with their value to patients, which has become the focus of public concern. We aimed to assess the value of new cancer drugs approved for solid cancer in China and to explore the association between price and value of drugs. Methods We identified all new drugs for solid tumor that approved by the China's National Medical Products Administration (NMPA) between 2016 and 2020. The value of these drugs was assessed according to the American Society of Clinical Oncology Value Framework (ASCO-VF) and the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). We calculated Cohen's κ statistic to describe agreement between the two frameworks. Spearman's correlation coefficient was used to evaluate the correlation between price and value of drugs. Results Between 2016 and 2020, 37 new drugs were approved by the NMPA for solid tumor and we could evaluate the value of 28 drugs (76%). Eight (29%) of drugs were approved for non-small-cell lung cancer and 6 (21%) for breast cancer. ASCO-VF scores had a range of -20 to 110.1, and the median score was 43.3 (inter-quartile range 27.1-58.35). Only seven drugs (25%) met the ASCO-VF cutoff score. By the ESMO-MCBS, 13 drugs showed a meaningful value. Agreement between these two frameworks thresholds was only fair (κ = 0.515, P < 0.05). We found no statistically significant correlation between launch price of drugs and clinical benefit according to both frameworks. Conclusions Not all NMPA-approved new cancer drugs had meaningful value as measured by ASCO-VF or ESMO-MCBS. There was no significant correlation between drug price and the level of clinical benefit.
Collapse
Affiliation(s)
- Jing Luo
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Shunlong Ou
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Hua Wei
- Department of Pharmacy, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Xiaoli Qin
- Department of Pharmacy, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Rui Peng
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Song Wang
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Qian Jiang
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| |
Collapse
|
19
|
Lin S, Huang Y, Dong L, Li M, Wang Y, Gu D, Wu W, Nian D, Luo S, Huang X, Xu X, Weng X. The correlation between the costs and clinical benefits of PD-1/PD-L1 inhibitors in malignant tumors: An evaluation based on ASCO and ESMO frameworks. Front Pharmacol 2023; 14:1114304. [PMID: 36909180 PMCID: PMC9995671 DOI: 10.3389/fphar.2023.1114304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
Background: Life expectancy for patients with malignant tumors has been significantly improved since the presence of the programmed cell death protein-1/programmed cell death protein ligand-1 (PD-1/PD-L1) inhibitors in 2014, but they impose heavy financial burdens for patients, the healthcare system and the nations. The objective of this study was to determine the survival benefits, toxicities, and monetary of programmed cell death protein-1/programmed cell death protein ligand-1 inhibitors and quantify their values. Methods: Randomized controlled trials (RCTs) of PD-1/PD-L1 inhibitors for malignant tumors were identified and clinical benefits were quantified by American Society of Clinical Oncology Value Framework (ASCO-VF) and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). The drug price in Micromedex REDBOOK was used to estimate monthly incremental drug costs (IDCs) and the correlation between clinical benefits and incremental drug costs of experimental and control groups in each randomized controlled trial, and the agreement between two frameworks were calculated. Results: Up to December 2022, 52 randomized controlled trials were included in the quantitative synthesis. All the randomized controlled trials were evaluated by American society of clinical oncology value framework, and 26 (50%) met the American society of clinical oncology value framework "clinical meaningful value." 49 of 52 randomized controlled trials were graded by European society for medical oncology magnitude of clinical benefit scale, and 30 (61.2%) randomized controlled trials achieved European Society for Medical Oncology criteria of meaningful value. p-values of Spearman correlation analyses between monthly incremental drug costs and American society of clinical oncology value framework/European society for medical oncology magnitude of clinical benefit scale scores were 0.9695 and 0.3013, respectively. In addition, agreement between two framework thresholds was fair (κ = 0.417, p = 0.00354). Conclusion: This study suggests that there might be no correlation between the cost and clinical benefit of programmed cell death protein-1/programmed cell death protein ligand-1 inhibitors in malignancy, and the same results were observed in subgroups stratified by drug or indication. The results should be a wake-up call for oncologists, pharmaceutical enterprises and policymakers, and meanwhile advocate the refining of American Society of Clinical Oncology and European Society for Medical Oncology frameworks.
Collapse
Affiliation(s)
- Shen Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yaping Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liangliang Dong
- Institute for Health and Aging, University of California, San Francisco, San Francisco, CA, United States
| | - Meiyue Li
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yahong Wang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Dian Gu
- Institute for Health and Aging, University of California, San Francisco, San Francisco, CA, United States
| | - Wei Wu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dongni Nian
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shaohong Luo
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoting Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiongwei Xu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiuhua Weng
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,National Regional Medical Center, Department of Pharmacy, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| |
Collapse
|
20
|
Jenei K, Aziz Z, Booth C, Cappello B, Ceppi F, de Vries EGE, Fojo A, Gyawali B, Ilbawi A, Lombe D, Sengar M, Sullivan R, Trapani D, Huttner BD, Moja L. Cancer medicines on the WHO Model List of Essential Medicines: processes, challenges, and a way forward. THE LANCET GLOBAL HEALTH 2022; 10:e1860-e1866. [PMID: 36183737 DOI: 10.1016/s2214-109x(22)00376-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
The selection of cancer medicines for national procurement requires deliberate evaluation of population benefit, budget impact, sustainability, and health system capacity. However, this process is complicated by numerous challenges, including the large volume and rapid pace of newly developed therapies offering marginal gains at prohibitively high prices. The WHO Model List of Essential Medicines (EML) and Model List of Essential Medicines for Children (EMLc) have undergone a series of evidence-based updates to ensure recommended cancer medicines offer meaningful clinical benefit. This Health Policy paper describes how cancer medicines are listed on the EML and EMLc, including two updated WHO processes: (1) the formation of the Cancer Medicines Working Group, and (2) additional selection principles for recommending cancer medicines, including a minimum overall survival benefit of 4-6 months with improvement to quality of life compared with standard treatment. These updates, along with proposals to include formal price considerations, additional selection criteria, and multisectoral collaboration (eg, voluntary licensing) promote procurement of high-value essential cancer medicines on national formularies in the context of supporting sustainable health systems to achieve universal health coverage.
Collapse
Affiliation(s)
- Kristina Jenei
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Zeba Aziz
- Department of Medical Oncology, Hameed Latif Hospital, Lahore, Pakistan
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Bernadette Cappello
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Francesco Ceppi
- Paediatric Haematology-Oncology Unit, Division of Paediatrics, Department Woman-Mother-Child, University Hospital of Lausanne, Lausanne, Switzerland
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Antonio Fojo
- Division of Hematology and Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Andre Ilbawi
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Dorothy Lombe
- Regional Cancer Treatment Services, MidCentral District Health Board, Palmerston North, New Zealand
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, Mumbai, India
| | - Richard Sullivan
- Kings Health Partners Comprehensive Cancer Centre, King's College London, Institute of Cancer Policy, London, UK
| | - Dario Trapani
- Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pharmaceutical Sciences, Università del Piemonte Orientale Amedeo Avogadro, Novara, Italy; European Institute of Oncology, IRCCS, Milan, Italy
| | - Benedikt D Huttner
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Lorenzo Moja
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| |
Collapse
|
21
|
Hwang TJ, Kesselheim AS, Tibau A, Lee CC, Vokinger KN. Clinical Benefit and Expedited Approval of Cancer Drugs in the United States, European Union, Switzerland, Japan, Canada, and Australia. JCO Oncol Pract 2022; 18:e1522-e1532. [PMID: 35731996 PMCID: PMC9509186 DOI: 10.1200/op.21.00909] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Regulatory agencies have sought to speed up the review of new cancer medicines and reduce delays in approval between countries. We examined trends in regulatory review times and association with clinical benefit for new cancer medicines in six jurisdictions: United States (Food and Drug Administration [FDA]), European Union (European Medicines Agency [EMA]), Switzerland (Swissmedic), Japan (Pharmaceuticals and Medical Devices Agency [PMDA]), Canada (Health Canada), and Australia (Therapeutic Goods Administration). METHODS: We studied all new cancer drugs approved in the six aforementioned jurisdictions from 2007 to 2020. We extracted all applicable expedited programs, total regulatory review times, and, for drugs first approved by the FDA, times to subsequent regulatory approval. Clinical benefit was assessed using the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale value framework and ASCO-Cancer Research Committee's targets. Nonparametric Kruskal-Wallis test was used to compare total review times for high versus low clinical benefit drugs. RESULTS: One hundred and twenty eight drugs received initial approval in at least one of the six included jurisdictions. Most drugs approved by the FDA (91%) and Health Canada (59%) qualified for at least one expedited program within those jurisdictions, compared with 46% of EMA approvals and 18% of PMDA approvals. The FDA was the first regulator to approve 102 (80%) drugs. Delays in submission accounted for a median of 20.2% (EMA) to 83.8% (PMDA) of the time to subsequent approval. There was no association between high clinical benefit and shorter total review times. CONCLUSION: Most new cancer therapies were approved first by the FDA, and delays in submission of regulatory applications accounted for substantial delays in approving cancer drugs in other countries. Regulators should prioritize faster review for drugs with high clinical benefit.
Collapse
Affiliation(s)
- Thomas J. Hwang
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Cancer, Dana-Farber Cancer Institute and Division of Urological Surgery, Brigham and Women's Hospital, Boston, MA
- 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, MA
| | - 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, MA
| | - Ariadna Tibau
- Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - ChangWon C. Lee
- 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, MA
| | - Kerstin N. Vokinger
- 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, MA
- Institute of Law, University of Zurich, Zurich, Switzerland
| |
Collapse
|
22
|
Jiwnani S, Penumadu P, Ashok A, Pramesh CS. Lung Cancer Management in Low and Middle-Income Countries. Thorac Surg Clin 2022; 32:383-395. [PMID: 35961746 DOI: 10.1016/j.thorsurg.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Lung cancer is an increasing problem in the developing world due to rising trends in smoking, high incidence of air pollution, lack of awareness and screening, delayed presentation, and diagnosis at the advanced stage. Even after diagnosis, there are disparities in access to health care facilities and inequitable distribution of resources and treatment options. In addition, the shortage of trained personnel and infrastructure adds to the challenges faced by patients with lung cancer in these regions. A multi-pronged effort targeting tobacco cessation, health promotion and awareness, capacity building, and value-based care are the need of the hour.
Collapse
Affiliation(s)
- Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, India.
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Medical Education and Research, JIPMER, 5343, 3rd Floor, SSB, Gorimedu, Pondicherry 605006, India
| | - Apurva Ashok
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Tata Memorial Hospital, 3rd Floor, Dr. E. Borges Road, Parel, Mumbai 400012, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Tata Memorial Hospital, Main Building, Ground Floor, Dr. E. Borges Road, Parel, Mumbai 400012, India
| |
Collapse
|
23
|
Sengar M, Fundytus A, Hopman W, Pramesh CS, Radhakrishnan V, Ganesan P, Mathew A, Lombe D, Jalink M, Gyawali B, Trapani D, Roitberg F, De Vries EGE, Moja L, Ilbawi A, Sullivan R, Booth CM. Cancer Medicines: What Is Essential and Affordable in India? JCO Glob Oncol 2022; 8:e2200060. [PMID: 35853192 PMCID: PMC9812506 DOI: 10.1200/go.22.00060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are available in routine practice. METHODS This is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice. RESULTS The global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P < .001) and work exclusively in the private health system (52% v 17%, P < .001). 14/20 most commonly selected medicines were conventional cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system. CONCLUSION Most high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India.
Collapse
Affiliation(s)
- Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Adam Fundytus
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Oncology, Queen's University, Kingston, Canada
| | - Wilma Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Aju Mathew
- Malankara Orthodox Syrian Church Medical College, Kolenchery, India
| | | | - Matthew Jalink
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, 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, the 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
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada
| |
Collapse
|
24
|
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.
Collapse
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:
| |
Collapse
|
25
|
Jalali R, Nogueira-Rodrigues A, Das A, Sirohi B, Panda PK. Drug Development in Low- and Middle-Income Countries: Opportunity or Exploitation? Am Soc Clin Oncol Educ Book 2022; 42:1-8. [PMID: 35658520 DOI: 10.1200/edbk_10033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Low- and middle-income countries (LMICs) represent a diverse group of regions with varied cancer presentation. Drug development and accessibility across these regions have primarily been dependent on the trials initiated and conducted across high-income countries. Representation of LMIC regions in these trials in terms of study population has been minimal, leading to inequitable distribution of optimal and affordable cancer care. In spite of many challenges, LMICs have now increasingly been able to contribute to anticancer drug development. The opportunities present in LMICs must be explored and used in conjunction with due collaborative efforts from high-income countries, health care planners, and regulatory agencies. Global drug development trials should not only factor in suitable representation of LMICs but also design studies with pragmatic objectives and endpoints so that the trial results lead to equitable and affordable cancer care. Strengthening collaboration between cancer researchers from LMICs and high-income countries and empowering the local investigator with adequate resources will help remove current disparities.
Collapse
Affiliation(s)
- Rakesh Jalali
- Neuro-Oncology Cancer Management Team, Apollo Proton Cancer Centre, Taramani, Chennai, India
| | - Angelica Nogueira-Rodrigues
- Federal University of Minas Gerais, DOM Oncologia, Grupo Oncoclínicas, EVA Brazilian Group of Gynecologic Cancer, LACOG, Porto Alegre, Brazil
| | - Arunangshu Das
- Department of Oncology, Square Hospitals Ltd, Dhaka, Bangladesh
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Taramani, Chennai, India
| | - Pankaj Kumar Panda
- Clinical Research Secretariat, Apollo Proton Cancer Centre, Taramani, Chennai, India
| |
Collapse
|
26
|
|
27
|
Salgado CM, Garcia-Perdomo HA, Reis LO. Evaluation of maintenance of the common androgen deprivation therapy with the new antiandrogen therapy in patients with castration-resistant prostate cancer: a systematic review. Int Urol Nephrol 2022; 54:1187-1192. [PMID: 35384583 DOI: 10.1007/s11255-022-03201-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/27/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Advanced prostate cancer does not respond to traditional androgen deprivation therapy (ADT) at some point in the treatment. The development of new hormonal agents demonstrated clear efficacy and changed the treatment scenario. OBJECTIVES To evaluate the use of new antiandrogens alone versus their use in combination with maintenance ADT in patients with advanced castration-resistant prostate cancer. METHODS A literature systematic review of randomized clinical trials, cohorts, and real-life studies including patients who received the new antiandrogens with or without ADT due to histologic confirmed advanced castration-resistant prostate adenocarcinoma was carried out. RESULTS 2181 articles were identified and three studies were included with a total of 246 patients. Two studies were randomized clinical trials, and the third was a retrospective study, which showed similar results for both arms, in relation to PSA response, radiological progression-free survival, and testosterone levels, in addition to cost analysis with savings avoided in the ADT maintenance-free arm. Despite the positive data, it is still not possible to categorically state whether there is a statistical benefit in suspending the ADT during the use of new antiandrogens, due to the heterogeneity of the studies. CONCLUSION The literature is limited on the issue. Available data are still immature with no clear benefit of the use of newer antiandrogens alone in the setting of advanced castration-resistant prostate cancer.
Collapse
Affiliation(s)
- Carla Manzoni Salgado
- Urology and Oncology, Center for Life Sciences, Pontifical Catholic University of Campinas-PUC-Campinas, Av. John Boyd Dunlop, Unnumbered
- Jd. Ipaussurama, Campinas, SP, 13060-904, Brazil.
| | | | - Leonardo O Reis
- UroScience, Department of Surgery, Urology, Faculty of Medical Sciences, State University of Campinas-Unicamp, Campinas, SP, Brazil.
| |
Collapse
|
28
|
Pramesh CS, Badwe RA, Bhoo-Pathy N, Booth CM, Chinnaswamy G, Dare AJ, de Andrade VP, Hunter DJ, Gopal S, Gospodarowicz M, Gunasekera S, Ilbawi A, Kapambwe S, Kingham P, Kutluk T, Lamichhane N, Mutebi M, Orem J, Parham G, Ranganathan P, Sengar M, Sullivan R, Swaminathan S, Tannock IF, Tomar V, Vanderpuye V, Varghese C, Weiderpass E. Priorities for cancer research in low- and middle-income countries: a global perspective. Nat Med 2022; 28:649-657. [PMID: 35440716 PMCID: PMC9108683 DOI: 10.1038/s41591-022-01738-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/09/2022] [Indexed: 01/22/2023]
Abstract
Cancer research currently is heavily skewed toward high-income countries (HICs), with little research conducted in, and relevant to, the problems of low- and middle-income countries (LMICs). This regional discordance in cancer knowledge generation and application needs to be rebalanced. Several gaps in the research enterprise of LMICs need to be addressed to promote regionally relevant research, and radical rethinking is needed to address the burning issues in cancer care in these regions. We identified five top priorities in cancer research in LMICs based on current and projected needs: reducing the burden of patients with advanced disease; improving access and affordability, and outcomes of cancer treatment; value-based care and health economics; quality improvement and implementation research; and leveraging technology to improve cancer control. LMICs have an excellent opportunity to address important questions in cancer research that could impact cancer control globally. Success will require collaboration and commitment from governments, policy makers, funding agencies, health care organizations and leaders, researchers and the public.
Collapse
Affiliation(s)
- C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Rajendra A Badwe
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nirmala Bhoo-Pathy
- Centre for Epidemiology and Evidence-Based Practice, University of Malaya, Kuala Lumpur, Malaysia
| | - Christopher M Booth
- Departments of Oncology and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Anna J Dare
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - David J Hunter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Satish Gopal
- Centre for Global Health, National Cancer Institute, Rockville, MD, USA
| | - Mary Gospodarowicz
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Peter Kingham
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tezer Kutluk
- Faculty of Medicine and Cancer Institute, Hacettepe University, Ankara, Turkey
| | | | | | | | | | | | - Manju Sengar
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Ian F Tannock
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | | | - Verna Vanderpuye
- National Center for Radiotherapy Oncology and Nuclear Medicine and Korle Bu Teaching Hospital, Accra, Ghana
| | | | | |
Collapse
|
29
|
Anisman H, Kusnecov AW. Moving forward—The science and the patient. Cancer 2022. [DOI: 10.1016/b978-0-323-91904-3.00011-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Bujosa A, Moltó C, Hwang TJ, Tapia JC, Vokinger KN, Templeton AJ, Gich I, Barnadas A, Amir E, Tibau A. Associations With Definitive Outcomes and Clinical Benefit of Cancer Drugs at the Time of Marketing Approval and in the Postmarketing Period. J Natl Compr Canc Netw 2021; 19:1-9. [PMID: 34560672 DOI: 10.6004/jnccn.2021.7003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Most anticancer drugs are approved by regulatory agencies based on surrogate measures. This article explores the variables associated with overall survival (OS), quality of life (QoL), and substantial clinical benefit among anticancer drugs at the time of approval and in the postmarketing period. METHODS Anticancer drugs approved by the FDA between January 2006 and December 2015 and with postmarketing follow-up until April 2019 were identified. We evaluated trial-level data supporting approval and any updated OS and/or QoL data. We applied the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) and the ASCO Value Framework (ASCO-VF) to initial and follow-up studies. RESULTS We found that 58 drugs were approved for 96 indications based on 96 trials. At registration, approval was based on improved OS in 39 trials (41%) and improved QoL in 16 of 45 indications (36%). Postmarketing data showed an improvement in OS for 28 of 59 trials (47%) and in QoL for 22 of 48 indications (46%). At the time of approval, 25 of 94 (27%) and 26 of 80 scorable trials (33%) met substantial benefit thresholds using the ESMO-MCBS and ASCO-VF, respectively. In the postmarketing period, 37 of 69 (54%) and 35 of 65 (54%) trials met the substantial benefit thresholds. Drugs with companion diagnostics and immune checkpoint inhibitors were associated significantly with substantial clinical benefit. CONCLUSIONS Compared with the time of approval, more anticancer drugs showed improved OS and QoL and met the ESMO-MCBS or ASCO-VF thresholds for substantial benefit over the course of postmarketing time. However, only approximately half of the trials met the threshold for substantial benefit. Companion diagnostic drugs and immunotherapy seemed to be associated with greater clinical benefit.
Collapse
Affiliation(s)
- Aida Bujosa
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Consolación Moltó
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Thomas J Hwang
- 2Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - José Carlos Tapia
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Kerstin N Vokinger
- 3Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Arnoud J Templeton
- 4Department of Medical Oncology, St. Claraspital Basel, and Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ignasi Gich
- 5Department of Epidemiology, Hospital de la Santa Creu i Sant Pau, and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain; and
| | - Agustí Barnadas
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Eitan Amir
- 6Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| |
Collapse
|
32
|
Abstract
Value-based care within insurance design utilizes evidence-based medicine as a means of defining high-value versus low-value diagnostics and treatments. The goals of value-based care are to shift spending and coverage toward high-value care and reduce the use of low-value practices. Within oncology, several value-based methods have been proposed and implemented. We review value-based care being used within oncology, including defining the value of oncology drugs through frameworks, clinical care pathways, alternative payment models including the Oncology Care Model, value-based insurance design, and reducing low-value care including the Choosing Wisely initiatives.
Collapse
|
33
|
Singh AG, Chaukar D, Gupta S, Pramesh CS, Sullivan R, Chaturvedi P, Badwe R. A prospective study to determine the cost of illness for oral cancer in India. Ecancermedicalscience 2021; 15:1252. [PMID: 34267808 PMCID: PMC8241452 DOI: 10.3332/ecancer.2021.1252] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Indexed: 12/24/2022] Open
Abstract
India accounts for almost a third of the global burden of oral cancer, a situation worsened by the inability to afford care. When available, aid is often insufficient, and costing is based on informal estimations. This study objectively determines direct healthcare costs of oral cancer in India. The study was performed from a healthcare provider's perspective using a validated bottom-up method. Care pathways were determined by prospectively observing the natural management of 100 oral cancer patients treated between October 2019 and March 2020. Specific costing categories were built across services, and apportioned values for each interaction was averaged. Costs of treatment and service utilisation were obtained using probabilistic sensitivity analyses. The unit cost of treating advanced stages (United States Dollar (USD) 2,717) was found to be 42% greater than early stages (USD1,568). There was an 11% reduction in unit costs with increases in socioeconomic status. Medical equipment accounted for 97.8% of capital costs, with the highest contributor being imaging services. Variable costs for surgery in advanced stages were 1.4 times higher than early stages. Compared to surgery alone, the average cost of treatment increased by 44.6% with adjuvant therapy. These results show that over the next decade, India will incur an economic burden of USD 3 billion towards the direct healthcare of oral cancer. Early detection and prevention strategies leading to 20% reduction in advanced stage disease could save USD 30 million annually. These results are critical to deliver a disease-driven and objective reform for oral cancer care.
Collapse
Affiliation(s)
| | | | - Sudeep Gupta
- Tata Memorial Centre and HBNI, Mumbai 400012, India
| | - C S Pramesh
- Tata Memorial Centre and HBNI, Mumbai 400012, India
| | - Richard Sullivan
- Institute of Cancer Policy, Guy’s Hospital, St Thomas Street, London SE1 9RT, UK
| | | | | |
Collapse
|
34
|
Leighl NB, Nirmalakumar S, Ezeife DA, Gyawali B. An Arm and a Leg: The Rising Cost of Cancer Drugs and Impact on Access. Am Soc Clin Oncol Educ Book 2021; 41:1-12. [PMID: 33956494 DOI: 10.1200/edbk_100028] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Increasing cancer drug prices present global challenges to treatment access and cancer outcomes. Substantial variability exists in drug pricing across countries. In countries without universal health care, patients are responsible for treatment costs. Low- or middle-income countries are heavily impacted, with limited patient access to novel cancer treatments. Financial toxicity is seen across cancer types, countries, and health care systems. Those at highest risk include younger patients, new immigrants, visible minority groups, and those without private health coverage. Currently, cancer drug pricing does not correlate with value or clinical benefit. Value-based pricing of oncology drugs may incentivize development of higher-value medicines and eliminate excess spending on drugs that yield little benefit. Generics and biosimilars in oncology can also improve affordability and patient access, offering dramatic reductions in drug spending while maintaining patient benefit. Oncologists can promote value-based care by following evidence-based clinical guidelines that avoid low-value treatments. Researchers can also engage in value-based research that critically explores optimal cancer drug dosing, schedules, and treatment duration and defines patient populations most likely to benefit (e.g., through biomarker selection). Cancer Groundshot proposes that we improve outcomes for today's patients with cancer, including broader global access for high-value treatments, promotion of affordable cancer control strategies, and reduction of cancer morbidity and mortality through low-cost prevention and screening initiatives. Moving forward, major oncology societies recommend promoting uniform global access to essential cancer medicines and avoiding financial harm for patients as key principles in addressing the affordability of cancer drugs.
Collapse
Affiliation(s)
- Natasha B Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sharon Nirmalakumar
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Doreen A Ezeife
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
35
|
Value-based radiotherapy: A new chapter of the ESTRO-HERO project. Radiother Oncol 2021; 160:236-239. [PMID: 33992629 DOI: 10.1016/j.radonc.2021.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/09/2021] [Indexed: 01/19/2023]
Abstract
Radiotherapy interventions are rapidly evolving and improving, holding promise for better patient outcomes, yet at the possible detriment of higher societal costs. The ESTRO-HERO value-based radiotherapy project aims to develop a framework defining and assessing the value of radiotherapy innovations, to support clinical implementation and equitable access, within a sustainable healthcare system.
Collapse
|
36
|
Del Paggio JC, Berry JS, Hopman WM, Eisenhauer EA, Prasad V, Gyawali B, Booth CM. Evolution of the Randomized Clinical Trial in the Era of Precision Oncology. JAMA Oncol 2021; 7:728-734. [PMID: 33764385 PMCID: PMC7995135 DOI: 10.1001/jamaoncol.2021.0379] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/10/2021] [Indexed: 01/10/2023]
Abstract
IMPORTANCE The randomized clinical trial (RCT) in oncology has evolved since its widespread adoption in the 1970s. In recent years, concerns have emerged regarding the use of putative surrogate end points, such as progression-free survival (PFS), and marginal effect sizes. OBJECTIVE To describe contemporary trends in oncology RCTs and compare these findings with earlier eras of RCT design and output. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of systemic therapy RCTs in breast, colorectal, and non-small cell lung cancer published in 7 major journals between 2010 and 2020. This strategy replicates prior work and allows for comparison of trends with RCTs published between 1995 to 2004 and 2005 to 2009. MAIN OUTCOMES AND MEASURES Data on RCT design, funding, results, and reporting were extracted from the published RCT report. Findings from the current period (2010-2020) were compared with data from RCTs published from 1995 to 2004 and 2005 to 2009. Descriptive and bivariate statistics were used to analyze temporal trends. RESULTS The cohort included 298 RCTs (132 [44%] breast, 111 [37%] non-small cell lung cancer, 55 [19%] colorectal cancer). Experimental treatment included molecular inhibitor (171 of 298 [57%]), cytotoxic (83 of 298 [28%]), hormone (15 of 298 [5%]), and immune (24 of 298 [8%]) therapies. Sixty-nine percent (206 of 298) of RCTs were of palliative intent. The most common primary end point is now PFS; this has increased substantially over time (from 0% [0 of 167] to 18% [25 of 137] to 42% [125 of 298]; P < .001). Of 298 RCTs, 265 (89%) are now funded by industry (previously 95 of 167 [57%] and 107 of 137 [78%]; P < .001). Fifty-eight percent (173 of 298) of trials met their primary end point. Among positive trials, median improvement in overall survival and PFS was 3.4 and 2.9 months, respectively. More than one-third (117 of 298 [39%]) of reports used a professional medical writer; this increased substantially during the study period (from 3 of 27 [11%] in 2010 to 12 of 18 [67%] in 2020; P < .001). CONCLUSIONS AND RELEVANCE This cohort study suggests that contemporary oncology RCTs now largely measure putative surrogate end points and are almost exclusively funded by the pharmaceutical industry. The increasing role of medical writers warrants attention. To demonstrate that new cancer treatments are high value, the oncology community needs to consider the extent to which study end points and target effect size provide meaningful benefit to patients.
Collapse
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
| | - John S. Berry
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Queen’s University, Kingston, Canada
| | - Wilma M. Hopman
- Kingston General Health Research Institute, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
| | | | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California at San Francisco
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Queen’s University, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
- Department of Oncology, Queen’s University, Kingston, Canada
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Queen’s University, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
- Department of Oncology, Queen’s University, Kingston, Canada
| |
Collapse
|
37
|
Gross S, Sohl CD. Readying students for careers in industry: A guided inquiry activity to prepare students for success in biotechnology and pharmaceutical industry positions. BIOCHEMISTRY AND MOLECULAR BIOLOGY EDUCATION : A BIMONTHLY PUBLICATION OF THE INTERNATIONAL UNION OF BIOCHEMISTRY AND MOLECULAR BIOLOGY 2021; 49:407-415. [PMID: 33569919 DOI: 10.1002/bmb.21491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 06/12/2023]
Abstract
While science students are well prepared for careers in biotechnology and pharmaceutical sciences in terms of technical expertise and critical thinking, they rarely have an opportunity to practice the due diligence required for success in industry in their coursework. This includes framing their expertise as solutions to challenges a company may be experiencing, an important skill for the interview process. As most academics have not applied for positions in industry, they may feel ill equipped to help students practice the important skills of framing their expertise within company goals and to discuss the business and financial concepts relevant to careers in scientific industry. Here, we describe an educational activity first developed by a leader in the biotech/pharmaceutical industry that was modified and given educational context by an academic in a class of upper-level undergraduate and graduate students. In this guided inquiry activity, students were instructed to select a start-up company in their field-ideally one to which they intended to apply for a job. Students were empowered by scaffolded hands-on exercises to research the company's scientific focus and finances, and to frame how their expertise could help companies achieve stated goals. Students compiled and delivered their research as an in-class presentation.
Collapse
Affiliation(s)
- Stefan Gross
- From Department of Biochemistry, Agios Pharmaceuticals, Cambridge, Massachusetts, USA
- Gordon Entrepreneurship Institute, Tufts University School of Engineering, Medford, Massachusetts, USA
- Department of Developmental, Molecular, and Chemical Biology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Christal D Sohl
- Department of Chemistry and Biochemistry, San Diego State University, San Diego, California, USA
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Bae G, Bae S, Lee D, Han J, Koo DH, Kim DY, Kim HJ, Oh SY, Lee HY, Lee JH, Han HS, Ha H, Kang JH. Value Frameworks: Adaptation of Korean Versions of Value Frameworks for Oncology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063139. [PMID: 33803663 PMCID: PMC8002926 DOI: 10.3390/ijerph18063139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/23/2023]
Abstract
This study sought to adapt the existing value framework (VF) to produce a reliable and valid Korean oncology VF. Two VFs developed by The American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) were selected for examination in the present study. Forward and backward translations were conducted for six high-priced drugs indicated for non-small-cell lung cancer and multiple myeloma. Inter-rater reliability was measured based on the intraclass correlation coefficient (ICC) and variation was described using the coefficient of variation. The relative weights of factors critically considered by Korean oncologists were derived following the analytic hierarchy process (AHP), and focus group interviews (FGIs) were used to obtain qualitative data regarding the applications of these two VFs in the Korean setting. The ICCs of the Korean VFs were 0.895 (0.654-0.983) for ASCO and 0.726 (0-0.982) for ESMO translations, suggesting excellent reliability for ASCO and good reliability for ESMO. AHP demonstrated that clinical benefit has the highest priority, which is consistent with the ASCO VF. The FGIs suggested that the result for AHP is acceptable and that both ESMO and ASCO VFs should be used complementarily. Although further evaluation with a larger sample size is needed, the Korean versions of ESMO/ASCO VFs are valid and reliable tools and are acceptable to Korean stakeholders, yet they should be applied with caution.
Collapse
Affiliation(s)
- Green Bae
- College of Pharmacy, Ewha Womans University, Seoul 03760, Korea; (G.B.); (S.B.); (J.H.)
| | - SeungJin Bae
- College of Pharmacy, Ewha Womans University, Seoul 03760, Korea; (G.B.); (S.B.); (J.H.)
| | - Donghwan Lee
- Department of Statistics, Ewha Womans University, Seoul 03760, Korea;
| | - Juhee Han
- College of Pharmacy, Ewha Womans University, Seoul 03760, Korea; (G.B.); (S.B.); (J.H.)
| | - Dong-Hoe Koo
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03063, Korea;
| | - Do Yeun Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Seoul 10326, Korea;
| | - Hee-Jun Kim
- Division of Hematology/Medical Oncology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul 06974, Korea;
| | - Sung Young Oh
- Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan 49236, Korea;
| | - Hee Yeon Lee
- Division of Oncology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul 07345, Korea;
| | - Jong Hwan Lee
- Department of Pharmaceutical Benefits, Health Insurance Review & Assessment, Wonju 26465, Korea;
| | - Hye Sook Han
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongju 28644, Korea;
| | - Hyerim Ha
- Division of Hematology & Oncology, Department of Internal Medicine, Inha University Hospital, Incheon 400 711, Korea;
| | - Jin Hyoung Kang
- Medical Oncology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 07345, Korea
- Correspondence: ; Tel.: +82-2258-6043
| |
Collapse
|
40
|
Vogler S. Can we achieve affordable cancer medicine prices? Developing a pathway for change. Expert Rev Pharmacoecon Outcomes Res 2021; 21:321-325. [PMID: 33653228 DOI: 10.1080/14737167.2021.1898951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Sabine Vogler
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG/Austrian National Public Health Institute), Vienna, Austria
| |
Collapse
|
41
|
Cramer-van der Welle CM, Peters BJM, Deenen MJ, Schramel FMNH, van de Garde EMW. Trends in Drug Costs and Overall Survival in Patients with Metastatic Non-small Cell Lung Cancer in The Netherlands Diagnosed from 2008 Through 2014. PHARMACOECONOMICS - OPEN 2021; 5:121-127. [PMID: 32533521 PMCID: PMC7895888 DOI: 10.1007/s41669-020-00220-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND The Value-Based Health Care concept defines patient value as patient-relevant outcomes divided by costs. The aim of the present study was to assess the development of systemic treatment costs over the years compared with changes in overall survival (OS) at the level of a diagnosis of stage IV non-small cell lung cancer (NSCLC). METHODS All patients diagnosed (in 2008-2014) with stage IV NSCLC and treated with systemic treatment in six Dutch large teaching hospitals (Santeon network) were included. We collected data on OS and amounts of drug units (milligrams) for every drug in the applied systemic cancer treatments, until death. These amounts were multiplied by Dutch unit costs (Euros/mg) expressed in 2018 Euros to construct total drug costs per line of treatment per patient. Costs for day care visits were added for drugs requiring parenteral administration. RESULTS Data were collected from 1214 patients. Median OS and mean total drug costs showed no significant variation over the years (p = 0.437 and p = 0.693, respectively). Mean total drug costs per 1 year of survival ranged from €20,665 to €26,438 during the period under study. Costs for first-line systemic treatment were significantly higher in 2011-2014 compared with 2008-2010. CONCLUSION This study shows that overall drug costs were stable over the years, despite a relative increase in first-line treatment costs. Median OS remained at around 8 months from year to year. These trend data are very relevant as background for the assessment of costs and achieved outcomes in the more recent years.
Collapse
Affiliation(s)
| | - Bas J M Peters
- Department of Clinical Pharmacy, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, The Netherlands
| | - Franz M N H Schramel
- Department of Pulmonary Diseases, St Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
| | - Ewoudt M W van de Garde
- Department of Clinical Pharmacy, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
42
|
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]
|
43
|
Wells JC, Sharma S, Del Paggio JC, Hopman WM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Sullivan R, Booth CM. An Analysis of Contemporary Oncology Randomized Clinical Trials From Low/Middle-Income vs High-Income Countries. JAMA Oncol 2021; 7:379-385. [PMID: 33507236 DOI: 10.1001/jamaoncol.2020.7478] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The burden of cancer falls disproportionally on low-middle-income countries (LMICs). It is not well known how novel therapies are tested in current clinical trials and the extent to which they match global disease burden. Objectives To describe the design, results, and publication of oncology randomized clinical trials (RCTs) and examine the extent to which trials match global disease burden and how trial methods and results differ across economic settings. Design, Setting, and Participants In this retrospective cohort study, a literature search identified all phase 3 RCTs evaluating anticancer therapies published from 2014 to 2017. Randomized clinical trials were classified based on World Bank economic classification. Descriptive statistics were used to compare RCT design and results from high-income countries (HICs) and low/middle-income countries (LMICs). Statistical analysis was conducted in January 2020. Main Outcomes and Measures Differences in the design, results, and output of RCTs between HICs and LMICs. Results The study cohort included 694 RCTs: 636 (92%) led by HICs and 58 (8%) led by LMICs. A total of 601 RCTs (87%) tested systemic therapy and 88 RCTs (13%) tested radiotherapy or surgery. The proportion of RCTs relative to global deaths was higher for breast cancer (121 RCTs [17%] and 7% of deaths) but lower for gastroesophageal cancer (38 RCTs [6%] and 14% of deaths), liver cancer (14 RCTs [2%] and 8% of deaths), pancreas cancer (14 RCTs [2%] and 5% of deaths), and cervical cancer (9 RCTs [1%] and 3% of deaths). Randomized clinical trials in HICs were more likely than those in LMICs to be funded by industry (464 [73%] vs 24 [41%]; P < .001). Studies in LMICs were smaller than those in HICs (median, 219 [interquartile range, 137-363] vs 474 [interquartile range, 262-743] participants; P < .001) and more likely to meet their primary end points (39 of 58 [67%] vs 286 of 636 [45%]; P = .001). The observed median effect size among superiority trials was larger in LMICs compared with HICs (hazard ratio, 0.62 [interquartile range, 0.54-0.76] vs 0.84 [interquartile range, 0.67-0.97]; P < .001). Studies from LMICs were published in journals with lower median impact factors than studies from HICs (7 [interquartile range, 4-21] vs 21 [interquartile range, 7-34]; P < .001). Publication bias persisted when adjusted for whether a trial was positive or negative (median impact factor: LMIC negative trial, 5 [interquartile range, 4-6] vs HIC negative trial, 18 [interquartile range, 6-26]; LMIC positive trial, 9 [interquartile range, 5-25] vs HIC positive trial, 25 [interquartile range, 10-48]; P < .001). Conclusions and Relevance This study suggests that oncology RCTs are conducted predominantly by HICs and do not match the global burden of cancer. Randomized clinical trials from LMICs are more likely to identify effective therapies and have a larger effect size than RCTs from HICs. This study suggests that there is a funding and publication bias against RCTs led by LMICs. Policy makers, research funders, and journals need to address this issue with a range of measures including building capacity and capability in RCTs.
Collapse
Affiliation(s)
- J Connor Wells
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Shubham Sharma
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Joseph C Del Paggio
- Department of Oncology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Deborah Mukherji
- Department of Hematology/Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nazik Hammad
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ajay Aggarwal
- Institute of Cancer Policy, King's College London, London, United Kingdom.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
44
|
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.
Collapse
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
| |
Collapse
|
45
|
Chen EY, Cook M, Deig C, Arastu A, Prasad V, Nabavizadeh N, Lopez CD, Kardosh A. Application of ASCO Value Framework to Treatment Advances in Hepatocellular Carcinoma. JCO Oncol Pract 2021; 17:e461-e468. [PMID: 33411593 DOI: 10.1200/op.20.00558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Determination of the comparative efficacy of one therapy over another for hepatocellular carcinoma (HCC) can be challenging. Application of a recognized value framework to published studies could objectively compare the potential benefit across available therapies. MATERIALS AND METHODS An umbrella review of phase III trials for HCC therapies was performed. ASCO Value Framework Net Health Benefit Score version 2 (ASCO-NHB v2) scores, the primary analysis, and European Society of Medical Oncology Magnitude of Clinical Benefit Scale version 1.1 scores, the secondary analysis, were computed using selected drug registration trials. Both scores were compared between drugs that were Food and Drug Administration (FDA)-approved by 2020 and those that were not. RESULTS Of the 22 studies identified, nine were FDA-approved and 13 were not. Across 22 trials, the median overall survival (OS) was 9.2 months (range, 1.9-16.4 months), with a median gain of 0.35 month (range, 2.3-3.3 months). HCC therapies that were FDA-approved showed longer OS (median 10.7 v 7.9 months, P < .01) and higher ASCO NHB scores (+18.4 v -5.7 scores, P < .01). The median gain in OS was 2.2 months in the approved treatments compared with -0.3 months in the unapproved group, with no difference in progression-free survival between the two groups. CONCLUSION The nine FDA-approved therapies for HCC have higher mean NHB score than those that were not FDA-approved. The application of ASCO-NHB v2 and other proposed value frameworks could examine data of future therapies for HCC through a patient-oriented approach.
Collapse
Affiliation(s)
- Emerson Y Chen
- Division of Hematology Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR
| | - Madeline Cook
- School of Medicine, Oregon Health & Science University, Portland, OR
| | - Christopher Deig
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Asad Arastu
- Division of Medicine, Oregon Health & Science University, Portland, OR
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Charles D Lopez
- Division of Hematology Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR
| | - Adel Kardosh
- Division of Hematology Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR
| |
Collapse
|
46
|
Jiang Q, Feng M, Li Y, Lang J, Wei H, Yu T. Choosing PD-1 Inhibitors in Oncology Setting, Left or Right?-Lessons From Value Assessment With ASCO-VF and ESMO-MCBS. Front Pharmacol 2021; 11:574511. [PMID: 33390946 PMCID: PMC7775497 DOI: 10.3389/fphar.2020.574511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/23/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Influx of innovative therapies and dramatic rise in prices have been prompting value-driven decision-making. Both the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) have independently proposed value assessment frameworks. Objectives: To comprehensively examine the value of nivolumab and pembrolizumab by two value assessment frameworks with a cohort of published randomized controlled trials and offer insight into the association between these two frameworks. Methods: Trials were identified with a cutoff date of Nov 30th, 2019. Receiver operating characteristic curves were generated to establish the predictive value of ASCO-VF score to meet ESMO-MCBS grade and discriminate the agreement of these two value assessment tools. Spearman correlation was used to assess the association between monthly cost and ASCO-VF score/ESMO-MCBS grade. Results: 19 randomized controlled trials were eligible. seven (36.8%) trials were of treatment included nivolumab while 12 (63.2%) pembrolizumab. 8 (42.1%) of the trials were of treatments for non-small-cell lung cancer, 5 (26.3%) for melanoma, 2 (10.5%) were for head and neck squamous cell carcinoma, 2 (10.5%) for gastric or gastro-oesophageal junction cancer and 1 (5.3%) for urothelial cancer and renal-cell carcinoma respectively. ASCO scores ranged from 7 to 94.7 with median 40.90. 11 (57.9%) trials met the ESMO criteria for meaningful value achieved. Of 14 trials not meeting the ASCO cutoff score, only 8 did not meet the meaningful ESMO criteria. Agreement between these two frameworks thresholds was only fair (κ = 0.412, P<0.05). A negative correlation was noted between increment monthly cost and value assessment results. Conclusion: There is only fair correlation between ASCO and ESMO value assessment frameworks. Not all treatment with nivolumab and pembrolizumab meet valuable thresholds.
Collapse
Affiliation(s)
- Qian Jiang
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Centre, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Mei Feng
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Centre, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Youping Li
- China Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jinyi Lang
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Centre, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hua Wei
- School of Pharmacy, Chengdu Medical College, Chengdu, China.,Department of Pharmacy, Dujiangyan People's Hospital, Dujiangyan Medical Center, Dujiangyan, China
| | - Ting Yu
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Centre, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| |
Collapse
|
47
|
Jordan B. [Cost/benefit analysis of cancer drugs]. Med Sci (Paris) 2020; 36:1095-1097. [PMID: 33151876 DOI: 10.1051/medsci/2020205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A detailed analysis of the clinical benefit for 47 approved cancer drugs, using two internationally recognized assessment systems, shows essentially no correlation between clinical benefit and weekly treatment costs. This is true both in the USA and in four European countries, although prices are dramatically lower in Europe.
Collapse
Affiliation(s)
- Bertrand Jordan
- UMR 7268 ADÉS, Aix-Marseille, Université/EFS/CNRS ; CoReBio PACA, case 901, Parc scientifique de Luminy, 13288 Marseille Cedex 09, France
| |
Collapse
|
48
|
Hwang TJ, Ross JS, Vokinger KN, Kesselheim AS. Association between FDA and EMA expedited approval programs and therapeutic value of new medicines: retrospective cohort study. BMJ 2020; 371:m3434. [PMID: 33028575 PMCID: PMC7537471 DOI: 10.1136/bmj.m3434] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To characterize the therapeutic value of new drugs approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) and the association between these ratings and regulatory approval through expedited programs. DESIGN Retrospective cohort study. SETTING New drugs approved by the FDA and EMA between 2007 and 2017, with follow-up through 1 April 2020. DATA SOURCES Therapeutic value was measured using ratings of new drugs by five independent organizations (Prescrire and health authorities of Canada, France, Germany, and Italy). MAIN OUTCOME MEASURES Proportion of new drugs rated as having high therapeutic value; association between high therapeutic value rating and expedited status. RESULTS From 2007 through 2017, the FDA and EMA approved 320 and 268 new drugs, respectively, of which 181 (57%) and 39 (15%) qualified for least one expedited program. Among 267 new drugs with a therapeutic value rating, 84 (31%) were rated as having high therapeutic value by at least one organization. Compared with non-expedited drugs, a greater proportion of expedited drugs were rated as having high therapeutic value among both FDA approvals (45% (69/153) v 13% (15/114); P<0.001) and EMA approvals (67% (18/27) v 27% (65/240); P<0.001). The sensitivity and specificity of expedited program for a drug being independently rated as having high therapeutic value were 82% (95% confidence interval 72% to 90%) and 54% (47% to 62%), respectively, for the FDA, compared with 25.3% (16.4% to 36.0%) and 90.2% (85.0% to 94.1%) for the EMA. CONCLUSIONS Less than a third of new drugs approved by the FDA and EMA over the past decade were rated as having high therapeutic value by at least one of five independent organizations. Although expedited drugs were more likely than non-expedited drugs to be highly rated, most expedited drugs approved by the FDA but not the EMA were rated as having low therapeutic value.
Collapse
Affiliation(s)
- 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, MA, USA
- Laboratory for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland
| | - Joseph S Ross
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Kerstin N Vokinger
- Laboratory for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland
- Institute of Law, University of Zurich, Zurich, Switzerland
| | - 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, MA, USA
| |
Collapse
|
49
|
Mitchell AP, Tabatabai SM, Dey P, Ohn JA, Curry MA, Bach PB. Association Between Clinical Value and Financial Cost of Cancer Treatments: A Cross-Sectional Analysis. J Natl Compr Canc Netw 2020; 18:1349-1353. [PMID: 33022648 PMCID: PMC8354655 DOI: 10.6004/jnccn.2020.7574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 04/06/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The cost of cancer treatment has increased significantly in recent decades, but it is unclear whether these costs have been associated with commensurate improvement in clinical value. This study aimed to assess the association between the cost of cancer treatment and 4 of the 5 NCCN Evidence Blocks (EB) measures of clinical value: efficacy of regimen/agent, safety of regimen/agent, quality of evidence, and consistency of evidence. METHODS This is a cross-sectional, observational study. We obtained NCCN EB ratings for all recommended, first-line, and/or maintenance treatments for the 30 most prevalent cancers in the United States and calculated direct pharmacologic treatment costs (drug acquisition, administration fees, guideline-concordant supportive care medications) using Medicare reimbursement rates in January 2019. We used generalized estimating equations to estimate the association between NCCN EB measures and treatment cost with clustering at the level of the treatment indication. RESULTS A total of 1,386 treatments were included. Among time-unlimited treatments (those administered on an ongoing basis without a predetermined stopping point), monthly cost was positively associated with efficacy ($3,036; 95% CI, $1,782 to $4,289) and quality of evidence ($1,509; 95% CI, $171 to $2,847) but negatively associated with safety (-$1,470; 95% CI, -$2,790 to -$151) and consistency of evidence (-$2,003; 95% CI, -$3,420 to -$586). Among time-limited treatments (those administered for a predetermined interval or number of cycles), no NCCN EB measure was significantly associated with treatment cost. CONCLUSIONS An association between NCCN EB measures and treatment cost was inconsistent, and the magnitude of the association was small compared with the degree of cost variation among treatments with the same EB scores. The clinical value of cancer treatments does not seem to be a primary determinant of treatment cost.
Collapse
Affiliation(s)
- Aaron P. Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sara M. Tabatabai
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pranammya Dey
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
- Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer A. Ohn
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A. Curry
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B. Bach
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
50
|
Bomze D, Asher N, Hasan Ali O, Flatz L, Azoulay D, Markel G, Meirson T. Survival-Inferred Fragility Index of Phase 3 Clinical Trials Evaluating Immune Checkpoint Inhibitors. JAMA Netw Open 2020; 3:e2017675. [PMID: 33095247 PMCID: PMC7584930 DOI: 10.1001/jamanetworkopen.2020.17675] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE In science and medical research, extreme and dichotomous conclusions may be drawn based on whether the P value falls above or below the threshold. The fragility index (ie, the minimum number of changes from nonevents to events resulting in loss of statistical significance) captures the vulnerability of statistics in trials with binary outcomes. There are a growing number of clinical trials of immune checkpoint inhibitors (ICIs), as well as expanding eligibility for patients to receive them. The robustness of survival outcomes in randomized clinical trials (RCTs) should be evaluated using the fragility index extended to time-to-event data. OBJECTIVE To calculate the fragility of survival data in RCTs evaluating ICIs. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, data on phase 3 prospective RCTs investigating ICIs included in PubMed from inception until January 1, 2020, were extracted. Two- or three-group studies reporting results for overall survival were eligible for the survival-inferred fragility index (SIFI) calculation, which is the minimum number of reassignments of the best survivors from the interventional group to the control group resulting in loss of significance (defined as P < .05 by log-rank test). For nonsignificant results, a negative SIFI was calculated by reversing the direction of reassignment (from the control group to the interventional group). MAIN OUTCOMES AND MEASURES Survival-inferred fragility index. RESULTS A total of 45 phase 3 prospective RCTs (4 of which had 3 groups, for a total of 49 groups) were identified, of which 6 (13%) investigated anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) agents, 25 (56%) investigated anti-programmed cell death 1 (PD-1) agents, 12 (27%) investigated anti-programmed cell death 1 ligand 1 agents, and 3 (7%) investigated the combination of anti-CTLA-4 and anti-PD-1 agents. The median SIFI was 5 (interquartile range, -4 to 12) for the intention-to-treat analysis; for these trials, the SIFI was 1% or less of the total sample size in 17 of 49 populations (35%). In 25 of the 49 intention-to-treat populations (51%), the SIFI was less than the number of censored patients in the intervention group shortly after randomization (defined as <5% of the follow-up time). CONCLUSIONS AND RELEVANCE This study suggests that many phase 3 RCTs evaluating ICI therapies have a low SIFI for overall survival, resulting in uncertainty regarding their potential clinical benefit. Although not a definitive solution for the problems arising from dichotomization, SIFI provides an additional means of assessing and communicating the strength of statistical conclusions.
Collapse
Affiliation(s)
- David Bomze
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute for Immunobiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Nethanel Asher
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat-Gan, Israel
| | - Omar Hasan Ali
- Institute for Immunobiology, Kantonsspital St Gallen, St Gallen, Switzerland
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Lukas Flatz
- Institute for Immunobiology, Kantonsspital St Gallen, St Gallen, Switzerland
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
- Department of Oncology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Daniel Azoulay
- Center for Liver Diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Gal Markel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat-Gan, Israel
- Department of Clinical Microbiology and Immunology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Meirson
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat-Gan, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| |
Collapse
|