Costs and Clinical Outcomes among Patients with Second-Line Non-small Cell Lung Cancer in the Outpatient Community Setting

Potential Antiangiogenic Treatment Eligibility of Patients with Squamous Non-Small-Cell Lung Cancer: EPISQUAMAB Study (GFPC 2015-01)

BACKGROUND

Antiangiogenic agents have improved the prognosis of non-squamous non-small-cell lung cancers (NSCLCs), even though all the patients are not eligible to receive them because of counterindications linked to the tumor's characteristics or comorbidities. Much less information is available about the eligibility of patients with squamous non-small-cell lung cancers (SQ-NSCLCs) to receive antivascular endothelial growth-factor (VEGF) treatments, even though such molecules are being developed for this histology. This study was undertaken to determine the percentage of advanced SQ-NSCLC patients who would be eligible to receive an antiVEGF agent as second-line systemic therapy.

METHODS

This observational, multicenter, prospective study evaluated advanced SQ-NSCLC patients' criteria for ineligibility to receive an antiVEGF during a multidisciplinary meeting to choose their standard second-line systemic therapy.

RESULTS

Among the 317 patients included, 53.6% had at least one ineligibility criterion, and ~20% had at least two, with disease extension to large vessels (39.8%), tumor cavitation (20.5%), cardiovascular disease (11%) and/or hemoptysis (7.2%) being the most frequent. Patients with an ECOG performance score of 1/2 had more cardiovascular contraindications that those with scores of 0.

CONCLUSION

Almost half of the SQ-NSCLC patients included in this study would have been eligible to receive an antiVEGF agent. The development of these molecules for these indications should be encouraged.

Treatment Patterns by EGFR Mutation Status in Non-Small Cell Lung Cancer Patients in the USA: A Retrospective Database Analysis

INTRODUCTION

Targeted therapies, including tyrosine kinase inhibitors (TKIs) that target the sensitizing epidermal growth factor receptor (EGFR) gene are recommended for patients with non-small cell lung cancer (NSCLC). Most patients with NSCLC who test positive for the EGFR mutation and receive TKIs develop resistance to these drugs. Questions remain regarding which treatment sequence is optimal for patients with EGFR-mutant NSCLC, and few studies have evaluated patterns of TKI treatment use in NSCLC, irrespective of EGFR mutation status, in a real-world setting. This population-based study aimed to evaluate treatment patterns at a national level in the USA.

METHODS

This retrospective observational study used data from the US Oncology Network's iKnowMed database. Patients with advanced NSCLC who initiated first-line therapy with erlotinib and/or intravenous chemotherapy between January 1, 2012 and June 30, 2015 and met all other study criteria were included. Descriptive analyses assessed demographic and clinical characteristics and treatment patterns among the overall study cohort, as well as for specific erlotinib treatment subgroups, stratified by EGFR status.

RESULTS

Among the 3108 patients identified, 18.5% were EGFR positive, 49.8% were EGFR negative, and 31.7% were EGFR documented unknown. For the overall cohort, 18.4% received first-line erlotinib monotherapy, fewer than 1% received first-line combination therapy (erlotinib plus chemotherapy), 4.7% received second-line erlotinib monotherapy, and 3.3% received second-line combination therapy. First-line erlotinib monotherapy was used in 77.8% of all EGFR positive patients. Almost two-thirds of the overall cohort were not observed to have advanced to second-line therapy.

CONCLUSIONS

As treatment options evolve, this study provides real-world treatment patterns that suggest concordance with NCCN guidelines and confirm the remaining need to understand sequencing of therapies and related outcomes.

FUNDING

Eli Lilly and Company.

Real-World Treatment Patterns, Overall Survival, and Occurrence and Costs of Adverse Events Associated With Second-Line Therapies for Medicare Patients With Advanced Non-Small-Cell Lung Cancer

INTRODUCTION

Real-world data on current treatment practices for non-small-cell lung cancer (NSCLC) are needed to understand the place in therapy and potential economic impact of newer therapies.

PATIENTS AND METHODS

This retrospective cohort study identified patients ≥ 65 years old in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database with first-time diagnosis of stage IIIB/IV NSCLC from 2007-2011 who received second-line therapy after first-line platinum-based chemotherapy from 2007 through mid-2013. Second-line regimens, health care resource use, adverse events (AEs), and associated costs were analyzed descriptively. Overall survival was determined by Kaplan-Meier test. Costs were adjusted to 2013 US dollars.

RESULTS

We identified 4033 patients with advanced NSCLC who received second-line therapy (47% of those who received first-line platinum-based chemotherapy). Mean (SD) age was 73 (5) years, 2246 (56%) were male; 1134 (28%) and 2899 (72%) had squamous and nonsquamous NSCLC, respectively. The 4 most common second-line regimens were pemetrexed (22%), docetaxel (12%), carboplatin/paclitaxel (11%), and gemcitabine (7%). Median overall survival from second-line therapy initiation was 7.3 months (95% confidence interval, 7.0-7.7). Dyspnea and anemia were the most common AEs of interest, affecting 29% and 26% of patients, respectively; atypical pneumonia was associated with the highest AE-related costs (mean, $5339). The mean total per-patient-per-month cost was $10,885; AE-related per-patient-per-month costs totaled $1036 (10%). Costs were highest for pemetrexed-treated patients.

CONCLUSION

These real-world data illustrate the variety of second-line regimens, poor prognosis, and high cost of second-line chemotherapy for patients with advanced NSCLC treated before the approval of immunotherapies for these patients.

Real-World Treatment Patterns, Overall Survival, and Occurrence and Costs of Adverse Events Associated With First-line Therapies for Medicare Patients 65 Years and Older With Advanced Non-small-cell Lung Cancer: A Retrospective Study

PURPOSE

This study sought to better understand real-world treatment patterns, overall and non-small-cell lung cancer (NSCLC)-specific survival, adverse event (AE) occurrence, and economic impact of first-line cancer therapies in Medicare patients.

PATIENTS AND METHODS

This retrospective cohort study identified patients ≥ 65 years in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database who received a first-time advanced (stage IV) NSCLC diagnosis from 2007 to 2011, and who received first-line platinum-based chemotherapy from 2007 through mid-2013. First-line regimens, healthcare resource use, occurrence of AEs, and associated costs (2013 US dollars) were analyzed. Median survival was determined using the Kaplan-Meier method.

RESULTS

Surprisingly, only 46% of patients (n = 13,472) with stage IIIB/IV NSCLC received systemic therapy, and 5931 received platinum-based therapy. The mean age was 73 years, with 3354 (57%) males; 1489 (25%) had squamous and 4442 (75%) nonsquamous histology. The most common regimens were carboplatin doublets (70%), including carboplatin/paclitaxel (38%), carboplatin/pemetrexed (12%), carboplatin/gemcitabine (11%), and carboplatin/docetaxel (7%). The median overall survival from first-line therapy initiation was 7.2 months (95% confidence interval, 7.0-7.5 months). Dyspnea and anemia were the most common AEs of interest, whereas atypical pneumonia was associated with the greatest AE-related costs (mean, $5044). The mean total per-patient-per-month cost was $11,909, with AE-related costs comprising 9% of total costs. The highest costs and survival were observed for patients treated with carboplatin/pemetrexed and bevacizumab/carboplatin/paclitaxel.

CONCLUSIONS

These real-world data illustrate the most common first-line regimens by histology, overall survival, AEs, and some of the high AE-related costs of therapy for advanced NSCLC, and provides extremely useful information for clinicians.

Severe adverse events impact overall survival and costs in elderly patients with advanced non-small cell lung cancer on second-line therapy

OBJECTIVES

Elderly patients with advanced non-small lung cancer (aNSCLC) represent a high-risk patient population due to disease burden, comorbidities, and performance status, particularly after progressing on first-line therapy. Among elderly patients who receive second-line therapy, treatment related toxicities can have substantial impact on both clinical and economic outcomes. This study assessed the impact of severe adverse events (AEs) during second-line therapy on overall survival (OS) and all-cause heathcare costs in elderly with aNSCLC.

MATERIALS AND METHODS

Patients with aNSCLC aged ≥65 years who initiated second-line chemotherapy/targeted therapy were identified in the SEER-Medicare database (2007-2011). Fifty-seven AEs were identified by literature review and consultation with two oncologists. Severe AEs were defined as AEs that required a hospitalization and were operationalized based on AE diagnosis(es) recorded during hospitalizations. OS post-second-line initiation and healthcare costs during second-line were compared between patients with and without severe AEs.

RESULTS

Among 3967 patients initiating second-line therapy, 1624 (41%) had ≥1 severe AE, where hypertension (26%), anemia (24%), and pneumonia (23%) were most commonly reported. Patients with and without severe AEs had similar demographic and cancer characteristics at diagnosis and similar second-line treatment regimens, but patients with severe AEs had more comorbidities at second-line initiation. Median OS was lower in patients with versus without severe AEs (6 vs. 11 months). After multivariate adjustment, hazard of death was more than twice higher in patients with versus without severe AEs (adjusted hazard ratio [HR] 2.31, 95% CI 2.16-2.47). Healthcare costs were more than twice higher in patients with versus without severe AEs ($16,135 vs. $7559 per-patient-per-month).

CONCLUSION

Severe AEs among elderly patients with aNSCLC treated with second-line chemotherapy/targeted therapy were found to be associated with decreased OS and increased healthcare costs. Results suggest a potential link between severe AEs in second-line treated aNSCLC elderly and patient survival and economic burden to the healthcare system.

Identifying Subsequent Therapies in Patients with Advanced Non-Small Cell Lung Cancer and Factors Associated with Overall Survival

STUDY OBJECTIVES

To identify subsequent therapies used after first-line therapies in patients with advanced non-small cell lung cancer (NSCLC), compare overall survival (OS) associated with subsequent therapies, and evaluate factors associated with OS in these patients.

METHODS

The study was a retrospective cohort analysis of patients with advanced NSCLC (stage IIIB/IV) who were initiated on first-line therapy from January 1, 2008, through September 30, 2013, and afterward given subsequent chemotherapy (index date). Patients had to be 18 years or older at the time of diagnosis of advanced NSCLC. Patients were followed from the index date until one of the following end points: end of the study (September 30, 2014), disenrollment from the health plan, or death-whichever came the earliest. The primary outcome was OS. Kaplan-Meier curves and Cox proportional hazard models were used to analyze OS and evaluate the factors associated with OS.

RESULTS

The analysis included 1280 patients on subsequent therapies. The most common subsequent therapies were pemetrexed (284 patients [22%]), erlotinib (216 patients [17%]), and docetaxel (139 patients [11%]). Patients from the singlets group had a lower OS at 6.3 months compared with all other groups: pemetrexed based, combination of pemetrexed and bevacizumab based, bevacizumab based, doublets, and tyrosine kinase inhibitors (p<0.0001). Factors associated with greater OS included age younger than 65 years, female gender, and a longer time between initiation of first and subsequent therapies. Factors associated with a reduction in OS were pemetrexed-based or singlet regimens for subsequent therapy, diagnosis of squamous histology, and a higher number of adverse events prior to subsequent therapy.

CONCLUSION

We found that a subsequent therapy consisting of singlets is associated with reduced OS compared with other chemotherapy groups. Patient characteristics such as female gender, age younger than 65 years, diagnosis of nonsquamous histology, and/or a longer time frame between initiation of first-line and subsequent chemotherapy are associated with longer survival.

Treatment patterns and outcomes in patients with non-squamous advanced non-small cell lung cancer receiving second-line treatment in a community-based oncology network

OBJECTIVES

This retrospective study used the US Oncology iKnowMed(TM) database, billing claims, and chart reviews to report treatment patterns and outcomes in late-stage non-small cell lung cancer (NSCLC) in US community oncology practices.

MATERIALS AND METHODS

Eligibility criteria included non-squamous NSCLC, stage IIIB/IV at diagnosis, ECOG performance status (PS) <3, and initiation of 2nd-line therapy (defined as index date) between 1/1/2007 and 6/30/2011 with ≥ 1 year follow-up. Key outcomes were overall survival (OS), progression-free survival(PFS), time-to-progression (TTP), and time-to-hospitalization (post-index date). Kaplan–Meier and Cox proportional hazard models were used to characterize the distribution and predictors of outcomes.

RESULTS

1168 patients were eligible for the study. The most frequent 2nd-line therapies were pemetrexed(54.4%), erlotinib-containing regimens (17.6%), and docetaxel (10.0%). Median OS and PFS were 7.5 (95%confidence interval [CI]: 6.6–8.4) and 4.1 (95% CI: 3.7–4.5) months, respectively; 57% of patients were hospitalized post-index date. EGFR testing rates were 2.3% before 2010, 15.2% in 2010, and 32.0% in 2011 (P < .001). Of EGFR-positive patients, 50.0% received erlotinib-containing regimens compared with 16.9% of EGFR-negative patients (P = 0.001). An increased risk of shorter time-to-hospitalization, after controlling for other covariates, was associated with PS = 1 (hazard ratio [HR] = 1.51; P < .001) or PS = 2(HR = 1.68; P = .001) compared with PS = 0, pre-existing comorbid fatigue (HR = 1.64; P = .003) compared with no comorbid fatigue, and progression (HR = 1.92; P < .001), when it occurred, compared with no progression. Compared with other 2nd-line treatment, erlotinib-containing regimens prolonged adjusted TTP (HR = 0.69; P = .015).

CONCLUSIONS

This retrospective observational study provides new insights into treatment patterns,biomarker testing, and outcomes in advanced NSCLC within the context of a large community oncology network. Outcomes of these community practice patients, although poor, were similar to those reported in 2nd-line clinical trials for relevant regimens. EGFR testing in community practice rose rapidly after 2010.

A review of economic impact of targeted oral anticancer medications

There has been a rapid increase in the use of targeted oral anticancer medications (OAMs) in the past decade. As OAMs are often expensive, economic consideration play a significant role in the decision to prescribe, receive or cover them. This paper performs a systematic review of costs or budgetary impact of targeted OAMs to better understand their economic impact on the healthcare system, patients as well as payers. We present our review in a summary table that describes the method and main findings, take into account multiple factors, such as country, analytical approach, cost type, study perspective, timeframe, data sources, study population and care setting when we interpret the results from different papers, and discuss the policy and clinical implications. Our review raises a concern regarding the role of sponsorship on findings of economic analyses as the vast majority of pharmaceutical company-sponsored studies reported cost advantages toward the sponsor's drugs.

Treatment patterns and healthcare costs among patients with advanced non-small-cell lung cancer

SUMMARY Aim: To identify contemporary first- and second-line treatment patterns for advanced non-small-cell lung cancer (aNSCLC) and associated costs. Methods: This study identified aNSCLC patients through an oncology registry linked to a large US commercial claims database. Patients with aNSCLC (stage IIIb or IV) and continuous enrollment in the health plan from diagnosis until death were included. First and second lines of therapy and their associated costs were determined. Results: The most common first-line regimens (n = 335) were platinum–taxane doublets alone (29%) or in combination with bevacizumab (14%) or pemetrexed (6%). Most second-line regimens (n = 74) contained pemetrexed, bevacizumab and/or erlotinib. Mean total healthcare costs ranged from US$19,182 to US$167,847 (first-line) and from US$35,737 to US$135,364 (second-line). Systemic therapy represented 20–55% of first-line and 22–68% of second-line total costs. Conclusion: Pemetrexed and targeted therapies are prevalent in both first- and second-line regimens. Total and systemic therapy-related costs exhibited considerable variability by regimen.

A cross-country review of data collected on non-small cell lung cancer (NSCLC) patients in cancer registries, databases, retrospective and non-randomized prospective studies

INTRODUCTION

An increased number of pharmacotherapies exist to treat advanced NSCLC. This necessitates a review of the available information on routine-care treatment patterns, the outcome of treatment, and resource utilization for patients diagnosed and treated with advanced NSCLC that could inform evidence-based treatment decisions and aid decisions on the most cost-effective treatment alternatives.

METHODS

PubMed and the Health Economic Evaluations Database were searched for retrospective or non-randomized prospective studies between January 2000 and May 2012 that included information on treatment patterns, treatment outcomes including health-related quality-of-life (HRQoL), and resource utilization. In addition, registries and databases were identified from retrieved publications and internet searches. Data collected in registries and databases was summarized for eight European countries (Belgium, France, Germany, Italy, Sweden, Turkey, the Netherlands, the UK), Australia, and Canada.

RESULTS

The literature search resulted in 410 studies, whereof 87 studies met the study inclusion criteria. In total, 49 were retrospective chart reviews or database analyses, 30 non-randomized prospective studies, and eight HRQoL studies. Two studies compared treatment patterns and/or treatment outcomes across countries. Altogether, 181 cancer registries in the countries studied were identified. Clinical cancer-specific patient registries were identified in Australia and Germany. Databases or linkage systems that enable retrieval of complete information of patient disease history were found in Australia, Canada, the Netherlands, Sweden, and the UK. Cancer registries and databases were found to collect information on NSCLC patient demographics, NSCLC or lung cancer diagnosis, disease stage, performance status, treatment, treatment outcomes, and resource use. Differences existed between country registries and databases in whether information was collected on each of these data points.

CONCLUSION

The literature review revealed few published NSCLC studies on treatment, treatment outcomes, and resource use in routine clinical practice and on HRQoL. Registries and databases were found to collect some of this information, however not systematically.

Economic evaluation of pemetrexed versus erlotinib as second-line treatment of patients with advanced/metastatic non-small cell lung cancer in Greece: a cost minimization analysis

OBJECTIVES

An economic evaluation was conducted in conjunction with a prospective, multicenter, randomized trial, to compare pemetrexed with erlotinib in pretreated patients with metastatic non-small cell lung cancer (NSCLC) in Greece.

METHODS

The effectiveness of treatments examined was comparable; thus, cost minimization analysis was conducted to evaluate which option is less costly. Patient-level resource utilization data were combined with unit cost data, which were aggregated to compute the total treatment cost for each patient. The analysis was conducted with respect to the individual incurring the cost. Due to the limited life-expectancy of the patients, discounting was unnecessary. Since data were right censored, the Bang and Tsiatis method was employed to identify unbiased estimators of the mean cost per treatment arm, while other methods were employed for sensitivity analysis. To analyze uncertainty and to construct uncertainty intervals (UI), stochastic analysis was performed based on 5000 bootstrap replications.

RESULTS

The one-year survival rate was 28.3% in the pemetrexed arm and 31.7% in the erlotinib arm, while the corresponding median survival over the follow-up period was 7.1 and 6.7 months, respectively (P = 0.765). Total cost in the pemetrexed arm was €10508 (95% UI: €9552-€11488), while in the erlotinib arm the cost was €9563 (95% UI: €8499-€10711); thus, no statistically significant difference was found between the comparators (P = 0.206). Results remained constant for all sensitivity analyses.

CONCLUSIONS

There is no survival or cost difference between erlotinib and pemetrexed; thus, these therapies are equivalent. Further studies are needed to determine whether other parameters, such as quality of life, differ among treatment options.