1
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Al-Sukhun S, Tbaishat F, Hammad N. Breast Cancer Priorities in Limited-Resource Environments: The Price-Efficacy Dilemma in Cancer Care. Am Soc Clin Oncol Educ Book 2022; 42:1-7. [PMID: 35731988 DOI: 10.1200/edbk_349861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Breast cancer has become one of the leading causes of morbidity and mortality in low- and middle-income countries, where 62% of the world's total new cases are diagnosed. Therefore, the productivity loss because of premature death resulting from female breast cancer is also on the rise. The major challenge in low- and middle-income countries is to reduce the proportion of women presenting with advanced-stage disease, a challenge unlikely to be overcome by adoption of expensive national mammography screening programs. Awareness and education campaigns should focus not only on patients and societies but also on policy makers to address and optimize breast cancer care. Adaptation of existing guidelines and prioritization according to local resources are essential to address the unique needs and overcome the unique barriers of each society to facilitate practical implementation and improve outcomes. Emphasis on the principle of a cancer groundshot in addressing value in cancer care is vital to improving access to therapies that are proven to work rather than chasing after new drugs or innovations of doubtful or marginal clinical benefit. Until we have drug-pricing interventions that take into account the local income of each society, we must acknowledge the fact that the delivery of cancer care will never be the same all around the world.
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Affiliation(s)
| | - Fayez Tbaishat
- Department of Oncology, Al Bashir Hospital, Amman, Jordan
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2
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Del Paggio JC, Fundytus AM, Hopman WM, Pater JL, Chen BE, Brundage MD, Hay AE, Booth CM. Application of Value Frameworks to the Design of Clinical Trials: the Canadian Cancer Trials Group Experience. J Natl Cancer Inst 2021; 113:1422-1428. [PMID: 33760057 DOI: 10.1093/jnci/djab051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Use of value framework thresholds in the design of clinical trials may increase the proportion of randomized controlled trials (RCTs) that identify clinically meaningful advances for patients. Existing frameworks have not been applied to the research output of a cooperative cancer trials group. We apply value frameworks to the RCT output of the Canadian Cancer Trials Group (CCTG). METHODS Statistical design, study characteristics, and results of all published phase III trials of CCTG were abstracted. We applied the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) and American Society of Clinical Oncology Net Health Benefit (ASCO-NHB) to study results and the statistical power calculations to identify the proportion of all trials that were designed to detect a substantial clinical benefit. RESULTS During 1979-2017, CCTG published 113 phase III trials; 52.2% (59 of 113) of these trials were positive. Half (50.4%, 57 of 113) of trials were conducted in the palliative setting. In 37.2% (42 of 113) of trials the primary endpoint was overall survival; DFS or PFS was used in 38.9% (44 of 113) of trials. The ESMO-MCBS could be applied to the power calculation for 69 trials; 73.9% (51 of 69) of these trials were designed to detect an effect size that could meet ESMO-MCBS thresholds for substantial benefit. Among the 51 positive trials for which the ESMO-MCBS could be applied, 41.1% (21 of 51) met thresholds for substantial benefit. CONCLUSIONS Most CCTG phase III trials were designed to detect clinically meaningful differences in outcome, although less than half of positive trials met the threshold for substantial benefit. Application of value frameworks to the design of clinical trials is practical and may improve research efficiency and treatment options for patients.
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Affiliation(s)
- Joseph C Del Paggio
- Department of Medical Oncology, Thunder Bay Regional Health Sciences Centre and Northern Ontario School of Medicine, Thunder Bay, Canada
| | - Adam M Fundytus
- Department of Oncology, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Kingston General Hospital Research Institute, Kingston, ON, Canada
| | - Joseph L Pater
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Bingshu E Chen
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Michael D Brundage
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Annette E Hay
- Department of Medicine, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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Rodriguez A, Esposito F, Oliveres H, Torres F, Maurel J. Are Quality of Randomized Clinical Trials and ESMO-Magnitude of Clinical Benefit Scale Two Sides of the Same Coin, to Grade Recommendations for Drug Approval? J Clin Med 2021; 10:746. [PMID: 33668473 PMCID: PMC7918206 DOI: 10.3390/jcm10040746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 12/20/2022] Open
Abstract
The approval of a new drug for cancer treatment by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) is based on positive, well-designed randomized phase III clinical trials (RCTs). However, not all of them are analyzed to support the recommendations. For this reason, there are different scales to quantify and evaluate the quality of RCTs and the magnitude of the clinical benefits of new drugs for treating solid tumors. In this review, we discuss the value of the progression-free survival (PFS) as an endpoint in RCTs and the concordance between it and the overall survival (OS) as a measure of the quality of clinical trial designs. We summarize and analyze the different scales to evaluate the clinical benefits of new drugs such as the The American Society of Clinical Oncology value framework (ASCO-VF-NHB16) and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) and the concordance between them, focusing on metastatic colorectal cancer (mCRC). We propose several definitions that would help to evaluate the quality of RCT, the magnitude of clinical benefit and the appropriate approval of new drugs in oncology.
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Affiliation(s)
- Adela Rodriguez
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
| | - Francis Esposito
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
| | - Helena Oliveres
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
| | - Ferran Torres
- Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona, 08036 Barcelona, Spain
| | - Joan Maurel
- Department of Medical Oncology, Hospital Clinic of Barcelona,08036 Barcelona, Spain; (A.R.); (F.E.); (H.O.)
- Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Institut d’Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, 08036 Barcelona, Spain
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Arciero V, Delos Santos S, Koshy L, Rahmadian A, Saluja R, Everest L, Parmar A, Chan KKW. Assessment of Food and Drug Administration- and European Medicines Agency-Approved Systemic Oncology Therapies and Clinically Meaningful Improvements in Quality of Life: A Systematic Review. JAMA Netw Open 2021; 4:e2033004. [PMID: 33570573 PMCID: PMC7879236 DOI: 10.1001/jamanetworkopen.2020.33004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE For patients with cancer treated with palliative intent, quality of life (QOL) is a critical aspect of treatment decision-making, alongside survival. However, regulatory approval can be based solely on survival measures or antitumor activities, without QOL evidence. OBJECTIVE To investigate whether recently approved oncology therapies demonstrate clinically meaningful improvements in QOL. EVIDENCE REVIEW This systematic review study identified oncology drug indications approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) from January 2006 to December 2017 and supporting clinical trials (QOL publications identified to October 2019). Indications were evaluated for the presence of published QOL evidence; QOL benefits according to the American Society of Clinical Oncology Value Framework version 2.0 (ASCO-VF) and European Society of Medical Oncology Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS) QOL bonus criteria; and clinically meaningful improvements in QOL beyond minimal clinically important differences. Hematology trials were not evaluated by ESMO-MCBS. Associations between QOL evidence and approval year were examined using logistic regression models. FINDINGS In total, 214 FDA-approved (77 [36%] hematological) and 170 EMA-approved (52 [31%] hematological) indications were included. QOL evidence was published for 40% and 58% of FDA- and EMA-approved indications, respectively. QOL bonus criterion for ASCO-VF and ESMO-MCBS was met in 13% and 17% of FDA-approved and 21% and 24% of EMA-approved indications, respectively. Clinically meaningful improvements in QOL beyond minimal clinically important differences were noted in 6% and 11% of FDA- and EMA-approved indications, respectively. Availability of published QOL evidence at the time of approval increased over time for EMA (odds ratio [OR], 1.13; P = .03), however not for FDA (OR, 1.10; P = .12). Over time, no increase in awarded QOL bonuses or clinically meaningful improvements in QOL were found. CONCLUSIONS AND RELEVANCE The findings of this systematic review suggest that approved systemic oncology therapies often do not have published evidence to suggest QOL improvement, despite its recognized importance. Of indications with evidence of statistical improvement, few have demonstrated clinically meaningful improvements.
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Affiliation(s)
- Vanessa Arciero
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Seanthel Delos Santos
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Liza Koshy
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Amanda Rahmadian
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ronak Saluja
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Louis Everest
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ambica Parmar
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K. W. Chan
- Evaluative Clinical Sciences, Odette Cancer Centre Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
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5
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Villaflor VM, Massarelli E. Nasopharyngeal Cancer: Is the Addition of Chemotherapy to Radiotherapy Worthwhile in an Era of Value-Based Care? JCO Oncol Pract 2020; 16:711-712. [PMID: 32946323 DOI: 10.1200/op.20.00656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope Cancer Center, Duarte, CA
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Liang F, Zhang S, Wang Q, Li W. Clinical benefit of immune checkpoint inhibitors approved by US Food and Drug Administration. BMC Cancer 2020; 20:823. [PMID: 32867707 PMCID: PMC7457752 DOI: 10.1186/s12885-020-07313-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/18/2020] [Indexed: 12/17/2022] Open
Abstract
Background We describe the clinical benefit of immune checkpoint inhibitors using the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) and ASCO VF. Methods We identify all approved indications of immune checkpoint inhibitors based on RCTs between January 1, 2011 and September 30, 2018 by FDA. Information including medians and HR of OS (PFS or DFS) and 95% CI, grade 3 or 4 toxicities in each arm, QOL data, survival probability at fixed time were extracted. Results Immune checkpoint inhibitors were approved for 18 indications based on RCTs. All the indications meet the ESMO-MCBS 1.1 threshold for meaningful benefit. By the updated ASCO-VF, the median Net Health Benefit (NHB) of these agents was 55.3 (range 17.4–77.1). Two third of the indication gained the bonus points for durable survival benefits by updated ASCO VF. When updated results were incorporated in the assessment, clinical benefit of most approved immune checkpoint inhibitors increased with a median improvement of NHB of 10 (range 2–20). Conclusions Approved immune checkpoint inhibitors provided clinical meaningful benefit by ESMO-MCBS 1.1, and most of these agents reach the threshold for bonus points for durable survival in the updated ASCO VF.
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Affiliation(s)
- Fei Liang
- Medical Oncology, Shanghai Cancer Center, Fudan University, 270 Dongan Road, Shanghai, 200032, China.,Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Sheng Zhang
- Medical Oncology, Shanghai Cancer Center, Fudan University, 270 Dongan Road, Shanghai, 200032, China.
| | - Qin Wang
- Shanghai University of Engineering Science, Shanghai, China.
| | - Wenfeng Li
- Department of Medical oncology, the affiliated hospital of Qingdao University, Qingdao, China.
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Saluja R, Cheung M, Chan KKW. Correcting the Conclusion in a Study of Frameworks for Measurement of Absolute or Clinical Benefit-In Reply. JAMA Oncol 2019; 5:1807-1808. [PMID: 31621814 DOI: 10.1001/jamaoncol.2019.4132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ronak Saluja
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Matthew Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada.,Cancer Care Ontario, Toronto, Ontario, Canada
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