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Fariman SA, Jahangard Rafsanjani Z, Hasanzad M, Niksalehi K, Nikfar S. Upfront DPYD Genotype-Guided Treatment for Fluoropyrimidine-Based Chemotherapy in Advanced and Metastatic Colorectal Cancer: A Cost-Effectiveness Analysis. Value Health Reg Issues 2023; 37:71-80. [PMID: 37329861 DOI: 10.1016/j.vhri.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/26/2023] [Accepted: 04/29/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Fluoropyrimidines are the most widely used chemotherapy drugs for advanced and metastatic colorectal cancer (CRC). Individuals with certain DPYD gene variants are exposed to an increased risk of severe fluoropyrimidine-related toxicities. This study aimed to evaluate the cost-effectiveness of preemptive DPYD genotyping to guide fluoropyrimidine therapy in patients with advanced or metastatic CRC. METHODS Overall survival of DPYD wild-type patients who received a standard dose and variant carriers treated with a reduced dose were analyzed by parametric survival models. A decision tree and a partitioned survival analysis model with a lifetime horizon were designed, taking the Iranian healthcare perspective. Input parameters were extracted from the literature or expert opinion. To address parameter uncertainty, scenario and sensitivity analyses were also performed. RESULTS Compared with no screening, the genotype-guided treatment strategy was cost-saving ($41.7). Nevertheless, due to a possible reduction in the survival of patients receiving reduced-dose regimens, it was associated with fewer quality-adjusted life-years (9.45 vs 9.28). In sensitivity analyses, the prevalence of DPYD variants had the most significant impact on the incremental cost-effectiveness ratio. The genotyping strategy would remain cost-saving, as long as the genotyping cost is < $49 per test. In a scenario in which we assumed equal efficacy for the 2 strategies, genotyping was the dominant strategy, associated with less costs (∼$1) and more quality-adjusted life-years (0.1292). CONCLUSIONS DPYD genotyping to guide fluoropyrimidine treatment in patients with advanced or metastatic CRC is cost-saving from the perspective of the Iranian health system.
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Affiliation(s)
- Soroush Ahmadi Fariman
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mandana Hasanzad
- Medical Genomics Research Center, Tehran University of Medical Sciences, Tehran, Iran; Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kimia Niksalehi
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.
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2
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Traylor M, Walker JL, Corrigan AA, Hernandez MA, Newhouse SJ, Folarin AA, Patel H, Ross PJ, Sanderson JD, Spicer J, Prescott NJ, Mathew CG, Marinaki AM, Lewis CM. Exome array analysis of adverse reactions to fluoropyrimidine-based therapy for gastrointestinal cancer. PLoS One 2018; 13:e0188911. [PMID: 29715290 PMCID: PMC5929530 DOI: 10.1371/journal.pone.0188911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 11/15/2017] [Indexed: 12/31/2022] Open
Abstract
Fluoropyrimidines, including 5-fluororacil (5FU) and its pro-drug Capecitabine, are the common treatment for colorectal, breast, neck and head cancers—either as monotherapy or in combination therapy. Adverse reactions (ADRs) to the treatment are common and often result in treatment discontinuation or dose reduction. Factors contributing to ADRs, including genetic variation, are poorly characterized. We performed exome array analysis to identify genetic variants that contribute to adverse reactions. Our final dataset consisted of 504 European ancestry individuals undergoing fluoropyrimidine-based therapy for gastrointestinal cancer. A subset of 254 of these were treated with Capecitabine. All individuals were genotyped on the Illumina HumanExome Array. Firstly, we performed SNP and gene-level analyses of protein-altering variants on the array to identify novel associations the following ADRs, which were grouped into four phenotypes based on symptoms of diarrhea, mucositis, and neutropenia and hand-and-foot syndrome. Secondly, we performed detailed analyses of the HLA region on the same phenotypes after imputing the HLA alleles and amino acids. No protein-altering variants, or sets of protein-altering variants collapsed into genes, were associated with the main outcomes after Bonferroni correction. We found evidence that the HLA region was enriched for associations with Hand-and-Foot syndrome (p = 0.023), but no specific SNPs or HLA alleles were significant after Bonferroni correction. Larger studies will be required to characterize the genetic contribution to ADRs to 5FU. Future studies that focus on the HLA region are likely to be fruitful.
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Affiliation(s)
- Matthew Traylor
- Department of Medical and Molecular Genetics, King’s College London, London, United Kingdom
- * E-mail:
| | - Jemma L. Walker
- Department of Medical and Molecular Genetics, King’s College London, London, United Kingdom
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adele A. Corrigan
- Purine Research Laboratory, GSTS Pathology, Guy’s and St. Thomas’ Hospital NHS Foundation Trust, St. Thomas Hospital, London, United Kingdom
| | - Monica A. Hernandez
- Purine Research Laboratory, GSTS Pathology, Guy’s and St. Thomas’ Hospital NHS Foundation Trust, St. Thomas Hospital, London, United Kingdom
| | - Stephen J. Newhouse
- National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and (Institute of Psychiatry), King’s College London, London, United Kingdom
| | - Amos A. Folarin
- National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and (Institute of Psychiatry), King’s College London, London, United Kingdom
| | - Hamel Patel
- National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and (Institute of Psychiatry), King’s College London, London, United Kingdom
| | - Paul J. Ross
- Department of Gastroenterology, Guy’s and St. Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
| | - Jeremy D. Sanderson
- Department of Gastroenterology, Guy’s and St. Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
| | - James Spicer
- Division of Cancer Studies, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Natalie J. Prescott
- Department of Medical and Molecular Genetics, King’s College London, London, United Kingdom
| | - Christopher G. Mathew
- Department of Medical and Molecular Genetics, King’s College London, London, United Kingdom
- Sydney Brenner Institute for Molecular Bioscience, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthony M. Marinaki
- Purine Research Laboratory, GSTS Pathology, Guy’s and St. Thomas’ Hospital NHS Foundation Trust, St. Thomas Hospital, London, United Kingdom
| | - Cathryn M. Lewis
- Department of Medical and Molecular Genetics, King’s College London, London, United Kingdom
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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Mazzuca F, Borro M, Botticelli A, Mazzotti E, Marchetti L, Gentile G, La Torre M, Lionetto L, Simmaco M, Marchetti P. Pre-treatment evaluation of 5-fluorouracil degradation rate: association of poor and ultra-rapid metabolism with severe toxicity in a colorectal cancer patients cohort. Oncotarget 2018; 7:20612-20. [PMID: 26967565 PMCID: PMC4991479 DOI: 10.18632/oncotarget.7991] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/15/2016] [Indexed: 12/22/2022] Open
Abstract
Despite the wide use of 5-fluorouracil-based chemotherapy, development of severe toxicity that follow the treatment is not a rare event. The efforts to establish pretreatment tools for toxicity prediction, led to the development of various pharmacogenetic and biochemical assays, mainly targeted to assess the activity level of dihydropyrimidine dehydrogenase (DPD), the main metabolizing enzyme for 5-fluorouracil. Using peripheral blood mononuclear cells, we developed a biochemical assay, that is not limited to the evaluation of DPD activity, but determines the net result of all the enzymatic transformation of 5FU, in terms of the amount of drug consumed by the cells in a time unit. This parameter, named 5-fluorauracil degradation rate, presents a normal distribution inside the population and highlight the presence of an ultra-rapid metabolizers class of subjects, besides the expected poor metabolizers class. Here we will show that, in a colorectal cancer patient cohort, both poor and ultra-rapid metabolizers have significantly increased the risk of developing severe toxicity (grade3–4). Patient stratification depending on the individual 5-fluorouracil degradation rate allows to identify a 10% of the overall population at high risk of developing severe toxicity, compared to the 1.3% (as assessed in the Italian population) identified by the most commonly employed pharmacogenetic test, including the DPD polymorphism IVS14+1G>A.
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Affiliation(s)
- Federica Mazzuca
- Oncology Unit, Sant'Andrea Hospital, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Marina Borro
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Andrea Botticelli
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Eva Mazzotti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Luca Marchetti
- Department of Clinical Oncology, Policlinico Umberto I, Rome, Italy
| | | | - Marco La Torre
- Department of Clinical Oncology, Policlinico Umberto I, Rome, Italy
| | | | - Maurizio Simmaco
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Paolo Marchetti
- Oncology Unit, Sant'Andrea Hospital, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.,Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
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Wang B, Walsh SJ, Saif MW. Pancytopenia and Severe Gastrointestinal Toxicities Associated with 5-Fluorouracil in a Patient with Thymidylate Synthase (TYMS) Polymorphism. Cureus 2016; 8:e798. [PMID: 27774364 PMCID: PMC5071174 DOI: 10.7759/cureus.798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
5-Fluorouracil (5-FU) is one of the most commonly used chemotherapeutic agents in solid tumors, including colon, gastric and breast cancers. The pharmacogenetic syndrome of dihydropyrimidine dehydrogenase (DPD) deficiency leading to severe toxicity after administration of 5-flourouracil (5-FU) and capecitabine has been well-recognized. However, the data about the association of the target enzyme, thymidylate synthase (TYMS) with the toxicity of these agents is limited. A 50-year-old Caucasian woman with T2N2M0 Stage IIIB squamous cell rectal cancer after local surgical excision initiated 5-FU therapy with mitomycin-C and radiation therapy in the adjuvant setting. Following the first treatment with 5-FU, she developed grade III mucositis and grade IV neutropenia which delayed her second dose of therapy. Following her second dose of 5-FU, she again developed grade III mucositis, grade II diarrhea, pancytopenia, fever, and rectal bleeding requiring hospitalization. She was treated with blood and platelet transfusion, pegfilgrastim, IV antibiotics, and supportive therapy. Due to her severe clinical toxicity following chemotherapy involving 5-FU, we tested her for both DPD deficiency andTYMS polymorphisms. The patient was found to be homozygous for the TYMS polymorphism 5’TSER genotype 2R/2R*f, which has been associated with increased 5-FU drug sensitivity and susceptibility to 5-FU toxicity. Our case report further underlines the fact that TYMS polymorphism not only predicts response to 5-FU by relating to intratumoral-TYMS mRNA expression but also the toxicity in these patients receiving fluoropyrimidines. In brief, TYMS genotype variations present a dilemma in 5-FU-driven cancer therapy- overexpression leads to decreased drug sensitivity and poor prognosis, while underexpression leads to the manifestation of toxic drug effects that may halt therapy altogether. Future prospective translational studies in a larger population are warranted to validate its role as a predictive and prognostic factor.
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Affiliation(s)
- Bo Wang
- Internal Medicine, Tufts Medical Center, Tufts University School of Medicine
| | | | - Muhammad W Saif
- Hematology/Oncology, Tufts Medical Center, Tufts University School of Medicine
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Genotype-phenotype correlations in 5-fluorouracil metabolism: a candidate DPYD haplotype to improve toxicity prediction. THE PHARMACOGENOMICS JOURNAL 2015. [PMID: 26216193 DOI: 10.1038/tpj.2015.56] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
5-Fluorouracil is among the most widely used anticancer drug, but a fraction of treated patients develop severe toxicity, with potentially lethal injuries. The predictive power of the available pretreatment assays, used to identify patients at risk of severe toxicity, needs improvements. This study aimed to correlate a phenotypic marker of 5-fluorouracil metabolism (the individual degradation rate of 5-fluorouracil-5-FUDR) with 15 functional polymorphisms in the dihydropyrimidine dehydrogenase gene (DPYD). Single SNP (single-nucleotide polymorphism) analysis revealed that the SNPs rs1801160, rs1801265, rs2297595 and rs3918290 (splice site variant IVS14+1G>A) were significantly associated with a decreased value of 5-FUDR, and the rs3918290 causing the larger decrease. Multi-SNP analysis showed that a three-SNP haplotype (Hap7) involving rs1801160, rs1801265 and rs2297595 causes a marked decrease in 5-FUDR, comparable to that caused by the splice site variant rs3918290, which is the main pharmacogenetic marker associated with severe fluorouracil toxicity. The similar effect played by Hap7 and by the splice site variant rs3918290 upon individual 5-FUDR suggests that Hap7 could also represent a similar determinant of fluorouracil toxicity. Haplotype assessment could improve the predictive value of DPYD genetic markers aimed at the pre-emptive identification of patients at risk of severe 5-fluorouracil toxicity.The Pharmacogenomics Journal advance online publication, 28 July 2015; doi:10.1038/tpj.2015.56.
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