Effectiveness of neoadjuvant concurrent chemoradiotherapy versus up-front proctectomy in clinical stage II-III rectal cancer: A population-based study

Effectiveness of image-guided radiotherapy for rectal cancer patients treated with neoadjuvant concurrent chemoradiotherapy: A population-based propensity score-matched analysis

AIM

The effects of image-guided radiotherapy (IGRT, an advanced RT technology) have been debated in the literature. We compared the outcomes of locally advanced rectal cancer (LARC) patients treated with neoadjuvant concurrent chemoradiotherapy (NCCRT; with vs without IGRT) in a large population-based propensity score (PS)-matched analysis.

METHODS

We identified LARC patients diagnosed between 2007 and 2015 via the Taiwan cancer registry (TCR) and constructed a PS-matched cohort to balance observable potential confounders. Outcomes (R0 resection, overall survival, incidence of local regional recurrence [ILRR], rectal cancer mortality [IRCM], other cancer mortality [IOCM] and cardiovascular mortality [ICVM]) were obtained from TCR and the national death registry. We compared the hazard ratio (HR) of death and other endpoints between IGRT and non-IGRT groups. We performed supplementary analysis (SA) to evaluate the robustness of these results in a subgroup, taking an additional potential confounder into account.

RESULTS

Our study population comprised of 586 patients that were balanced with regard to observed covariables. There was no significant difference in HR for death (0.99; 95% confidence interval 0.70-1.39; P = 0.94) between IGRT and non-IGRT groups. There were also no significant differences in R0 resection, ILRR, IRCM, IOCM or ICVM. The results of our SA were consistent with these findings.

CONCLUSION

For LARC patients treated with NCCRT, the treatment outcome was not significantly different among patients treated with and without IGRT. Further study is needed to clarify these results with consideration to additional potential confounding factors and toxicity profiles at endpoints.

Capecitabine versus 5-fluorouracil in neoadjuvant chemoradiotherapy of locally advanced rectal cancer: A meta-analysis

BACKGROUND

The differences in efficacy between capecitabine and 5-fuorouracil (5-FU) in neoadjuvant chemoradiotherapy (CRT) of locally advanced rectal cancer (LARC) are not well recognized. We performed this meta-analysis to analyze the effect of capecitabine and 5-FU on neoadjuvant CRT to more accurately understand the differences between the 2 drugs.

METHODS

MEDLINE, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Database were performed to identify all published studies investigating the efficacy of capecitabine in neoadjuvant CRT of LARC versus 5-FU before August, 2017. Primary endpoint was the odds ratio (OR) for improving pathological complete response (pCR) rate of patients with LARC. Secondary endpoints were the ORs of efficiency for downstaging tumor and increasing R0 resection in patients with LARC. Safety analyses were also performed. The OR was the principal measurement of effect, which was calculated as capecitabine group versus 5-FU group, and was presented as a point estimate with 95% confidence intervals (CIs). All calculations and statistical tests were performed using RevMan 5.3 software.

RESULTS

In all, 2916 patients with LARC enrolled in the 10 studies were divided into capecitabine group (n = 1451) and 5-FU group (n = 1465). The meta-analysis showed that capecitabine improved pCR (OR 1.34, 95% CI 1.10-1.63), and R0 resection rate (OR 1.92, 95% CI 1.10-3.36). There were no statistically significant differences either in overall downstaging rate (OR 1.31, 95% CI 0.79-2.16) or in the tumor downstaging rate (OR 1.24, 95% CI 0.79-1.92), but there was a significant difference of the nodal downstaging rate between the 2 groups (OR 1.68, 95% CI 1.11-2.54). There was no statistically significant difference in sphincter preservation rate between the 2 groups (OR 1.36, 95% CI 0.96-1.92). No obvious safety concerns about mortality and complications were raised in these studies. There were no statistically significant differences in 3-year disease-free-survival (OR 1.29, 95% CI 0.75-2.20), and in grade 3 to 4 acute toxicity during CRT (OR 0.63, 95% CI 0.31-1.30).

CONCLUSIONS

Compared with 5-FU-based neoadjuvant CRT, capecitabine-based neoadjuvant CRT can safely improve pCR, nodal down-staging, ad R0 resection of patients with LARC.

Effect of dendritic cell-cytokine-induced killer cells in patients with advanced colorectal cancer combined with first-line treatment

BACKGROUND

Surgical resection combined with adjuvant chemotherapy is considered as the gold-standard treatment for advanced colorectal cancer patients. These patients have a poor 5-year survival rate of 5% or less. Furthermore, a large dose of chemotherapy can produce adverse side effects and severe toxicity. Therefore, this retrospective study aimed to evaluate the efficacy of dendritic cell-cytokine-induced killer (DC-CIK) cell infusion as an adjuvant therapy in patients with advanced colorectal cancer combined with first-line treatment.

METHODS

A total of 142 patients with stage III/IV colorectal carcinoma who had been treated with first-line therapy were included in this study. Among these patients, 71 patients received first-line treatment only (non-DC-CIK group), while the other 71 patients who had similar demographic and clinical characteristics received a DC-CIK cell infusion combined with first-line treatment (DC-CIK group). These patients were followed up until August 2014. Data were analyzed by Kaplan-Meier and Cox regression.

RESULTS

Our results showed that the 5-year overall survival (OS) rate for the DC-CIK group versus the non-DC-CIK group was 41.3 versus 19.4% (p = 0.001) and the 5-year progression-free survival (PFS) rate for the DC-CIK group versus the non-DC-CIK group was 57.4 versus 33.6% (p = 0.022).

CONCLUSIONS

Our results showed that patients with advanced colorectal cancer might benefit from DC-CIK immunotherapy combined with first-line therapy by significantly prolonging 5-year OS and PFS.

Cost-effectiveness of neoadjuvant concurrent chemoradiotherapy versus esophagectomy for locally advanced esophageal squamous cell carcinoma: A population-based matched case-control study

Background

Neoadjuvant concurrent chemoradiotherapy (NCCRT) is often considered for locally‐advanced esophageal squamous cell carcinoma (LA‐ESCC) patients; however, no data regarding the cost‐effectiveness of this treatment is available. Our study aimed to evaluate the cost‐effectiveness of NCCRT versus esophagectomy for LA‐ESCC at population level.

Methods

We identified LA‐ESCC patients diagnosed within 2008–2009 and treated with either NCCRT or esophagectomy through the Taiwan Cancer Registry. We included potential confounding covariables (age, gender, residency, comorbidity, social‐economic status, disease stage, treating hospital level and surgeon's experience, and the use of endoscopic ultrasound before treatment) and used propensity score (PS) to construct a 1:1 population. The duration of interest was three years within the date of diagnosis. Effectiveness was measured as overall survival. We took the payer's perspective and converted the cost to 2014 United States dollars (USD). In sensitivity analysis, we evaluated the potential impact of an unmeasured confounder on the statistical significance of incremental net benefit at suggested willingness‐to‐pay.

Results

Our study population constituted 150 PS matched subjects. The mean cost (2014 USD) and survival (year) were higher for NCCRT compared with esophagectomy (US$91,460 vs. $75,836 for cost; 2.2 vs. 1.8 for survival) with an estimated incremental cost‐effectiveness ratio of US$39,060/life‐year.

Conclusions

When compared to esophagectomy, NCCRT is likely to improve survival and is probably more cost‐effective. Cost‐effectiveness results should be interpreted with caution given our results were sensitive to potential unmeasured confounder(s) in sensitivity analysis.

Cost and effectiveness of image-guided radiotherapy for non-operated localized lung cancer: a population-based propensity score-matched analysis

BACKGROUND

Image-guided radiotherapy (IGRT) is a novel technology to enhance RT delivery accuracy. However, the clinical effectiveness and cost-effectiveness are less clear. The aim of our study is to compare the cost and effectiveness of conventional fractionated RT for non-operated localized lung cancer delivered with vs. without IGRT via this population-based propensity score (PS) matched analysis.

METHODS

We identified eligible patients diagnosed within 2007-2010 through a comprehensive population-based database containing cancer, death registries, and reimbursement data in Taiwan. The primary duration of interest (DOI) was 2 years within diagnosis. Effectiveness was measured as survival whereas direct medical cost was measured from the payers' perspective. In supplementary analysis (SA), we estimated the cost-effectiveness in consider of out-of-pocket (OOP) payment and 4 years as DOI.

RESULTS

Our study population constituted 124 patients. Within 2 years, both the mean cost (2014 USD) and survival (life-year, LY) were higher for IGRT ($60,774 vs. $60,554; 1.43 vs. 1.37). The incremental cost-effectiveness ratio (ICER) when IGRT was compared to non-IGRT was 3,667 (USD/LY). The chance for IGRT to be cost-effective was around 68% & 70% at willingness-to-pay threshold 50,000 USD/LY and 150,000 USD/LY respectively. IGRT remained cost-effective in SA.

CONCLUSIONS

We provide the first empirical evidence that when compared to non-IGRT, IGRT was potentially cost-effective.

Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative to conventional surgery (CS). We aimed to estimate the short-term cost-effectiveness of VATS vs. CS for clinical stage I non-small cell lung cancer (NSCLC-c-stage-I) patients from the payer's perspective (National Health Insurance).

METHODS

We identified NSCLC-c-stage-I patients diagnosed and received surgery within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was 1 year. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment.

RESULTS

Our study population constituted 966 patients. The mean hospital stay [days, standard deviation (SD)] were 14.4 [7] and 16.1 (7.7) for VATS and CS respectively (P=0.002). The mean cost (2013 USD) and survival (year) was $22,316 vs. $21,976 and 0.98 vs. 0.974 for VATS vs. CS. The probability for VATS to be cost-effective (i.e., positive net benefit) was 0.49 & 0.56 at willingness-to-pay (WTP) 50,000 & 100,000 USD/life-year, respectively.

CONCLUSIONS

We provide the first empirical evidence that when compared to CS, VATS was potentially cost-effective in the short term (1 year) within the common WTP levels in Taiwan.

Cost-effectiveness of chemotherapy combined with thoracic radiotherapy versus chemotherapy alone for limited stage small cell lung cancer: A population-based propensity-score matched analysis

BACKGROUND

The addition of thoracic radiotherapy improves the outcome of limited stage small cell lung cancer (LS-SCLC), however, the cost-effectiveness of this process has never been reported. We aimed to estimate the short-term cost-effectiveness of chemotherapy combined with thoracic radiotherapy (C-TRT) versus chemotherapy alone (C/T) for LS-SCLC patients from the payer's perspective (Taiwan National Health Insurance).

METHODS

We identified LS-SCLC patients diagnosed within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was one year within diagnosis. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment. We used a net benefit (NB) approach to evaluate the cost-effectiveness at various willingness-to-pay (WTP) levels. Sensitivity analysis regarding potential unmeasured confounder(s) was performed.

RESULTS

Our study population constituted 74 patients. The mean cost (2013 USD) and survival (year) was higher for C-TRT (42 439 vs. 28 357; 0.94 vs. 0.88). At the common WTP level (50 000 USD/life-year), C-TRT was not cost effective (incremental NB - 11 082) and the probability for C-TRT to be cost effective (i.e. positive net benefit) was 0.005. The result was moderately sensitive to potential unmeasured confounder(s) in sensitivity analysis.

CONCLUSIONS

We provide evidence that when compared to C/T, C-TRT is effective in improving survival, but is not cost-effective in the short-term at a common WTP level from a payer's perspective. This information should be considered by clinicians when discussing thoracic radiotherapy with their LS-SCLC patients.

Immune response, safety, and survival and quality of life outcomes for advanced colorectal cancer patients treated with dendritic cell vaccine and cytokine-induced killer cell therapy

Purpose. To determine the immune response after dendritic cell (DC) vaccine and cytokine-induced killer cells (CIK) therapy and assess its associated toxicity, survival benefit, and changes in the quality of life (QOL) of advanced colorectal cancer (CRC) patients. Methods. We recruited 100 patients with unresectable CRC orrelapsed CRC after surgery who received DC vaccine and CIK cells (group immunotherapy, group I), and, as a control, 251 patients who had similar characteristics and underwent similar treatments, except for this immunotherapy (group nonimmunotherapy, group NI). After a follow-up period of 489.2 ± 160.4 days, overall survival (OS) of the two groups was compared using the Kaplan-Meier method. Results. In group I, 62% of patients developed a positive delayed type hypersensitivity response, and most patients showed an improvement in physical strength (75.2%), appetite (74.2%), sleeping (72.1%), and body weight (70.1%). Adverse events were fever (29.5%), insomnia (19.2%), anorexia (9.1%), sore joints (5.4%), and skin rash (1.0%). No toxicity was observed in patients treated with DC vaccine and CIK therapy. OS was significantly longer in group I than in group NI (P = 0.043). Conclusion. DC vaccine and CIK therapy were safe and could induce an immune response against CRC, thereby improving QOL and prolonging OS.