Incidence and prevalence of neuroendocrine tumors of the lung: analysis of a US commercial insurance claims database

Clinical management of typical and atypical carcinoids/neuroendocrine tumors in ENETS centres of excellence (CoE): Survey from the ENETS lung NET task force

Lung carcinoid tumours are neuroendocrine neoplasms originating from the bronchopulmonary tract's neuroendocrine cells, accounting for only 1%-3% of all lung cancers but 30% of all neuroendocrine tumours. The incidence of lung carcinoids, both typical and atypical, has been increasing over the years due to improved diagnostic methods and increased awareness among clinicians and pathologists. The most recent WHO classification includes a subgroup of lung carcinoids with atypical morphology and higher mitotic count and/or Ki67 labelling index. Despite appropriate surgery, the 5-year survival rate for atypical carcinoids barely exceeds 50%-70%. The role of adjuvant therapy in lung carcinoids is not well-defined, and clinical decisions are generally based on the presence of high-risk features. Long-term follow-up is essential to monitor for recurrence, although the optimal follow-up protocol remains unclear. To address the lack of consensus in clinical management decisions, the European Neuroendocrine Tumor Society (ENETS) initiated a survey among 20 expert centres. The survey identified varied opinions on approaches to imaging, surgery, use of adjuvant therapy, and follow-up protocols. Notably, the absence of dedicated multidisciplinary lung neuroendocrine tumour boards in some centres was evident. Experts agreed on the need for a prospective adjuvant trial in high-risk patients, emphasizing the feasibility of such a study. In conclusion, the study highlights the need for a more uniform adoption of existing guidelines in the management of lung carcinoid tumours and emphasizes the importance of international collaboration to advance research and patient care. Close collaboration between healthcare providers and patients is vital for effective long-term surveillance and management of these rare tumours.

Advancing the utilization of real-world data and real-world evidence in clinical pharmacology and translational research-Proceedings from the ASCPT 2023 preconference workshop

Real-world data (RWD) and real-world evidence (RWE) are now being routinely used in epidemiology, clinical practice, and post-approval regulatory decisions. Despite the increasing utility of the methodology and new regulatory guidelines in recent years, there remains a lack of awareness of how this approach can be applied in clinical pharmacology and translational research settings. Therefore, the American Society of Clinical Pharmacology & Therapeutics (ASCPT) held a workshop on March 21st, 2023 entitled "Advancing the Utilization of Real-World Data (RWD) and Real-World Evidence (RWE) in Clinical Pharmacology and Translational Research." The work described herein is a summary of the workshop proceedings.

Competing risk analysis of cardiovascular-specific mortality in typical carcinoid neoplasms of the lung: A SEER database analysis

Cardiovascular mortality (CVM) is a growing concern for cancer survivors. This study aimed to investigate the mortality patterns of individuals with typical carcinoid (TC) tumors, identify independent predictors of CVM, and compare these risk variables with those associated with TC deaths. The Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2019 was utilized for obtaining data on patients with TC. Standardized mortality rates were employed to evaluate the risk of CVM while multivariate competing risk models were used to determine the association between patient characteristics and the probability of CVM or TC-related deaths. Our findings show that TC patients had an increased risk of CVM, with an standardized mortality rates of 1.12 (95% CI:1.01-1.25). Furthermore, we discovered that age at diagnosis, marital status, year of diagnosis, SEER stage, site, year of diagnosis, surgery, radiotherapy, and chemotherapy all contributed independently to the risk of CVM in patients with TC, whereas age at diagnosis, sex, race, SEER stage, site, year of diagnosis, surgery, radiotherapy, and chemotherapy all contributed significantly to TC mortality. Compared to the general population in the United States, patients with TC are significantly more likely to acquire CVM. Timely introduction of cardioprotective treatments is critical for preventing CVM in patients with TC.

Estimation of oral disease burden from claims and self-reported data

OBJECTIVE

To compare the use of Medicaid and commercial claims data with self-reported survey data in estimating the prevalence of oral disease burden.

METHODS

We analyzed 2018 Medicaid claims from the IBM Watson Medicaid Marketscan database, commercial claims from the IBM Dental Database, and Medical Expenditure Panel Survey (MEPS) data. The estimate of oral disease burden was based on standard metrics using periodontal and caries-related Current Dental Terminology (CDT) procedure codes. A direct comparison between the data sets was also done.

RESULTS

Unweighted Medicaid and commercial enrollees were 11.6 and 10.5 million, respectively. The weighted proportion from MEPS for Medicaid and commercial plans ranged from 80 to 208 million people. Estimates of caries-related treatments were calculated from IBM Watson and MEPS data for Medicaid enrollees (13% vs. 12%, respectively) and commercial claims (25% vs. 17%, respectively). Prevalence of periodontal related treatments for those with a dental visit was estimated for IBM Watson and MEPS enrollees for Medicaid (0.7% vs. 0.5%, respectively) and commercial claims (7% vs. 1.6%, respectively). Dental disease estimates were higher in individuals with at least one dental visit across cohorts. Prevalence of disease for those with a dental visit based on specific procedures were higher in commercial plans than in Medicaid.

CONCLUSIONS

Claims data has the potential to serve as a proxy measure for the estimate of dental disease burden in a population.

Gastroenteropancreatic Neuroendocrine Tumors

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are the most common type of neuroendocrine tumors and are being increasingly identified in clinical practice. The diagnosis, staging, management, and surveillance of GEP-NETs rely heavily on endoscopy, and consequently, it is important for gastroenterologists to have a solid understanding of these tumors. This article reviews the presentation, diagnosis, and management of both localized and advanced GEP-NETs, with increased emphasis on the role of endoscopy, to enable gastroenterologists and other practitioners to have the necessary tools for the care of patients with these tumors.

Neuroendocrine Tumors: An Analysis of Prevalence, Incidence, and Survival in a Hospital-Based Study in Ecuador

Neuroendocrine tumors (NETs) represent a heterogeneous malignancy group of neoplasms, with a limited amount of data from Latin America. Thus, this observational study aimed to provide data about the prevalence, incidence, and survival rates for NET in Ecuadorian hospitals. The study was conducted using data from the Society for the Fight Against Cancer (SOLCA). We evaluated patients with NETs (2000−2020) using the HJ-Biplot method and Cox proportional hazards. Annual age-adjusted incidence and limited-duration prevalence in multivariable analyses as well as hazard ratios (HRs) for mortality and survival were obtained. In the years 2000−2020, the age-adjusted incidence rate increased by 9-fold in the stomach and by 7-fold in the breast. The incidence rates were 1.38 per 100,000 persons in the lung and at 1.79 per 100,000 persons in gastroenteropancreatic sites (rectum, stomach, and pancreas). The prevalence increased from 0.0027% in 2000 to 0.0736% in 2019 and 0.0245% in 2020. Overall survival was worse for metastatic NETs (HR, 4.061; 95% CI, 1.932−8.540; p < 0.001) and advanced local NETs (HR, 2.348; 95% CI, 1.007−5.475 p < 0.048) than for localized NETs. In conclusion, the NET incidence increased in the last 20 years and survival decreased over time, especially for metastatic tumors in the pancreas and the nostril.

Use of Real-World Evidence to Drive Drug Development Strategy and Inform Clinical Trial Design

Interest in real-world data (RWD) and real-world evidence (RWE) to expedite and enrich the development of new biopharmaceutical products has proliferated in recent years, spurred by the 21st Century Cures Act in the United States and similar policy efforts in other countries, willingness by regulators to consider RWE in their decisions, demands from third-party payers, and growing concerns about the limitations of traditional clinical trials. Although much of the recent literature on RWE has focused on potential regulatory uses (e.g., product approvals in oncology or rare diseases based on single-arm trials with external control arms), this article reviews how biopharmaceutical companies can leverage RWE to inform internal decisions made throughout the product development process. Specifically, this article will review use of RWD to guide pipeline and portfolio strategy; use of novel sources of RWD to inform product development, use of RWD to inform clinical development, use of advanced analytics to harness "big" RWD, and considerations when using RWD to inform internal decisions. Topics discussed will include the use of molecular, clinicogenomic, medical imaging, radiomic, and patient-derived xenograft data to augment traditional sources of RWE, the use of RWD to inform clinical trial eligibility criteria, enrich trial population based on predicted response, select endpoints, estimate sample size, understand disease progression, and enhance diversity of participants, the growing use of data tokenization and advanced analytical techniques based on artificial intelligence in RWE, as well as the importance of data quality and methodological transparency in RWE.

Exploration of machine learning techniques to examine the journey to neuroendocrine tumor diagnosis with real-world data

Aim: Machine learning reveals pathways to neuroendocrine tumor (NET) diagnosis. Patients & methods: Patients with NET and age-/gender-matched non-NET controls were retrospectively selected from MarketScan claims. Predictors (e.g., procedures, symptoms, conditions for which NET is misdiagnosed) were examined during a 5-year pre-period to understand presence of and time to NET diagnosis using conditional inference trees. Results: Among 3460 patients with NET, 70% had a prior misdiagnosis. 10,370 controls were included. Decision trees revealed combinations of factors associated with a high probability of being a patient with NET (e.g., abdominal pain, an endoscopic/biopsy procedure, vomiting) or longer times to diagnosis (e.g., asthma diagnosis with visits to >6 providers). Conclusion: Decision trees provided a unique examination of the journey to NET diagnosis.

A Population-Based Systematic Clinical Analysis With a Single-Center Case Series of Patients With Pulmonary Large Cell Neuroendocrine Carcinoma

BACKGROUND AND OBJECTIVES

This study aims to conduct an updated systematic analysis of patients with pulmonary large cell neuroendocrine carcinoma (PLCNC) in recent decades, concerning incidence and mortality trends, demographics, treatments, survival and death causes.

METHODS

Patients who were diagnosed with PLCNC at the Peking Union Medical College Hospital (PUMCH) between 2000 to 2020 were retrospectively analyzed. The population-based Surveillance, Epidemiology, and End Results (SEER) database were also retrieved. Frequencies and average annual age-adjusted rates (AAR) of PLCNC patients were calculated and analyzed by Joint-point regression. Univariate and multivariate Cox regression were used for identifying prognostic factors. Predictive nomograms for overall survival (OS) and cancer-specific survival (CSS) were developed and then validated by calculating C-index values and drawing calibration curves. Survival curves were plotted using the Kaplan-Meier method and compared by log-rank test. Causes of death were also analyzed by time latency.

RESULTS

A total of 56 PLCNC patients of the PUMCH cohort were included. Additionally, the PLCNC patients in the SEER database were also identified from different subsets. The AAR from 2001 to 2017 were 3.21 (95%CI: 3.12-3.30) per million. Its incidence and mortality rates in PLCNC patients increased at first but seemed to decline in recent years. Besides TNM stage and treatments, older age and male gender were independently associated with poorer survival, while marital status only affected CSS other than OS. The nomograms for OS and CSS presented great predictive ability and calibration performance. Surgery gave significantly more survival benefits to PLCNC patients, and chemotherapy might add survival benefits to stage II-IV. However, radiation therapy seemed to only improve stage III patients' survival.

CONCLUSIONS

This study supported some previous studies in terms of incidence, survival, and treatment options. The mortality rates seemed to decline recently, after an earlier increase. Among PLCNC patients, most of the deaths occurred within the first five years, while other non-PLCNC diseases increased after that. Thus, careful management and follow-up of other comorbidities are of equal importance. Our study may partly solve the dilemma caused by PLCNC's rarity and inspire more insights in future researches.

The Risk of Second Primary Malignancies in Patients With Lung Neuroendocrine Tumors: A Population-Based Study on SEER Database

PURPOSE

We investigated the at-risk sites of second primary malignancies (SPMs) and evaluate the risk factors of SPMs among lung neuroendocrine tumors (LNETs) survivors by using the surveillance, epidemiology, and end results (SEER) database.

METHODS

Propensity-score matching was performed to conduct a case-control study from the surveillance, epidemiology, and end results (SEER) database. Cox regression analysis and multiple primary standardized incidence ratios were performed to investigate the risk factors of occurrence of SPMs among patients with LNETs.

RESULTS

Of 3,206 patients with LNETs after matching, 539 developed SPMs. The risk of developing SPMs was higher in older patients (55-74 vs ≦54: hazard ratios [HR] 1.875; age ≧75 vs ≦54: HR 2.713), higher-stage of LNETs (regional vs localized: HR 1.387; distant vs localized: HR 2.732) and recent periods of diagnosis (2004-2014 vs 1984-1993: HR 1.735). Patients with SCLC, TC and LENEC had a higher risk for SPMs compared to general population. Lung and bronchus, larynx and some digestive organs had higher risk for SPMs while some sex hormone related organs like prostate, breast, and female reproductive system had a lower incidence of SPMs.

CONCLUSIONS

Patients with LNETs had overall higher risks of SPMs than general population. Different types of second primary malignancies occurred in different periods after LNETs were diagnosed. Further investigations are required to screen different second primary malignancies for those with primary LNETs.

Healthcare costs and resource utilization in patients with severe aplastic anemia in the US

Purpose: This study aimed to evaluate the healthcare resource utilization (HCRU) and costs for patients with severe aplastic anemia (SAA) using US claims data. Methods: This retrospective, observational database study analyzed claims data from the Truven MarketScan databases. SAA patients aged ≥2 years identified between 2014 and 2017 who were continuously enrolled for 6 months before their first SAA treatment or blood transfusion, with a ≥6-month follow-up, were included. Baseline demographics and comorbidities were evaluated. Monthly all-cause and SAA-related HCRU and direct costs in the follow-up period were analyzed and differences were presented for all patients and across age groups. Results: With an average follow-up period of 21.5 months, 939 patients were included in the study. Monthly all-cause and SAA-related HCRU [mean (SD)] were 1.65 days (2.61 days) and 0.18 days (0.70 days) for length of stay, 0.18 (0.23) and 0.01 (0.04) for hospital admissions, 0.25 (0.30) and 0.02 (0.07) for ER visits, 2.24 (1.40) and 0.46 (0.99) for office visits, and 2.90 (2.64) and 0.55 (1.31) for outpatient visits, respectively. On average, SAA patients received 0.15 (0.57) blood transfusions per month. Mean monthly all-cause direct costs were $28,280 USD ($36,127) [US dollars, mean (SD)]. Direct costs related to admissions were $11,433 USD (SD $25,040), followed by $624 USD ($1,703) for ER visits, $528 USD ($694) for office visits, $7,615 USD ($13,273) for outpatient visits, and $5,998 USD ($11,461) for pharmacy expenses. Monthly SAA-related direct costs averaged $7,884 USD (SD $16,254); of these costs, $1,608 USD ($7,774) were from admissions, $47 USD ($257) from ER visits, $127 USD ($374) from office visits, $1,462 USD ($4,994) from outpatient visits, and $4,451 USD ($10,552) from pharmacy expenses. Conclusion: SAA is associated with high economic burden, with costs comparable to blood malignancies, implying that US health plans should consider appropriately managing SAA while constraining the total healthcare costs when making formulary decisions.

Treatment adherence, healthcare resource utilization, and costs in patients with lung neuroendocrine tumors (lung NETs) in the USA

OBJECTIVE

To assess first-line treatment adherence, healthcare resource utilization, and costs in lung NET patients initiating pharmacologic treatments.

METHODS

In two US claims databases, patients aged ≥18 years with ≥1 inpatient or ≥2 outpatient lung NET claims within 12 months were identified. The first claim for pharmacologic treatments (e.g. somatostatin analogs [SSAs], cytotoxic chemotherapy [CC], targeted therapy [TT]) following diagnosis, between July 1, 2009-December 31, 2014, was defined as the index date. A 6-month pre-index period without any NET treatment, and ≥1-year post-index enrollment were required. Proportion of days covered (PDC) was calculated during follow-up. Descriptive statistics, including means, standard deviations, and frequencies/percentages for continuous and categorical data, respectively, were reported.

RESULTS

Of 354 patients with 1-year of follow-up, 252 initiated CC, 89 SSA, 3 TT, and 10 various combinations. Due to sample sizes, the remaining results focus only on CC and SSAs. Mean PDC (SD) was 0.320 (0.176) for CC and 0.673 (0.322) for SSAs; CC users had a mean (SD) of 33.3 (23.8) office visits and 0.79 (1.39) hospitalizations; SSA users had 23.1 (12.4) visits and 0.48 (1.07) hospitalizations. Mean total (SD) annual cost for CC users was $124,383 (135,836) and $98,713 (81,495) for SSA users. Among 163 patients with 2 years of follow-up, the annual mean cost in the second-year was $43,026 lower and $8110 higher than the first-year for CC and SSAs, respectively.

CONCLUSIONS

The majority of patients with lung NETs initiated CC; only about one quarter initiated SSA in the first-line. This descriptive study updates the utilization and costs of pharmacologically-treated lung NETs.