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Duenas-Gonzalez A, Gonzalez-Fierro A, Bornstein-Quevedo L, Gutierrez-Delgado F, Kast RE, Chavez-Blanco A, Dominguez-Gomez G, Candelaria M, Romo-Pérez A, Correa-Basurto J, Lizano M, Perez-de la Cruz V, Robles-Bañuelos B, Nuñez-Corona D, Martinez-Perez E, Verastegui E. Multitargeted polypharmacotherapy for cancer treatment. theoretical concepts and proposals. Expert Rev Anticancer Ther 2024:1-13. [PMID: 38913911 DOI: 10.1080/14737140.2024.2372336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION The pharmacological treatment of cancer has evolved from cytotoxic to molecular targeted therapy. The median survival gains of 124 drugs approved by the FDA from 2003 to 2021 is 2.8 months. Targeted therapy is based on the somatic mutation theory, which has some paradoxes and limitations. While efforts of targeted therapy must continue, we must study newer approaches that could advance therapy and affordability for patients. AREAS COVERED This work briefly overviews how cancer therapy has evolved from cytotoxic chemotherapy to current molecular-targeted therapy. The limitations of the one-target, one-drug approach considering cancer as a robust system and the basis for multitargeting approach with polypharmacotherapy using repurposing drugs. EXPERT OPINION Multitargeted polypharmacotherapy for cancer with repurposed drugs should be systematically investigated in preclinical and clinical studies. Remarkably, most of these proposed drugs already have a long history in the clinical setting, and their safety is known. In principle, the risk of their simultaneous administration should not be greater than that of a first-in-human phase I study as long as the protocol is developed with strict vigilance to detect early possible side effects from their potential interactions. Research on cancer therapy should go beyond the prevailing paradigm targeted therapy.
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Affiliation(s)
- Alfonso Duenas-Gonzalez
- Departamento de Medicina Genómica y Toxicología Ambiental, Instituto de Investigaciones Biomédicas UNAM, Mexico City, Mexico
- Subdireccion de Investigación Básica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Aurora Gonzalez-Fierro
- Subdireccion de Investigación Básica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | - Francisco Gutierrez-Delgado
- Centro de Estudios y Prevención del Cancer Tuxtla Gutiérrez, Chiapas, México; Latin American School of Oncology (ELO), México City, Mexico
| | - Richard E Kast
- Head of Faculty, Brain Study, IIAIG Study Center, Burlington, VT, USA
| | - Alma Chavez-Blanco
- Subdireccion de Investigación Básica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | - Myrna Candelaria
- Departamento de Hematología, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Adriana Romo-Pérez
- Instituto de Química, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Jose Correa-Basurto
- Laboratorio de Diseño y Desarrollo de Nuevos Fármacos e Innovación Biotecnológica, SEPI-ESM, Instituto Politécnico Nacional, México, Mexico City, Mexico
| | - Marcela Lizano
- Departamento de Medicina Genómica y Toxicología Ambiental, Instituto de Investigaciones Biomédicas UNAM, Mexico City, Mexico
- Subdireccion de Investigación Básica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Veronica Perez-de la Cruz
- Neurobiochemistry and Behavior Laboratory, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | | | - David Nuñez-Corona
- Subdireccion de Investigación Básica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Erandi Martinez-Perez
- Subdireccion de Investigación Básica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Emma Verastegui
- Departamento de Cuidados Paliativos, Division de Cirugia, Instituto Nacional de Cancerologia, Mexico City, Mexico
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Lim AM, Le Tourneau C, Hurt C, Laskar SG, Steuer CE, Chow VLY, Szturz P, Henson C, Day AT, Bates JE, Lazarakis S, McDowell L, Mehanna H, Yom SS. Assessment of endpoint definitions in recurrent and metastatic mucosal head and neck squamous cell carcinoma trials: Head and Neck Cancer International Group consensus recommendations. Lancet Oncol 2024; 25:e308-e317. [PMID: 38936389 DOI: 10.1016/s1470-2045(24)00068-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 06/29/2024]
Abstract
Transparent and precise endpoint definitions are a crucial aspect of clinical trial conduct and reporting, and are used to communicate the benefit of an intervention. Previous studies have identified inconsistencies in endpoint definitions across oncological clinical trials. Here, the Head and Neck Cancer International Group assessed endpoint definitions from phase 3 trials or trials considered practice-changing for patients with recurrent or metastatic mucosal head and neck squamous cell carcinoma, published between 2008 and 2021. We identify considerable and global heterogeneity in endpoint definitions, which undermines the interpretation of results and development of future studies. We show how fundamental components of even incontrovertible endpoints such as overall survival vary widely, highlighting an urgent need for increased rigour in reporting and harmonisation of endpoints.
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Affiliation(s)
- Annette M Lim
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France; INSERM U900 Research unit, Institut Curie, Paris, France; Paris-Saclay University, Paris, France
| | - Chris Hurt
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Sarbani G Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Velda L Y Chow
- Division of Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong Special Administrative Region, China
| | - Petr Szturz
- Department of Oncology, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
| | - Christina Henson
- Department of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, OK, USA
| | - Andrew T Day
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, TX, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), University of Birmingham, Edgbaston, Birmingham, UK
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, CA, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, CA, USA.
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Kinnersley B, Sud A, Everall A, Cornish AJ, Chubb D, Culliford R, Gruber AJ, Lärkeryd A, Mitsopoulos C, Wedge D, Houlston R. Analysis of 10,478 cancer genomes identifies candidate driver genes and opportunities for precision oncology. Nat Genet 2024:10.1038/s41588-024-01785-9. [PMID: 38890488 DOI: 10.1038/s41588-024-01785-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 05/01/2024] [Indexed: 06/20/2024]
Abstract
Tumor genomic profiling is increasingly seen as a prerequisite to guide the treatment of patients with cancer. To explore the value of whole-genome sequencing (WGS) in broadening the scope of cancers potentially amenable to a precision therapy, we analysed whole-genome sequencing data on 10,478 patients spanning 35 cancer types recruited to the UK 100,000 Genomes Project. We identified 330 candidate driver genes, including 74 that are new to any cancer. We estimate that approximately 55% of patients studied harbor at least one clinically relevant mutation, predicting either sensitivity or resistance to certain treatments or clinical trial eligibility. By performing computational chemogenomic analysis of cancer mutations we identify additional targets for compounds that represent attractive candidates for future clinical trials. This study represents one of the most comprehensive efforts thus far to identify cancer driver genes in the real world setting and assess their impact on informing precision oncology.
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Affiliation(s)
- Ben Kinnersley
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
- University College London Cancer Institute, University College London, London, UK
| | - Amit Sud
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Centre for Immuno-Oncology, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew Everall
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Alex J Cornish
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Daniel Chubb
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Richard Culliford
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Andreas J Gruber
- Systems Biology & Biomedical Data Science Laboratory, University of Konstanz, Konstanz, Germany
| | - Adrian Lärkeryd
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Costas Mitsopoulos
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, UK
| | - David Wedge
- Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Richard Houlston
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK.
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Patel K, Ivanov A, Jocelyn T, Hantel A, Garcia JS, Abel GA. Patient-Reported Outcomes in Phase 3 Clinical Trials for Blood Cancers: A Systematic Review. JAMA Netw Open 2024; 7:e2414425. [PMID: 38829615 PMCID: PMC11148691 DOI: 10.1001/jamanetworkopen.2024.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/01/2024] [Indexed: 06/05/2024] Open
Abstract
Importance Published research suggests that patient-reported outcomes (PROs) are neither commonly collected nor reported in randomized clinical trials (RCTs) for solid tumors. Little is known about these practices in RCTs for hematological malignant neoplasms. Objective To evaluate the prevalence of PROs as prespecified end points in RCTs of hematological malignant neoplasms, and to assess reporting of PROs in associated trial publications. Evidence Review All issues of 8 journals known for publishing high-impact RCTs (NEJM, Lancet, Lancet Hematology, Lancet Oncology, Journal of Clinical Oncology, Blood, JAMA, and JAMA Oncology) between January 1, 2018, and December 13, 2022, were searched for primary publications of therapeutic phase 3 trials for adults with hematological malignant neoplasms. Studies that evaluated pretransplant conditioning regimens, graft-vs-host disease treatment, or radiotherapy as experimental treatment were excluded. Data regarding trial characteristics and PROs were extracted from manuscripts and trial protocols. Univariable analyses assessed associations between trial characteristics and PRO collection or reporting. Findings Ninety RCTs were eligible for analysis. PROs were an end point in 66 (73%) trials: in 1 trial (1%) as a primary end point, in 50 (56%) as a secondary end point, and in 15 (17%) as an exploratory end point. PRO data were reported in 26 of 66 primary publications (39%): outcomes were unchanged in 18 and improved in 8, with none reporting worse PROs with experimental treatment. Trials sponsored by for-profit entities were more likely to include PROs as an end point (49 of 55 [89%] vs 17 of 35 [49%]; P < .001) but were not significantly more likely to report PRO data (20 of 49 [41%] vs 6 of 17 [35%]; P = .69). Compared with trials involving lymphoma (18 of 29 [62%]) or leukemia or myelodysplastic syndrome (18 of 28 [64%]), those involving plasma cell disorders or multiple myeloma (27 of 30 [90%]) or myeloproliferative neoplasms (3 of 3 [100%]) were more likely to include PROs as an end point (P = .03). Similarly, compared with trials involving lymphoma (3 of 18 [17%]) or leukemia or myelodysplastic syndrome (5 of 18 [28%]), those involving plasma cell disorders or multiple myeloma (16 of 27 [59%]) or myeloproliferative neoplasms (2 of 3 [67%]) were more likely to report PROs in the primary publication (P = .01). Conclusions and Relevance In this systematic review, almost 3 of every 4 therapeutic RCTs for blood cancers collected PRO data; however, only 1 RCT included PROs as a primary end point. Moreover, most did not report resulting PRO data in the primary publication and when reported, PROs were either better or unchanged, raising concern for publication bias. This analysis suggests a critical gap in dissemination of data on the lived experiences of patients enrolled in RCTs for hematological malignant neoplasms.
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Affiliation(s)
- Kishan Patel
- Department of Internal Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Alexandra Ivanov
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tajmah Jocelyn
- Center for Clinical Investigation, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jacqueline S. Garcia
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A. Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
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Naci H, Zhang Y, Woloshin S, Guan X, Xu Z, Wagner AK. Overall survival benefits of cancer drugs initially approved by the US Food and Drug Administration on the basis of immature survival data: a retrospective analysis. Lancet Oncol 2024; 25:760-769. [PMID: 38754451 DOI: 10.1016/s1470-2045(24)00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/24/2024] [Accepted: 03/14/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND New cancer drugs can be approved by the US Food and Drug Administration (FDA) on the basis of surrogate endpoints while data on overall survival are still incomplete or immature, with too few deaths for meaningful analysis. We aimed to evaluate whether clinical trials with immature survival data generated evidence of overall survival benefit during the period after marketing authorisation, and where that evidence was reported. METHODS In this retrospective analysis, we searched Drugs@FDA to identify cancer drug indications approved between Jan 1, 2001, and Dec 31, 2018, on the basis of immature survival data. We systematically collected publicly available data on postapproval overall survival results in labelling (Drugs@FDA), journal publications (MEDLINE via PubMed), and clinical trial registries (ClinicalTrials.gov). The primary outcome was availability of statistically significant overall survival benefits during the period after marketing authorisation (until March 31, 2023). Additionally, we evaluated the availability and timing of overall survival findings in labelling, journal publications, and ClinicalTrials.gov records. FINDINGS During the study period, the FDA granted marketing authorisation to 223 cancer drug indications, 95 of which had overall survival as an endpoint. 39 (41%) of these 95 indications had immature survival data. After a minimum of 4·3 years of follow-up during the period after marketing authorisation (and median 8·2 years [IQR 5·3-12·0] since FDA approval), additional survival data from the pivotal trials became available in either revised labelling or publications, or both, for 38 (97%) of 39 indications. Additional data on overall survival showed a statistically significant benefit in 12 (32%) of 38 indications, whereas mature data yielded statistically non-significant overall survival findings for 24 (63%) indications. Statistically significant evidence of overall survival benefit was reported in either labelling or publications a median of 1·5 years (IQR 0·8-2·3) after initial approval. The median time to availability of statistically non-significant overall survival results was 3·3 years (2·2-4·5). The availability of overall survival results on ClinicalTrials.gov varied considerably. INTERPRETATION Fewer than a third of indications approved with immature survival data showed a statistically significant overall survival benefit after approval. Notable inconsistencies in timing and availability of information after approval across different sources emphasise the need for better reporting standards. FUNDING None.
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Affiliation(s)
- Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK; The Lisa Schwartz Foundation for Truth in Medicine, Norwich, VT, USA.
| | - Yichen Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Steven Woloshin
- The Lisa Schwartz Foundation for Truth in Medicine, Norwich, VT, USA; The Center for Medicine in the Media, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Ziyue Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Anita K Wagner
- The Lisa Schwartz Foundation for Truth in Medicine, Norwich, VT, USA; Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Iskander R, Moyer H, Fergusson D, McGrath S, Benedetti A, Kimmelman J. The Benefits and Risks of Receiving Investigational Solid Tumor Drugs in Randomized Trials : A Systematic Review and Meta-analysis. Ann Intern Med 2024; 177:759-767. [PMID: 38684102 DOI: 10.7326/m23-2515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Many patients participate in cancer trials to access new therapies. The extent to which new treatments produce clinical benefit for trial participants is unclear. PURPOSE To estimate the progression-free survival (PFS) and overall survival (OS) advantage of assignment to experimental groups in randomized trials for 6 solid tumors. DATA SOURCES ClinicalTrials.gov was searched for trials of investigational drugs with results posted between 2017 and 2021. STUDY SELECTION Investigational drugs were defined as those not yet having full approval from the U.S. Food and Drug Administration for the study indication. Trials were included if they were randomized and tested drugs or biologics. DATA EXTRACTION Data extraction was completed by 2 independent reviewers. Data were pooled using a random-effects model. DATA SYNTHESIS The sample included 128 trials comprising 141 comparisons of a new drug and a comparator. These comparisons included 47 050 patients. The pooled hazard ratio for PFS was 0.80 (95% CI, 0.75 to 0.85), indicating statistically significant benefit for patients in experimental groups. This corresponded to a median PFS advantage of 1.25 months (CI, 0.80 to 1.68 months). The pooled hazard ratio for OS was 0.92 (CI, 0.88 to 0.95), corresponding to a survival gain of 1.18 months (CI, 0.72 to 1.71 months). The absolute risk for a serious adverse event for comparator group patients was 29.56% (CI, 26.64% to 32.65%), with an increase in risk of 7.40% (CI, 5.66% to 9.14%) for patients in experimental groups. LIMITATIONS Trials in this sample were heterogeneous. Comparator group interventions were assumed to reflect standard of care. CONCLUSION Assignment to experimental groups produces statistically significant survival gains. However, the absolute survival gain is small, and toxicity is statistically significantly greater. The findings of this review provide reassuring evidence that patients are not meaningfully disadvantaged by assignment to comparator groups. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Renata Iskander
- Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada (R.I., H.M., J.K.)
| | - Hannah Moyer
- Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada (R.I., H.M., J.K.)
| | - Dean Fergusson
- Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada (D.F.)
| | - Sean McGrath
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts (S.M.)
| | - Andrea Benedetti
- Departments of Medicine and of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada (A.B.)
| | - Jonathan Kimmelman
- Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada (R.I., H.M., J.K.)
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Lengliné E, Baba J, de Boissieu P, Beaufils A, Desbiolles A, Diatta T, Cochat P, Chevret S. Composite event-free-survival as an endpoint in oncology drug evaluation: Review and guidance perspectives from the Haute Autorité de Santé (HAS). Eur J Cancer 2024; 204:114047. [PMID: 38653034 DOI: 10.1016/j.ejca.2024.114047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The use of right-censored composite endpoints, such as progression-free survival, has been questioned in haemato-oncology trials due to potential bias in estimated treatment effect. This may impact the accuracy of health technology evaluations. We hypothesized that there is heterogeneity and potential sources of bias in the reporting of composite endpoints to health technology assessment (HTA) bodies. METHODS We reviewed the submissions for reimbursement of oncology drugs in 2021 and 2022 that used a composite endpoint in the pivotal trial, after appraisal by the French HTA body. The retrieved information included the clinical study report, protocol, and statistical analysis plan submitted by the industry. All events of the composite endpoint and all causes of censored observations were measured. The design characteristics and treatment effect estimates were recorded. FINDINGS Seventy-six submissions were selected, including seven without a right-censored endpoint and four evaluating associations, resulting in 65 analysed records: 17 for haematological and 48 for solid tumours. Out these 65 submissions, 47 (72·3%) used a randomized controlled design, and 18 (27·7%) a non-comparative design. The most frequently used composite endpoint was progression-free survival, used in 54 (83·1%) of the submissions. Censoring was possibly informative in 51 (92·7%) cases, mostly due to the onset of new treatment (44/51, 86·3%) and/or discontinuation of follow-up (33/51, 64·7%). In contrast, 38 (58·5%) trials reported a quantification of censored observations, with only 12/51 (23·5%) quantifying the informative ones. The estimated treatment effect on the composite outcome increased with the amount of censoring, suggesting a higher benefit of the drug, but remained below that on survival with poor evidence of surrogacy (R-squared=0·23). INTERPRETATION Clinical study reports should be improved in terms of reporting censoring, while stakeholders should be aware of this potential source of bias. At a minimum, sensitivity analysis that ignores intercurrent events should be requested.
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Affiliation(s)
- Etienne Lengliné
- Hematology department, Hôpital Saint-Louis AP-HP, Paris, France.
| | - Joachim Baba
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Paul de Boissieu
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Alexandre Beaufils
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Alice Desbiolles
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Thierno Diatta
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Pierre Cochat
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Sylvie Chevret
- ECSTRRA Team, Université Paris Cité, UMR1153, INSERM, Paris, France
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Wilson BE, Sengar M, Tregear M, van der Graaf WTA, Luca Battisti NM, Csaba DL, Soto-Perez-de-Celis E, Gyawali B, Booth CM. Common Sense Oncology: Equity, Value, and Outcomes That Matter. Am Soc Clin Oncol Educ Book 2024; 44:e100039. [PMID: 38788178 DOI: 10.1200/edbk_100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
While some recent drug treatments have been transformative for patients with cancer, many treatments offer small benefits despite high clinical toxicity, time toxicity and financial toxicity. Moreover, treatments that do provide substantial clinical benefits are not available to many patients globally due to issues with availability and affordability. The Common Sense Oncology's vision is that patients will have access to treatments that provide meaningful improvements in outcomes that matter, regardless of where they live. In recognition of the growing challenges in the field of oncology, Common Sense Oncology seeks to achieve this vision by improving evidence generation, evidence interpretation and evidence communication.
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Affiliation(s)
- Brooke E Wilson
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
- School of Population Health, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Manju Sengar
- Tata Memorial Hospital, Affiliated to Homi Bhabha National Institute, Mumbai, India
| | | | - Winette T A van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Nicolò Matteo Luca Battisti
- Department of Medicine, Breast Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Inequalities Focused Topic Network, European Cancer Organisation, Brussels, Belgium
- International Society of Geriatric Oncology, Geneva, Switzerland
| | - Degi Laszlo Csaba
- Faculty of Sociology and Social Work, Babeş-Bolyai University, Cluj Napoca, Romania
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
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Michaeli DT, Michaeli T, Albers S, Michaeli JC. Clinical trial design and treatment effects: a meta-analysis of randomised controlled and single-arm trials supporting 437 FDA approvals of cancer drugs and indications. BMJ Evid Based Med 2024:bmjebm-2023-112544. [PMID: 38760158 DOI: 10.1136/bmjebm-2023-112544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES This study aims to analyse the association between clinical trial design and treatment effects for cancer drugs with US Food and Drug Administration (FDA) approval. DESIGN Cross-sectional study and meta-analysis. SETTING Data from Drugs@FDA, FDA labels, ClincialTrials.gov and the Global Burden of Disease study. PARTICIPANTS Pivotal trials for 170 drugs with FDA approval across 437 cancer indications between 2000 and 2022. MAIN OUTCOME MEASURES Treatment effects were measured in HRs for overall survival (OS) and progression-free survival (PFS), and in relative risk for tumour response. Random-effects meta-analyses and meta-regressions explored the association between treatment effect estimates and clinical trial design for randomised controlled trials (RCTs) and single-arm trials. RESULTS Across RCTs, greater effect estimates were observed in smaller trials for OS (ß=0.06, p<0.001), PFS (ß=0.15, p<0.001) and tumour response (ß=-3.61, p<0.001). Effect estimates were larger in shorter trials for OS (ß=0.08, p<0.001) and PFS (ß=0.09, p=0.002). OS (ß=0.04, p=0.006), PFS (ß=0.10, p<0.001) and tumour response (ß=-2.91, p=0.004) outcomes were greater in trials with fewer centres. HRs for PFS (0.54 vs 0.62, p=0.011) were lower in trials testing the new drug to an inactive (placebo/no treatment) rather than an active comparator. The analysed efficacy population (intention-to-treat, per-protocol, or as-treated) was not consistently associated with treatment effects. Results were consistent for single-arm trials and in multivariable analyses. CONCLUSIONS Pivotal trial design is significantly associated with measured treatment effects. Particularly small, short, single-centre trials testing a new drug compared with an inactive rather than an active comparator could overstate treatment outcomes. Future studies should verify results in unsuccessful trials, adjust for further confounders and examine other therapeutic areas. The FDA, manufacturers and trialists must strive to conduct robust clinical trials with a low risk of bias.
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Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- German Cancer Research Center-Hector Cancer Institute, University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Sebastian Albers
- Department of Trauma Surgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Julia Caroline Michaeli
- Department of Obstetrics and Gynaecology, LMU University Hospital, LMU Munich, Munich, Germany
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10
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Balijepalli C, Gullapalli L, Joshy J, Rawson NSB. The impact of willingness-to-pay threshold on price reduction recommendations for oncology drugs: a review of assessments conducted by the Canadian Agency for Drugs and Technologies in Health. J Comp Eff Res 2024; 13:e230178. [PMID: 38567953 PMCID: PMC11037021 DOI: 10.57264/cer-2023-0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Since late 2020, the Canadian Agency of Drugs and Technologies in Health (CADTH) has been using a threshold of $50,000 (CAD) per quality-adjusted life-year (QALY) for both oncology and non-oncology drugs. When used for oncology products, this threshold is hypothesized to have a higher impact on the time to access these drugs in Canada. We studied the impact of price reductions on time to engagement and negotiation with the pan-Canadian Pharmaceutical Alliance for oncology drugs reviewed by CADTH between January 2020 and December 2022. Overall, 103 assessments reported data on price reductions recommended by CADTH to meet the cost-effectiveness threshold for reimbursement. Of these assessments, 57% (59/103) recommendations included a price reduction of greater than 70% off the list price. Eight percent (8/103) were not cost-effective even at a 100% price reduction. Of the 47 assessments that had a clear benefit, in 21 (45%) CADTH recommended a price reduction of at least 70%. The median time to price negotiation (not including time to engagement) for assessments that received at least 70% vs >70% price reduction was 2.6 vs 4.8 months. This study showed that there is a divergence between drug sponsor's incremental cost-effectiveness ratio (ICER) and CADTH revised ICER leading to a price reduction to meet the $50,000/QALY threshold. For the submissions with clear clinical benefit the median length of engagement (2.5 vs 3.3 months) and median length of negotiation (3.1 vs 3.6 months) were slightly shorter compared with the submissions where uncertainties were noted in the clinical benefit according to CADTH. This study shows that using a $50,000 per QALY threshold for oncology products potentially impacts timely access to life saving medications.
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Affiliation(s)
| | | | - Juhi Joshy
- Pharmalytics Group, Vancouver, BC V6B 2Z4, Canada
| | - Nigel SB Rawson
- Canadian Health Policy Institute, Toronto, ON, Canada
- Macdonald-Laurier Institute, Ottawa, ON, Canada
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11
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Xu W, Tang Y, Yang Y, Wang C, Liu C, Zhang J, Zhao L, Wang G. Depletion of CPNE7 sensitizes colorectal cancer to 5-fluorouracil by downregulating ATG9B expression. J Cell Mol Med 2024; 28:e18261. [PMID: 38526029 PMCID: PMC10962129 DOI: 10.1111/jcmm.18261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/10/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
We aimed to explore the biological function of CPNE7 and determine the impact of CPNE7 on chemotherapy resistance in colorectal cancer (CRC) patients. According to the Gene Expression Profiling Interactive Analysis database and previously published data, CPNE7 was identified as a potential oncogene in CRC. RT-qPCR and Western blotting were performed to verify the expression of CPNE7. Chi-square test was used to evaluate the associations between CPNE7 and clinical features. Cell proliferation, colony formation, cell migration and invasion, cell cycle and apoptosis were assessed to determine the effects of CPNE7. Transcriptome sequencing was used to identify potential downstream regulatory genes, and gene set enrichment analysis was performed to investigate downstream pathways. The effect of CPNE7 on 5-fluorouracil chemosensitivity was verified by half maximal inhibitory concentration (IC50). Subcutaneous tumorigenesis assay was used to examine the role of CPNE7 in sensitivity of CRC to chemotherapy in vivo. Transmission electron microscopy was used to detect autophagosomes. CPNE7 was highly expressed in CRC tissues, and its expression was correlated with T stage and tumour site. Knockdown of CPNE7 inhibited the proliferation and colony formation of CRC cells and promoted apoptosis. Knockdown of CPNE7 suppressed the expression of ATG9B and enhanced the sensitivity of CRC cells to 5-fluorouracil in vitro and in vivo. Knockdown of CPNE7 reversed the induction of the autophagy pathway by rapamycin and reduced the number of autophagosomes. Depletion of CPNE7 attenuated the malignant proliferation of CRC cells and enhanced the chemosensitivity of CRC cells to 5-fluorouracil.
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Affiliation(s)
- Weile Xu
- The Department of General surgeryThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
- The Department of General surgeryHebei Chest HospitalShijiazhuangHebeiChina
- The Second Department of SurgeryThe Fourth Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Yujie Tang
- The Department of Gastrointestinal surgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Yang Yang
- The Department of Gastrointestinal surgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Changjing Wang
- The Department of Gastrointestinal surgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Chen Liu
- The Department of Gastrointestinal surgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Jianqing Zhang
- The Department of Gastrointestinal surgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Lianmei Zhao
- Scientific Research CenterThe Fourth Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Guiying Wang
- The Department of General surgeryThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
- The Second Department of SurgeryThe Fourth Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
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12
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Chu Y, Liu Y, Yu Z, Zhan L, Lu T, Jiang Y, Fang X, Zhou X, Wang X. Maintenance and consolidation strategies for patients with untreated advanced follicular lymphoma: A systematic review and network meta-analysis of randomized trials. Cancer 2024; 130:1072-1082. [PMID: 38041532 DOI: 10.1002/cncr.35137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND The emergence of novel and efficient antibody maintenance approaches has provided more options for post-induction treatment of advanced follicular lymphoma (FL), and further comparisons are required to determine the most clinically beneficial regimen. The authors conducted a systematic review and meta-analysis to evaluate the maintenance or consolidation strategy. METHODS The authors performed two independent searches in PubMed, Web of Science, the Cochrane library databases, Scopus, and Embase for randomized controlled trials (RCTs) evaluating maintenance or consolidation therapy in untreated FL patients. Extracted data included the clinical characteristics, treatment regimen, progression-free survival (PFS), overall survival (OS), and adverse effects. They then pooled the data and used a Bayesian random-effects model to combine direct comparisons with indirect evidence. RESULTS The authors screened 1515 records and identified 13 eligible RCTs that assessed nine different regimens in 5681 advanced FL patients. Reconstructed individual survival data presented that obinutuzumab had the highest effect sizes and certainty of the evidence for PFS (hazard ratio, 0.43; 95% confidence interval, 0.22-0.79) and tolerability compared with observation. However, no benefit was observed in patients according to the OS, regardless of which regimen was taken. Considering other regimens, although an extended course of rituximab maintenance and consolidation therapies presented PFS benefits compared with standard rituximab maintenance, they were also associated with higher toxicity. CONCLUSIONS Although obinutuzumab and rituximab maintenance treatment improved PFS significantly, its clinical benefit requires further validation in larger populations. Furthermore, because few trials informed each treatment comparison, research is needed to refine the understanding of this complex and rapidly evolving treatment landscape.
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Affiliation(s)
- Yurou Chu
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Yingyue Liu
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Zhuoya Yu
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Linquan Zhan
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Tiange Lu
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Yujie Jiang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaosheng Fang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiangxiang Zhou
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, Shandong, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, Shandong, China
- National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
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13
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Elbaz J, Haslam A, Prasad V. An empirical analysis of overall survival in drug approvals by the US FDA (2006-2023). Cancer Med 2024; 13:e7190. [PMID: 38659418 PMCID: PMC11043668 DOI: 10.1002/cam4.7190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The US Food and Drug Administration (FDA) has expanded the use of surrogate markers in drugs approved for oncology/hematology indications. This has likely resulted in a greater number of approvals and possibly drugs coming to market faster, but it is unknown whether these drugs also improve overall survival (OS) for patients taking them. METHODS We sought to estimate the percentage of oncology drugs that have shown to improve OS in a cross-sectional analysis of US FDA oncology drug approvals (2006-2023). We searched for OS data in registration trials and the peer-reviewed literature. RESULTS We found 392 oncology drug approvals. Eighty-seven (22%) drug approvals were based on OS, 147 drug approvals were later tested for OS benefit (38% of all approvals and 48% of drugs approved on a surrogate), and 130 (33%) have yet to be tested for OS benefit. Of the 147 drug approvals later tested for OS, 109 (28% of all approvals and 74% of drugs later tested for OS) have yet to show OS benefit, whereas 38 (10% of all approvals and 26% of drugs later tested for OS benefit) were later shown to have OS benefit. In total, 125 out of 392 (32%) drugs approved for any indication have been shown to improve OS benefit at some point, and 267 (68%) have yet to show approval. CONCLUSION About 32% of all oncology drug approvals have evidence for an improvement in OS. Higher standards are needed in drug regulation to ensure that approved drugs are delivering better patient outcomes, specifically in regards to survival.
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Affiliation(s)
| | - Alyson Haslam
- University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Vinay Prasad
- University of California San FranciscoSan FranciscoCaliforniaUSA
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14
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Jung HA, Park B, Park S, Sun JM, Lee SH, Seok Ahn J, Ahn MJ. Survival benefit in EGFR-wild and ALK negative NSCLC patients who participate in clinical trials compared to standard-of-care: Propensity-matched analysis. Lung Cancer 2024; 190:107536. [PMID: 38493759 DOI: 10.1016/j.lungcan.2024.107536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/12/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES Advanced non-small cell lung cancer patients harboring EGFR mutation or ALK fusion have achieved significant survival benefit with targeted agents. In contrast, EGFR-wild type and ALK negative lung adenocarcinoma still have poor survival outcome. This study assessed the impact of participating in clinical trials on clinical outcomes in patients with EGFR-wild-type and ALK-negative lung adenocarcinoma. MATERIALS AND METHODS This study included patients with advanced EGFR-wild-type and ALK-negative lung adenocarcinoma who received systemic treatment between March 2017 and June 2022. We compared clinical outcomes between patients who participated in clinical trials and those treated with standard-of-care (SOC) using propensity score matching (PSM). RESULTS Overall, 1,686 patients with EGFR-wild-type and ALK-negative advanced lung adenocarcinoma were included in the final analysis. Of these, 1,380 (81.9 %) received SOC only and 306 (18.1 %) patients were enrolled in at least one clinical trial during their cancer journey. After PSM (1:1), 612 patients were matched to the SOC (n = 306) and clinical trial (n = 306) groups. Among those who participated in clinical trials, 27.8 % and 72.2 % were included in clinical trials involving targeted therapy and immunotherapy respectively. In the clinical trial group, more patients received targeted therapy (31.7 % vs. 5.5 %, p < 0.001) and immunotherapy (88.6 % vs. 62.8 %, p < 0.001) compared to the SOC group. The median overall survival was 17.1 months (95 % confidence interval [CI], 13.2-21.4) in the SOC group and 27.3 months (95 % CI, 22.1-32.4) in the clinical trial group (hazard ratio = 0.71, [95 % CI, 0.58-0.88, P = 0.002]). CONCLUSIONS This study demonstrated that participating in clinical trials resulted in a survival benefit that reduced the risk of death by 29.6% compared to receiving SOC in EGFR-wild-type and ALK-negative lung adenocarcinoma.
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Affiliation(s)
- Hyun Ae Jung
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Republic of Korea
| | - Sehhoon Park
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Jong-Mu Sun
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Se-Hoon Lee
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Jin Seok Ahn
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | - Myung-Ju Ahn
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea.
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15
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Wei Y, Zhang Y, Xu Z, Wang G, Zhou Y, Li H, Shi L, Naci H, Wagner AK, Guan X. Cancer drug indication approvals in China and the United States: a comparison of approval times and clinical benefit, 2001-2020. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 45:101055. [PMID: 38590780 PMCID: PMC10999698 DOI: 10.1016/j.lanwpc.2024.101055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/27/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
Background Perceived delays in cancer drug approvals have been a major concern for policymakers in China. Policies have been implemented to accelerate the launch of new cancer drugs and indications. This study aimed to assess similarities and differences between China and the United States in the approvals, timing, and clinical benefit evidence of cancer drug indications between 2001 and 2020. Methods This study retrospectively identified all cancer drugs and indications approved in both China and the United States from January 1st, 2001 to December 31, 2020, and described differences in approval times as well as in submission and review times. Information on the availability of overall survival benefit evidence by December 31, 2020, was collected. Univariate and multiple logistic regression analyses were used to assess whether evidence of benefit and other factors affected the propensity and timing of approvals of cancer drug indications in China. Findings Between 2001 and 2020, 229 indications corresponding to 145 cancer drugs approved in the United States were identified. Of those, 80 indications (34.9%) were also approved in China by the end of 2020. Cancer drug indications were approved in China at a median of 1273.5 days after approval in the United States. The median submission and review time differences for cancer drug indications in China were 1198.0 days and 180.0 days respectively. Submission time differences accounted for most of the approval time differences (p < 0.001). Indications supported by overall survival benefit evidence had shorter median review time differences (145.0 days) than those without such evidence (235.0 days, p = 0.008). Indications with overall survival benefit evidence were 3.94 times more likely to be approved in China compared to those without such evidence (p = 0.001), controlling for approval year, cancer type, and the prevalence of cancer by site. Interpretation FDA-approved cancer drug indications demonstrating a survival benefit were more likely to receive approvals in China with shorter regulatory review times compared to indications without such evidence. Given that manufacturer submission times were the main driver of cancer drug approval times in China, factors influencing submission timing should be explored. Funding No funding.
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Affiliation(s)
- Yuxuan Wei
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
| | - Yichen Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Ziyue Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Guoan Wang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yue Zhou
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huangqianyu Li
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
| | - Luwen Shi
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Anita K. Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, United States
| | - Xiaodong Guan
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
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16
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Michaeli T, Michaeli DT. Partial Orphan Cancer Drugs: US Food and Drug Administration Approval, Clinical Benefit, Trials, Epidemiology, Price, Beneficiaries, and Spending. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:449-457. [PMID: 38244983 DOI: 10.1016/j.jval.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/14/2023] [Accepted: 01/08/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES The Orphan Drug Act (ODA) incentivizes drug development for rare diseases with limited sales potential. Partial orphans-drugs used to treat rare and common diseases-frequently turn into multi-billion dollar blockbusters. This study analyzes partial orphan cancer drugs' development, approval, and economics. METHODS 170 drugs with US Food and Drug Administration approval for 455 cancer indications were identified (2000-2021). 110 full, 22 partial, and 38 non-orphan drugs were compared regarding their approval, benefits, trials, epidemiology, price, beneficiaries, and spending with data from regulatory documents, Global Burden of Disease study, and Medicare and Medicaid. RESULTS Full orphans, relative to partial and non-orphans, were more frequently monotherapies for hematologic cancers supported by smaller single-arm trials treating diseases with a lower incidence and higher severity. The time from first to second indication approval was 1 year shorter for partial than full orphans. Full orphans offered a greater overall survival (median: 4.0 vs 2.8 vs 2.8 months, P < .001) and progression-free survival benefit (median: 5.1 vs 2.5 vs 3.6 months, P < .001). Monthly prices were higher for full and partial than non-orphan drugs (median: $17 177 vs $13 284 vs $12 457, P < .001). Beneficiaries (8790 vs 4390 vs 1730) and spending ($570 vs $305 vs $156 million) per drug were greater for partial than non-and full orphans. CONCLUSIONS Although partial orphans' benefits, trials, and economics are more similar to non-than full orphans, they receive all of the ODA's benefits and are swiftly extended to new indications; resulting in greater spending. A maximum ODA revenue/patient threshold could limit expenditure on partial orphans.
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Affiliation(s)
- Thomas Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany; DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany; Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Daniel Tobias Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany; Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany.
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Sehdev SR, Rawson NSB, Aseyev OI, Buick CJ, Butler MO, Edwards S, Gill S, Gotfrit JM, Hsia CC, Juergens RA, Manna M, McCarthy JS, Mukherjee SD, Snow SL, Spadafora S, Stewart DJ, Wentzell JR, Wong RPW, Zalewski PG. Access to Oncology Medicines in Canada: Consensus Forum for Recommendations for Improvement. Curr Oncol 2024; 31:1803-1816. [PMID: 38668039 PMCID: PMC11048816 DOI: 10.3390/curroncol31040136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
Patient access to new oncology drugs in Canada is only possible after navigating multiple sequential systemic checkpoints for national regulatory approval, health technology assessment (HTA) and collective government price negotiation. These steps delay access and prevent health care providers from being able to prescribe optimal therapy. Eighteen Canadian oncology clinicians from the medicine, nursing and pharmacy professions met to develop consensus recommendations for defining reasonable government performance standards around process and timeliness to improve Canadian cancer patients' access to best care. A modified Delphi methodology was used to identify consensus on 30 questions involving five themes: accountability, disparities, endpoints, timeliness, and cost-effectiveness. It was agreed that greater transparency is required across regulatory and HTA processes. Health professionals in oncology are frustrated for their patients because they are unable to deliver the modern guideline-supported therapies they want to provide due to delays in approval or funding. Canadian health care providers request improvements in timely access to life-saving therapeutics in line with other comparator countries. Clinicians expect urgent improvements in Canadian health systems to give our patients their best chance of survival.
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Affiliation(s)
- Sandeep R. Sehdev
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | | | - Olexiy I. Aseyev
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON P7B 6V4, Canada
| | - Catriona J. Buick
- Faculty of Health, York University, Toronto, ON M3J 1P3, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Canadian Association of Nurses in Oncology/Association Canadienne des Infirmières en Oncologie, Vancouver, BC V6A 1B6, Canada
| | - Marcus O. Butler
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Scott Edwards
- Dr H Bliss Murphy Cancer Centre, Eastern Health, St. John’s, NL A1B 3V6, Canada
- School of Pharmacy, Memorial University of Newfoundland, St. John’s, NL A1B 3V6, Canada
| | - Sharlene Gill
- Department of Medicine, Division of Medical Oncology, University of British Columbia and BC Cancer, Vancouver, BC V5Z 1M9, Canada
| | - Joanna M. Gotfrit
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Cyrus C. Hsia
- Department of Medicine, Division of Hematology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | | | - Mita Manna
- Saskatoon Cancer Centre, Saskatoon, SK S7N 4H4, Canada
| | - Joy S. McCarthy
- Cancer Care Program, Newfoundland and Labrador Health Services, St. John’s, NL A1B 3V6, Canada
| | - Som D. Mukherjee
- Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | | | - Silvana Spadafora
- Algoma District Cancer Program, Sault Area Hospital, Sault Ste Marie, ON P6B 0A8, Canada
- Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada
| | - David J. Stewart
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Jason R. Wentzell
- Department of Pharmacy, the Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Ralph P. W. Wong
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Pawel G. Zalewski
- Lakeridge Health, Durham Regional Cancer Centre, Oshawa, ON L1G 8A2, Canada
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18
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Cantini L, Trapani D, Guidi L, Boscolo Bielo L, Scafetta R, Koziej M, Vidal L, Saini KS, Curigliano G. Neoadjuvant therapy in hormone Receptor-Positive/HER2-Negative breast cancer. Cancer Treat Rev 2024; 123:102669. [PMID: 38141462 DOI: 10.1016/j.ctrv.2023.102669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/25/2023]
Abstract
Neoadjuvant therapy is commonly used in patients with locally advanced or inoperable breast cancer (BC). Neoadjuvant chemotherapy (NACT) represents an established treatment modality able to downstage tumours, facilitate breast-conserving surgery, yet also achieve considerable pathologic complete response (pCR) rates in HER2-positive and triple-negative BC. For patients with HR+/HER2- BC, the choice between NACT and neoadjuvant endocrine therapy (NET) is still based on clinical and pathological features and not guided by biomarkers of defined clinical utility, differently from the adjuvant setting where gene-expression signatures have been widely adopted to drive decision-making. In this review, we summarize the evidence supporting the choice of NACT vs NET in HR+/HER2- BC, discussing the issues surrounding clinical trial design and proper selection of patients for every treatment. It is time to question the binary paradigm of responder vs non-responders as well as the "one size fits all" approach in luminal BC, supporting the utilization of continuous endpoints and the adoption of tissue and plasma-based biomarkers at multiple timepoints. This will eventually unleash the full potential of neoadjuvant therapy which is to modulate patient treatment based on treatment sensitivity and surgical outcomes. We also reviewed the current landscape of neoadjuvant studies for HR+/HER2- BC, focusing on antibody-drug conjugates (ADCs) and immunotherapy combinations. Finally, we proposed a roadmap for future neoadjuvant approaches in HR+/HER2- BC, which should be based on a staggered biomarker-driven treatment selection aiming at impacting long-term relevant endpoints.
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Affiliation(s)
| | - Dario Trapani
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; Division of New Drugs and Early Drug Development, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Lorenzo Guidi
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; Division of New Drugs and Early Drug Development, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Luca Boscolo Bielo
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; Division of New Drugs and Early Drug Development, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Roberta Scafetta
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; Division of New Drugs and Early Drug Development, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; Department of medical oncology, Campus Bio-Medico, University of Rome, Rome, Italy
| | | | | | | | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; Division of New Drugs and Early Drug Development, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy.
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19
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Storme G. Are We Losing the Final Fight against Cancer? Cancers (Basel) 2024; 16:421. [PMID: 38275862 PMCID: PMC10814389 DOI: 10.3390/cancers16020421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/13/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
Despite our increasing understanding of the biology and evolution of the cancer process, it is indisputable that the natural process of cancer creation has become increasingly difficult to cure, as more mutations are found with age. It is significantly more difficult to challenge the curative method when there is heterogeneity within the tumor, as it hampers clinical and genetic categorization. With advances in diagnostic technologies and screening leading to progressive tumor shrinkage, it becomes more difficult over time to evaluate the effects of treatment on overall survival. New treatments are often authorized based on early evidence, such as tumor response; disease-free, progression-free, meta-static-free, and event-free survival; and, less frequently, based on clinical endpoints, such as overall survival or quality of life, when standard guidelines are not available to approve pharmaceuticals. These clearances usually happen quite rapidly. Although approval takes longer, relative survival demonstrates the genuine worth of a novel medication. Pressure is being applied by pharmaceutical companies and patient groups to approve "new" treatments based on one of the above-listed measures, with results that are frequently insignificantly beneficial and frequently have no impact on quality of life.
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Affiliation(s)
- Guy Storme
- Department Radiation Oncology, UZ Brussel, Asfilstraat 20, 9031 Drongen, Belgium
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20
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Michaeli DT, Michaeli T. Launch and Post-Launch Prices of Injectable Cancer Drugs in the US: Clinical Benefit, Innovation, Epidemiology, and Competition. PHARMACOECONOMICS 2024; 42:117-131. [PMID: 37855850 DOI: 10.1007/s40273-023-01320-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Rising cancer drug prices adversely affect patients' adherence and survival. OBJECTIVE We aimed to identify and quantify factors associated with launch prices and post-launch price changes of injectable cancer drugs in the US from 2005 to 2023. DATA AND METHODS All anticancer drugs with US FDA approval between 2000 and 2022 were identified in the Drugs@FDA database. The sample was then restricted to cancer drugs covered under Medicare Part B (injectable drugs). Data characterizing each drug's clinical benefits, disease epidemiology, approved indications, competition, and price were obtained from FDA labels, the Global Burden of Disease study, and the Centers for Medicare and Medicaid Services. The association between launch/post-launch prices and collected variables was assessed in random-effects regressions. RESULTS Of 170 cancer drugs with FDA approval between 2000 and 2022, we identified 66 (39%) injectable cancer drugs with quarterly price data from 2005 to 2023. In 2023, mean prices amounted to $27,688 per month, with an average price increase of 94% from 2005 to 2023. Launch and post-launch price changes were significantly associated with the treated disease epidemiology. A 1% decline in disease incidence was associated with a 0.2511% (p = 0.008) increase in launch prices and a 0.0086% (p = 0.032) annual increase in post-launch prices. Accordingly, launch prices were 120% (p = 0.051) higher for orphan than non-orphan drugs, with 3% (p = 0.008) greater annual post-launch price increases. Post-launch prices declined by up to -2% annually as new supplemental indications were approved for the same drug. We found no consistent association between launch/post-launch prices and the drugs' clinical benefit in terms of overall survival, progression-free survival, and tumor response. The market entry of new competitors was not associated with price reductions. 28 of 33 drug pairs within the same class had positive correlation coefficients. Pearson correlation coefficients were high (>0.80) for PD-1/PD-L1 inhibitors, CD38 antibodies, CD20 antibodies, HER2 antibodies, and mTOR inhibitors. CONCLUSIONS Cancer drug prices regularly increase faster than inflation; however, there is no evidence that launch prices and post-launch price changes are aligned with the clinical benefit a drug offers to patients. In particular, patients with rare diseases experience greater price increases for their orphan drugs. There is no evidence that brand-brand competition results in drug price reductions.
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Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany.
| | - Thomas Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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21
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Brundage MD, Booth CM, Eisenhauer EA, Galica J, Kankesan J, Karim S, Koven R, McDonald V, Ng T, O’Donnell J, ten Hove J, Robinson A. Patients' attitudes and preferences toward delayed disease progression in the absence of improved survival. J Natl Cancer Inst 2023; 115:1526-1534. [PMID: 37458509 PMCID: PMC10699849 DOI: 10.1093/jnci/djad138] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Cancer patients' attitudes toward progression-free survival (PFS) gains offered by treatment are not well understood, particularly in the absence of overall survival (OS) gains. The objectives were to describe patients' willingness to accept treatment that offers PFS gains without OS gains, to compare these findings with treatments offering OS gains, and to qualitatively summarize patients' reasons for their preferences. METHODS A multicenter, cross-sectional, convergent mixed-methods study design recruited patients who had received at least 3 months of systemic therapy for incurable solid tumors. A treatment trade-off exercise determined the gains in imaging PFS that patients require to prefer additional systemic treatment for a scenario of a newly diagnosed, asymptomatic, incurable abdominal tumor. A qualitative, descriptive, thematic analysis explored factors influencing patients' decisions, and a narrative method integrated the quantitative and qualitative findings. RESULTS In total, 100 patients participated (63% were older than 60 years of age). If additional treatment with added toxicity offered no OS advantage, 17% would prefer it for no PFS benefit; 26% for some PFS benefit (range, 3-9 months), whereas 51% would decline it regardless of PFS benefit. Similarly, 71% preferred additional treatment offering a 6-month OS advantage dependent on described toxicity levels (P = .03). A spectrum of reasons for these preferences reflected the complexity of participants' attitudes and values. CONCLUSIONS Prolongation of time to progression was not universally valued. Most patients did not prefer treatments that negatively affect quality of life for PFS gains alone. Implications for individual decision making, policy, and trials research are discussed.
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Affiliation(s)
- Michael D Brundage
- Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | - Christopher M Booth
- Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | | | - Jacqueline Galica
- Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | | | | | - Rachel Koven
- Patient Advocate on behalf of Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | - Valerie McDonald
- Patient Advocate on behalf of Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | - Terry Ng
- Division of Medical Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer O’Donnell
- Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | - Julia ten Hove
- Cancer Care and Epidemiology, Queen’s University, Cancer Research Institute, Kingston, ON, Canada
| | - Andrew Robinson
- Cancer Centre of Southeastern Ontario, Kingston General Hospital, Kingston, ON, Canada
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22
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Schina A, Pedersen S, Spenning AL, Laursen OK, Pedersen C, Haslund CA, Schmidt H, Bastholt L, Svane IM, Ellebaek E, Donia M. Sustained improved survival of patients with metastatic melanoma after the introduction of anti-PD-1-based therapies. Eur J Cancer 2023; 195:113392. [PMID: 37924648 DOI: 10.1016/j.ejca.2023.113392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The introduction of modern therapies improved the median survival of patients with metastatic melanoma (MM). Here, we determined the real-world impact of modern treatments on the long-term survival of MM. METHODS In a population-based study, we extracted all cases of MM diagnosed in four non-consecutive years marked by major changes in available 1st line treatments (2012, 2014, 2016, and 2018) from the Danish MM Database. Patients were grouped into "trial-like" and "trial-excluded" based on common trial eligibility criteria. RESULTS We observed a sustained improved survival of "trial-like" patients diagnosed in 2016 or in 2018, compared to 2012 or 2014, but no major differences in 2018 versus 2016. In contrast, while survival of "trial-excluded" patients in 2016 was better compared to 2014 and 2012, survival in 2018 was improved over all previous years. We then developed a prognostic model based on multivariable stratified Cox regression, to predict the survival of newly diagnosed MM patients. Internal validation showed excellent discrimination and calibration, with a time-area-under-the-curve above 0.79 at multiple time horizons, for up to four years after diagnosis. CONCLUSIONS The introduction of modern treatments such as anti-PD-1 has led to a sustained, improved survival of real-world patients with MM, regardless of their eligibility for clinical trials. We provide an updateable prognostic model that can be used to improve patient information. Overall, these data highlight a positive population-based impact of modern treatments and can help health technology assessment agencies worldwide to evaluate the appropriateness of drug pricing based on known cost-benefit data.
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Affiliation(s)
- Aimilia Schina
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Sidsel Pedersen
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | | | | | - Cecilia Pedersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Henrik Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Bastholt
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Inge Marie Svane
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Eva Ellebaek
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.
| | - Marco Donia
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.
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23
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Frank C, Gyawali B, Booth CM. Common sense cancer care for older adults: Outcomes that matter. J Am Geriatr Soc 2023; 71:3977-3980. [PMID: 37539843 DOI: 10.1111/jgs.18529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/08/2023] [Indexed: 08/05/2023]
Affiliation(s)
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Christopher M Booth
- Department of Medicine, Queen's University, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Canada
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24
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Michaeli DT, Michaeli T. Cancer Drug Prices in the United States: Efficacy, Innovation, Clinical Trial Evidence, and Epidemiology. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1590-1600. [PMID: 37516196 DOI: 10.1016/j.jval.2023.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/24/2023] [Accepted: 06/29/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVES Rising cancer drug prices challenge patients and healthcare systems. Although prices are routinely assigned to original drug indications receiving US Food and Drug Administration (FDA) approval, the pricing of supplemental indication approvals remains uncertain. This study identifies and quantifies factors associated with cancer drug prices, distinctly analyzing original and supplemental indications. METHODS Clinical trial evidence and epidemiologic data supporting new indications' FDA approval (2003-2022) were collected from the Drugs@FDA database, ClinicalTrials.gov, and Global Burden of Disease study. Indication-specific monthly treatment costs were calculated for Medicare patients. The association between log-prices and collected variables were assessed in regression analyses. RESULTS We identified 145 drugs approved across 373 cancer indications. Drugs were priced at $24 444 per month on average (median = $16 013). For original indications, prices weakly correlated to improvements in overall survival (β = 0.28, P = .037) and progression-free survival (β = 0.16, P = .001). Original indications' prices were as follows: (1) negatively associated with disease incidence (β = -0.21, P < .001) and prevalence; (2) positively correlated with first-in-class drugs (26%, P = .057), gene and cell therapies (176%, P < .001), hematologic cancers (62%, P < .001), and severe diseases with substantial unmet needs (6% per disability-adjusted life-year, P < .001); and (3) negatively correlated to indications with randomized-controlled phase 3 trials. Prices were poorly associated with supplemental indications' efficacy, clinical evidence, and epidemiology. CONCLUSIONS Cancer drug prices are set based on the original indication's characteristics, thereby omitting the value of supplemental indications. Indication-specific pricing, coverage, and reimbursement policies considering each indication's safety, efficacy, innovativeness, and unmet needs are necessary to align a drug's value and price.
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Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Baden-Wuerttemberg, Germany; Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, North Rhine-Westphalia, Germany.
| | - Thomas Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, North Rhine-Westphalia, Germany; Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Baden-Wuerttemberg, Germany; Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg University, Heidelberg, Baden-Wuerttemberg, Germany; DKFZ-Hector Cancer Institute, University Medical Center Mannheim, Mannheim, Baden-Wuerttemberg, Germany
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25
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Ma X, Mao M, He J, Liang C, Xie HY. Nanoprobe-based molecular imaging for tumor stratification. Chem Soc Rev 2023; 52:6447-6496. [PMID: 37615588 DOI: 10.1039/d3cs00063j] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
The responses of patients to tumor therapies vary due to tumor heterogeneity. Tumor stratification has been attracting increasing attention for accurately distinguishing between responders to treatment and non-responders. Nanoprobes with unique physical and chemical properties have great potential for patient stratification. This review begins by describing the features and design principles of nanoprobes that can visualize specific cell types and biomarkers and release inflammatory factors during or before tumor treatment. Then, we focus on the recent advancements in using nanoprobes to stratify various therapeutic modalities, including chemotherapy, radiotherapy (RT), photothermal therapy (PTT), photodynamic therapy (PDT), chemodynamic therapy (CDT), ferroptosis, and immunotherapy. The main challenges and perspectives of nanoprobes in cancer stratification are also discussed to facilitate probe development and clinical applications.
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Affiliation(s)
- Xianbin Ma
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, P. R. China
| | - Mingchuan Mao
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, P. R. China
| | - Jiaqi He
- School of Life Science, Beijing Institute of Technology, Beijing 100081, P. R. China
| | - Chao Liang
- School of Life Science, Beijing Institute of Technology, Beijing 100081, P. R. China
| | - Hai-Yan Xie
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Chemical Biology Center, Peking University, Beijing, 100191, P. R. China.
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26
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Wilson BE, Sullivan R, Peto R, Abubakar B, Booth C, Werutsky G, Adams C, Saint-Raymond A, Fleming TR, Lyerly K, Gralow JR. Global Cancer Drug Development-A Report From the 2022 Accelerating Anticancer Agent Development and Validation Meeting. JCO Glob Oncol 2023; 9:e2300294. [PMID: 37944089 PMCID: PMC10645408 DOI: 10.1200/go.23.00294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/18/2023] [Indexed: 11/12/2023] Open
Abstract
Rapidly expanding systemic treatment options, combined with improved screening, diagnostic, surgical, and radiotherapy techniques, have led to improved survival outcomes for many cancers over time. However, these overall survival gains have disproportionately benefited patients in high-income countries, whereas patients in low- and middle-income countries (LMICs) continue to experience challenges in accessing timely and guideline concordant care. In September 2022, the Accelerating Anticancer Agent Development and Validation workshop was held, focusing on global cancer drug development. Panelists discussed key barriers such as the lack of diagnostic services and human resources, drug accessibility and affordability, lack of research infrastructure, and regulatory and authorization challenges, with a particular focus on Africa and Latin America. Potential opportunities to improve access and affordability were reviewed, such as the importance of prioritizing investments in diagnostics, investing health infrastructure and work force planning, coordinated drug procurement efforts and streamlined regulatory processing, incentivized pricing through regulatory change, and the importance of developing and promoting clinical trials that can answer relevant clinical questions for patients in LMICs. As a cancer community, we must continue to advocate for and work toward equitable access to high-quality interventions for patients, regardless of their geographical location.
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Affiliation(s)
- Brooke E. Wilson
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
- Department of Oncology, Guy's & St Thomas' NHS Trust, London, United Kingdom
| | - Richard Peto
- Department of Medical Statistics and Epidemiology, University of Oxford, Oxford, United Kingdom
| | - Bello Abubakar
- Department of Radiotherapy and Oncology, National Hospital Abuja, Abuja, Nigeria
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
| | - Gustavo Werutsky
- Department of Medical Oncology, Hospital São Lucas, Porto Alegre, Brazil
| | - Cary Adams
- Union for International Cancer Control, Geneva, Switzerland
| | - Agnes Saint-Raymond
- International Affairs Division, European Medicines Agency, Amsterdam, the Netherlands
| | | | - Kim Lyerly
- Departments of Surgery, Pathology, and Immunology, Duke University School of Medicine, Durham, NC
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27
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Wu Z, Chen T, Qian Y, Luo G, Liao F, He X, Xu W, Pu J, Ding S. High-Dose Ionizing Radiation Accelerates Atherosclerotic Plaque Progression by Regulating P38/NCOA4-Mediated Ferritinophagy/Ferroptosis of Endothelial Cells. Int J Radiat Oncol Biol Phys 2023; 117:223-236. [PMID: 37059236 DOI: 10.1016/j.ijrobp.2023.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Radiation therapy (RT) significantly increased the incidence of coronary artery diseases, especially atherosclerosis. Endothelial dysfunction has been the major side effect of RT among tumor patients who received RT. However, the involvement between endothelial dysfunction and radiation-induced atherosclerosis (RIA) remains unclear. Here, we constructed a murine model of RIA, aiming to uncover its underlying mechanisms and identify novel strategies for RIA prevention and treatment. METHODS AND MATERIALS Eight-week-old ApoE-/- mice that were fed a Western diet were subjected to partial carotid ligation (PCL). Four weeks later, ionizing radiation (IR) of 10 Gy was performed to verify the detrimental role of IR on atherogenesis. Ultrasound imaging, RT quantitative polymerase chain reaction, histopathology and immunofluorescence, and biochemical analysis were performed 4 weeks after IR. To study the involvement of endothelial ferroptosis induced by IR in RIA, mice after IR were administrated with ferroptosis agonist (cisplatin) or antagonist (ferrostatin-1) intraperitoneally. Western blotting, autophagic flux measurement, reactive oxygen species level detection, and coimmunoprecipitation assay were carried out in vitro. Furthermore, to determine the effect of ferritinophagy inhibition on RIA, in vivo knockdown of NCOA4 was carried out by pluronic gel. RESULTS We verified that accelerated plaque progression was concomitant with endothelial cell (EC) ferroptosis after IR induction, as suggested by a higher level of lipid peroxidation and changes in ferroptosis-associated genes in the PCL + IR group than in the PCL group within vasculature. In vitro experiments further validated the devastating effects of IR on oxidative stress and ferritinophagy in ECs. Mechanistic experiments revealed that IR induced EC ferritinophagy and subsequent ferroptosis in a P38/NCOA4-dependent manner. Both in vitro and in vivo experiments confirmed the therapeutic effect of NCOA4 knockdown in alleviating IR-induced ferritinophagy/ferroptosis of EC and RIA. CONCLUSIONS Our findings provide novel insights into the regulatory mechanisms of RIA and first prove that IR accelerates atherosclerotic plaque progression by regulating ferritinophagy/ferroptosis of ECs in a P38/NCOA4-dependent manner.
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Affiliation(s)
- Zhinan Wu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Taiwei Chen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuxuan Qian
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guqing Luo
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Liao
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinjie He
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wenyi Xu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Song Ding
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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28
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Booth CM, Sengar M, Goodman A, Wilson B, Aggarwal A, Berry S, Collingridge D, Denburg A, Eisenhauer EA, Ginsburg O, Goldstein D, Gunasekera S, Hammad N, Honda K, Jackson C, Karikios D, Knopf K, Koven R, Marini BL, Maskens D, Moraes FY, Mohyuddin GR, Poudyal BS, Pramesh CS, Roitberg F, Rubagumya F, Schott S, Sirohi B, Soto-Perez-de-Celis E, Sullivan R, Tannock IF, Trapani D, Tregear M, van der Graaf W, Vanderpuye V, Gyawali B. Common Sense Oncology: outcomes that matter. Lancet Oncol 2023; 24:833-835. [PMID: 37467768 DOI: 10.1016/s1470-2045(23)00319-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/21/2023]
Affiliation(s)
| | | | - Aaron Goodman
- University of California San Diego, San Diego, CA, USA
| | | | | | - Scott Berry
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | | | | | | | - Nazik Hammad
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | - Kevin Knopf
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian F Tannock
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | | | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology, and Nuclear Medicine, Accra, Ghana
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29
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Michaeli DT, Michaeli JC, Michaeli T. Advances in cancer therapy: clinical benefit of new cancer drugs. Aging (Albany NY) 2023; 15:5232-5234. [PMID: 37338507 PMCID: PMC10333065 DOI: 10.18632/aging.204839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/17/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Daniel Tobias Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | | | - Thomas Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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30
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Gloy V, Schmitt AM, Düblin P, Hirt J, Axfors C, Kuk H, Pereira TV, Locher C, Caquelin L, Walter-Claudi M, Lythgoe MP, Herbrand A, Kasenda B, Hemkens LG. The evidence base of US Food and Drug Administration approvals of novel cancer therapies from 2000 to 2020. Int J Cancer 2023; 152:2474-2484. [PMID: 36779785 DOI: 10.1002/ijc.34473] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/14/2023]
Abstract
Concerns have been raised that regulatory programs to accelerate approval of cancer drugs in cancer may increase uncertainty about benefits and harms for survival and quality of life (QoL). We analyzed all pivotal clinical trials and all non-pivotal randomized controlled trials (RCTs) for all cancer drugs approved for the first time by the FDA between 2000 and 2020. We report regulatory and trial characteristics. Effects on overall survival (OS), progression-free survival and tumor response were summarized in meta-analyses. Effects on QoL were qualitatively summarized. Between 2000 and 2020, the FDA approved 145 novel cancer drugs for 156 indications based on 190 clinical trials. Half of indications (49%) were approved without RCT evidence; 82% had a single clinical trial only. OS was primary endpoint in 14% of trials and QoL data were available from 25%. The median OS benefit was 2.55 months (IQR, 1.33-4.28) with a mean hazard ratio for OS of 0.75 (95%CI, 0.72-0.79, I2 = 42). Improvement for QoL was reported for 7 (4%) of 156 indications. Over time, priority review was used increasingly and the mean number of trials per indication decreased from 1.45 to 1.12. More trials reported results on QoL (19% in 2000-2005; 41% in 2016-2020). For 21 years, novel cancer drugs have typically been approved based on one single, often uncontrolled, clinical trial, measuring surrogate endpoints. This leaves cancer patients without solid evidence that novel drugs improve their survival or QoL and there is no indication towards improvement.
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Affiliation(s)
- Viktoria Gloy
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Andreas M Schmitt
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Medical Oncology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Pascal Düblin
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Julian Hirt
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
- International Graduate Academy, Institute of Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute of Nursing Science, Department of Health, Eastern Switzerland University of Applied Sciences, St. Gallen, Switzerland
| | - Cathrin Axfors
- Department for Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
| | - Hanna Kuk
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tiago V Pereira
- Applied Health Research Centre (AHRC) Li Ka Shing Knowledge Institute of St. Michael's Hospital University of Toronto Canada
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Clara Locher
- Univ Rennes, CHU Rennes, Inserm, Centre d'investigation clinique de Rennes (CIC1414), service de pharmacologie clinique, Institut de recherche en santé, environnement et travail (Irset), Rennes, France
| | - Laura Caquelin
- Univ Rennes, CHU Rennes, Inserm, Centre d'investigation clinique de Rennes (CIC1414), service de pharmacologie clinique, Institut de recherche en santé, environnement et travail (Irset), Rennes, France
| | | | - Mark P Lythgoe
- Department of Surgery & Cancer, Hammersmith Hospital, Imperial College London, London, UK
| | - Amanda Herbrand
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Benjamin Kasenda
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Lars G Hemkens
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
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Ojha RP, Lu Y, Narra K, Meadows RJ, Gehr AW, Mantilla E, Ghabach B. Survival After Implementation of a Decision Support Tool to Facilitate Evidence-Based Cancer Treatment. JCO Clin Cancer Inform 2023; 7:e2300001. [PMID: 37343196 PMCID: PMC10569767 DOI: 10.1200/cci.23.00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE Decision support tools (DSTs) to facilitate evidence-based cancer treatment are increasingly common in care delivery organizations. Implementation of these tools may improve process outcomes, but little is known about effects on patient outcomes such as survival. We aimed to evaluate the effect of implementing a DST for cancer treatment on overall survival (OS) among patients with breast, colorectal, and lung cancer. METHODS We used institutional cancer registry data to identify adults treated for first primary breast, colorectal, or lung cancer between December 2013 and December 2017. Our intervention of interest was implementation of a commercial DST for cancer treatment, and outcome of interest was OS. We emulated a single-arm trial with historical comparison and used a flexible parametric model to estimate standardized 3-year restricted mean survival time (RMST) difference and mortality risk ratio (RR) with 95% confidence limits (CLs). RESULTS Our study population comprised 1,059 patients with cancer (323 breast, 318 colorectal, and 418 lung). Depending on cancer type, median age was 55-60 years, 45%-67% were racial/ethnic minorities, and 49%-69% were uninsured. DST implementation had little effect on survival at 3 years. The largest effect was observed among patients with lung cancer (RMST difference, 1.7 months; 95% CL, -0.26 to 3.7; mortality RR, 0.95; 95% CL, 0.88 to 1.0). Adherence with tool-based treatment recommendations was >70% before and >90% across cancers. CONCLUSION Our results suggest that implementation of a DST for cancer treatment has nominal effect on OS, which may be partially attributable to high adherence with evidence-based treatment recommendations before tool implementation in our setting. Our results raise awareness that improved process outcomes may not translate to improved patient outcomes in some care delivery settings.
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Affiliation(s)
- Rohit P. Ojha
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Yan Lu
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Kalyani Narra
- Oncology and Infusion Center, JPS Health Network, Fort Worth, TX
| | - Rachel J. Meadows
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Aaron W. Gehr
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | | | - Bassam Ghabach
- Oncology and Infusion Center, JPS Health Network, Fort Worth, TX
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Michaeli T, Jürges H, Michaeli DT. FDA approval, clinical trial evidence, efficacy, epidemiology, and price for non-orphan and ultra-rare, rare, and common orphan cancer drug indications: cross sectional analysis. BMJ 2023; 381:e073242. [PMID: 37160306 PMCID: PMC10167557 DOI: 10.1136/bmj-2022-073242] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To analyze the US Food and Drug Administration (FDA) approval, trials, unmet needs, benefit, and pricing of ultra-rare (<6600 affected US citizens), rare (6600-200 000 citizens), and common (>200 000 citizens) orphan cancer drug indications and non-orphan cancer drug indications. DESIGN Cross sectional analysis. SETTING Data from Drugs@FDA, FDA labels, Global Burden of Disease study, and Medicare and Medicaid. POPULATION 170 FDA approved drugs across 455 cancer indications between 2000 and 2022. MAIN OUTCOME MEASURES Comparison of non-orphan and ultra-rare, rare, and common orphan indications regarding regulatory approval, trials, epidemiology, and price. Hazard ratios for overall survival and progression-free survival were meta-analyzed. RESULTS 161 non-orphan and 294 orphan cancer drug indications were identified, of which 25 were approved for ultra-rare diseases, 205 for rare diseases, and 64 for common diseases. Drugs for ultra-rare orphan indications were more frequently first in class (76% v 48% v 38% v 42%; P<0.001), monotherapies (88% v 69% v 72% v 55%; P=0.001), for hematologic cancers (76% v 66% v 0% v 0%; P<0.001), and supported by smaller trials (median 85 v 199 v 286 v 521 patients; P<0.001), of single arm (84% v 44% v 28% v 21%; P<0.001) phase 1/2 design (88% v 45% v 45% v 27%; P<0.001) compared with rare and common orphan indications and non-orphan indications. Drugs for common orphan indications were more often biomarker directed (69% v 26% v 12%; P<0.001), first line (77% v 39% v 20%; P<0.001), small molecules (80% v 62% v 48%; P<0.001) benefiting from quicker time to first FDA approval (median 5.7 v 7.1 v 8.9 years; P=0.02) than those for rare and ultra-rare orphan indications. Drugs for ultra-rare, rare, and common orphan indications offered a significantly greater progression-free survival benefit (hazard ratio 0.53 v 0.51 v 0.49 v 0.64; P<0.001), but not overall survival benefit (0.50 v 0.73 v 0.71 v 0.74; P=0.06), than non-orphans. In single arm trials, tumor response rates were greater for drugs for ultra-rare orphan indications than for rare or common orphan indications and non-orphan indications (objective response rate 57% v 48% v 55% v 33%; P<0.001). Disease incidence/prevalence, five year survival, and the number of available treatments were lower, whereas disability adjusted life years per patient were higher, for ultra-rare orphan indications compared with rare or common indications and non-orphan indications. For 147 on-patent drugs with available data in 2023, monthly prices were higher for ultra-rare orphan indications than for rare or common orphan indications and non-orphan indications ($70 128 (£55 971; €63 370) v $33 313 v $16 484 v $14 508; P<0.001). For 48 on-patent drugs with available longitudinal data from 2005 to 2023, prices increased by 94% for drugs for orphan indications and 50% for drugs for non-orphan indications on average. CONCLUSIONS The Orphan Drug Act of 1983 incentivizes development of drugs not only for rare diseases but also for ultra-rare diseases and subsets of common diseases. These orphan indications fill significant unmet needs, yet their approval is based on small, non-robust trials that could overestimate efficacy outcomes. A distinct ultra-orphan designation with greater financial incentives could encourage and expedite drug development for ultra-rare diseases.
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Affiliation(s)
- Thomas Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hendrik Jürges
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Daniel Tobias Michaeli
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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Storme GA. Breast Cancer: Impact of New Treatments? Cancers (Basel) 2023; 15:2205. [PMID: 37190134 PMCID: PMC10136973 DOI: 10.3390/cancers15082205] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Breast cancer treatment has seen tremendous progress since the early 1980s, with the first findings of new chemotherapy and hormone therapies. Screening started in the same period. METHODS A review of population data (SEER and the literature) shows an increase in recurrence-free survival until 2000 and it stagnates afterwards. RESULTS Over the period 1980-2000, the 15% survival gain was presented by pharma as a contribution of new molecules. The contribution of screening during that same period was not implemented by them, although screening has been accepted as a routine procedure in the States since the 1980s and everywhere else since 2000. CONCLUSIONS Interpretation of breast cancer outcome has largely focused on drugs, whereas other factors, such as screening, prevention, biologics, and genetics, were largely neglected. More attention should now be paid to examining the strategy based on realistic global data.
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Affiliation(s)
- Guy A Storme
- Department Radiation Oncology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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Does Therapeutic Repurposing in Cancer Meet the Expectations of Having Drugs at a Lower Price? Clin Drug Investig 2023; 43:227-239. [PMID: 36884210 PMCID: PMC10097740 DOI: 10.1007/s40261-023-01251-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 03/09/2023]
Abstract
Therapeutic repurposing emerged as an alternative to the traditional drug discovery and development model (DDD) of new molecular entities (NMEs). It was anticipated that by being faster, safer, and cheaper, the development would result in lower-cost drugs. As defined in this work, a repurposed cancer drug is one approved by a health regulatory authority against a non-cancer indication that then gains new approval for cancer. With this definition, only three drugs are repurposed for cancer: Bacillus Calmette-Guerin (BCG) vaccine (superficial bladder cancer, thalidomide [multiple myeloma], and propranolol [infantile hemangioma]). Each of these has a different history regarding price and affordability, and it is not yet possible to generalize the impact of drug repurposing on the final price to the patient. However, the development, including the price, does not differ significantly from an NME. For the end consumer, the product's price is unrelated to whether it followed the classical development or repurposing. Economic constraints for clinical development, and drug prescription biases for repurposing drugs, are barriers yet to be overcome. The affordability of cancer drugs is a complex issue that varies from country to country. Many alternatives for having affordable drugs have been put forward, however these measures have thus far failed and are, at best, palliative. There are no immediate solutions to the problem of access to cancer drugs. It is necessary to critically analyze the impact of the current drug development model and be creative in implementing new models that genuinely benefit society.
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Roze S, Bertrand N, Eberst L, Borget I. Projecting overall survival in health-economic models: uncertainty and maturity of data. Curr Med Res Opin 2023; 39:367-374. [PMID: 36628431 DOI: 10.1080/03007995.2023.2167442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE As lifetime horizons are considered for economic evaluations, the Kaplan-Meier (KM) estimate is used to extrapolate survival in cases of immature overall survival (OS) data. This study estimated the error induced by the choice of distribution when extrapolating different levels of OS maturity. METHODS Fifteen phase 3 trials reporting KM estimates of OS where at least 70% maturity (i.e. 70% of the population had died during follow-up) were included and compared to artificially created truncated data (30 and 50% maturity). Individual patient-data were reproduced using the Guyot algorithm based on digitized KM curves. Parametric survival distributions were fit for each arm in each study, for each maturity level, using the same time horizon (equal to the maximum follow-up). For each KM curve, the best distribution was chosen based on visual inspection, Akaike/Bayesian information criteria, and external validity. Outcomes were measured as life expectancy in months (LM) and life months gained (LMG). RESULTS The Weibull (33%), log-logistic (32%) and log-normal (27%) were most often selected as the best fitting distribution. Compared to LM at full maturity, LM was overestimated in 23 and 40% of cases, at 30 and 50% maturity, respectively. Mean absolute error was 2.12months at 30% maturity, and decreased to 0.88months at 50% maturity. When comparing to mature data, the mean percentage of error in LMG was 126.4 and 62.4% at 30 and 50% maturity, respectively. CONCLUSION The extent of OS maturity increases the risk of error when projecting long-term life expectancy for economic models. Even marginal gains in OS maturity result in more accurate estimations and should be considered when developing models.
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Affiliation(s)
| | | | - Lauriane Eberst
- Medical Oncology Department, Institut de Cancerologie de Strasbourg Europe, Strasbourg, France
| | - Isabelle Borget
- Department of Biostatistics and Epidemiology, Gustave Roussy, Oncostat, U1018 Inserm, Paris-Saclay University, "Ligue Contre le Cancer" labeled team, Villejuif, France
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Haslam A, Olivier T, Prasad V. Design, power, and alpha levels in randomized phase II oncology trials. ESMO Open 2023; 8:100779. [PMID: 36736072 PMCID: PMC10024120 DOI: 10.1016/j.esmoop.2022.100779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The statistical plan of a phase II trial should balance minimizing the premature termination of potentially beneficial therapies (i.e. false negatives) and the further, costly testing of ineffective drugs (i.e. false positives). We sought to examine the methodology, reporting, and bias in the interpretation of outcomes of phase II oncology trials in recent years. MATERIALS AND METHODS In a retrospective cross-sectional analysis, we reviewed all full-length articles published on PubMed from 1 January 2021 to 20 June 2022. We searched for data regarding the sample size calculation (number, α value, power, and expected effect size), the primary and secondary outcomes and results, and the authors' conclusion of the study. RESULTS About 5.4% of studies (n = 10) used a statistical power that was inferior to 80%, and 16.7% (n = 34) did not indicate the level of power for the sample size calculation. Approximately 16.7% (n = 31) of studies used a one-sided α level of ≤0.025; 17.7% (n = 33) of studies used a predefined threshold (no comparator effect size or difference between groups) to determine the sample size for efficacy. The percentage of studies with a positive authors' conclusion but not meeting the primary endpoint, or the endpoint was equivocal, was 27.4% (n = 51). CONCLUSION Many randomized phase II studies in oncology failed to report essential data for determining sample size calculations, many did not actually use a comparator to determine efficacy even though the studies were randomized, and many had positive conclusions even though the results were indeterminate or the primary endpoint was not met.
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Affiliation(s)
- A Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA.
| | - T Olivier
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA; Department of Oncology, Geneva University Hospital, Geneva, Switzerland
| | - V Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
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Hallinen T, Kivelä S, Soini E, Harjola VP, Pesonen M. Cost-Effectiveness of Empagliflozin in Combination with Standard Care versus Standard Care Only in the Treatment of Heart Failure Patients in Finland. Clinicoecon Outcomes Res 2023; 15:1-13. [PMID: 36636485 PMCID: PMC9831000 DOI: 10.2147/ceor.s391455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/16/2022] [Indexed: 01/07/2023]
Abstract
Purpose Sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin has recently been shown to improve the outcomes of heart failure (HF) patients regardless of patient's left ventricular ejection fraction by reducing the combined risk of cardiovascular death or hospitalization for worsening HF. The aim of this study was to assess the cost-effectiveness of adding empagliflozin to the standard care (SC) in comparison to SC only in the treatment of HF in Finland. Patients and Methods The assessment was performed in the cost-utility framework using two Markov cohort state-transition models, one for HF with reduced ejection fraction (HFrEF) and one for HF with preserved ejection fraction (HFpEF). The models have been primarily developed based on the EMPEROR-Reduced and EMPEROR-Preserved trials which informed the modelled patient characteristics, efficacy of treatments in terms of associated risks for heart failure hospitalizations, cardiovascular (CV) and non-CV death, treatment related adverse events (AE), and state- and event-specific health-related quality of life weights (EQ-5D). Direct health care costs were estimated from Finnish published references. Cost-effectiveness was assessed from health care payer perspective based on incremental cost-effectiveness ratio (ICER; cost per quality adjusted life-year [QALY] gained) and probability of cost-effectiveness (at willingness-to-pay [WTP] of 35,000 euros/QALY). The ICER was reported as the weighted (HFrEF, 43.5%; HFpEF, 56.5%) average result of the two models. Results Empagliflozin + SC treatment increased the average quality-adjusted life-expectancy, and treatment costs of HF patients by 0.15 QALYs and 1,594 euros, respectively, when compared to SC. An additional QALY with empagliflozin was thus gained at a cost of 10,621 euros. The probability of empagliflozin + SC being cost-effective compared to placebo + SC was 77.6% and 83.5% with WTP of 35,000 and 100,000 euros/QALY, respectively. Conclusion Empagliflozin is a cost-effective treatment for patients with HF in the Finnish health care setting.
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Affiliation(s)
- Taru Hallinen
- ESiOR Oy, Kuopio, Finland,Correspondence: Taru Hallinen, ESiOR Oy, Tulliportinkatu 2 LT 4, Kuopio, FI-70100, Finland, Tel +358 50 568 1894, Email
| | | | | | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
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38
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Courneya KS, Friedenreich CM. Designing, analyzing, and interpreting observational studies of physical activity and cancer outcomes from a clinical oncology perspective. Front Oncol 2023; 13:1098278. [PMID: 37124538 PMCID: PMC10147404 DOI: 10.3389/fonc.2023.1098278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/31/2023] [Indexed: 05/02/2023] Open
Abstract
Observational studies may play an important role in evaluating physical activity (PA) as a cancer treatment; however, few studies have been designed, analyzed, or interpreted from a clinical oncology perspective. The purpose of the present paper is to apply the Exercise as Cancer Treatment (EXACT) Framework to assess current observational studies of PA and cancer outcomes from a clinical oncology perspective and provide recommendations to improve their clinical utility. Recent systematic reviews and meta-analyses of over 130 observational studies have concluded that higher prediagnosis and postdiagnosis PA are associated with lower risks of cancer-specific and all-cause mortality. Most of these studies, however, have: (a) included cancer patients receiving heterogeneous treatment protocols, (b) provided minimal details about those cancer treatments, (c) assessed PA prediagnosis and/or postdiagnosis without reference to those cancer treatments, (d) reported mainly mortality outcomes, and (e) examined subgroups based on demographic and disease variables but not cancer treatments. As a result, current observational studies on PA and cancer outcomes have played a modest role in informing clinical exercise trials and clinical oncology practice. To improve their clinical utility, we recommend that future observational studies of PA and cancer outcomes: (a) recruit cancer patients receiving the same or similar first-line treatment protocols, (b) collect detailed data on all planned and unplanned cancer treatments beyond whether or not cancer treatments were received, (c) assess PA in relation to cancer treatments (i.e., before, during, between, after) rather than in relation to the cancer diagnosis (i.e., various time periods before and after diagnosis), (d) collect data on cancer-specific outcomes (e.g., disease response, progression, recurrence) in addition to mortality, (e) conduct subgroup analyses based on cancer treatments received in addition to demographic and disease variables, and (f) interpret mechanisms for any associations between PA and cancer-specific outcomes based on the clinical oncology scenario that is recapitulated rather than referencing generic mechanisms or discordant preclinical models. In conclusion, observational studies are well-suited to contribute important knowledge regarding the role of PA as a cancer treatment; however, modifications to study design and analysis are necessary if they are to inform clinical research and practice.
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Affiliation(s)
- Kerry S. Courneya
- Faculty of Kinesiology, Sport, and Recreation, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Kerry S. Courneya,
| | - Christine M. Friedenreich
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
- Departments of Oncology and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Meirson T, Nardone V, Pentimalli F, Markel G, Bomze D, D'Apolito M, Correale P, Giordano A, Pirtoli L, Porta C, Gray SG, Mutti L. Analysis of new treatments proposed for malignant pleural mesothelioma raises concerns about the conduction of clinical trials in oncology. J Transl Med 2022; 20:593. [PMID: 36514092 DOI: 10.1186/s12967-022-03744-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/29/2022] [Indexed: 12/15/2022] Open
Abstract
In this commentary, using existing clinical trial data and FDA approvals we propose that there is currently a critical need for an appropriate balancing between the financial impact of new cancer drugs and their actual benefit for patients. By adopting "pleural mesothelioma" as our clinical model we summarize the most relevant pertinent and available literature on this topic, and use an analysis of the reliability of the trials submitted for registration and/or recently published as a case in point to raise concerns with respect to appropriate trial design, biomarker based stratification and to highlight the ongoing need for balancing the benefit/cost ratio for both patients and healthcare providers.
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Affiliation(s)
- Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, 49100, Petah Tikva, Israel
| | - Valerio Nardone
- Department of Precision Oncology, University Hospital of Campania L. Vanvitelli, Naples, Italy
| | - Francesca Pentimalli
- Dipartimento di Medicina e Chirurgia, Libera Università Mediterranea "Giuseppe Degennaro", Bari, Italy
| | - Gal Markel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Bomze
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maria D'Apolito
- Unit of Medical Oncology, Oncology Department, Grand Metropolitan Hospital Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Pierpaolo Correale
- Unit of Medical Oncology, Oncology Department, Grand Metropolitan Hospital Bianchi Melacrino Morelli, Reggio Calabria, Italy.,Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, USA
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, USA.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Pirtoli
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, USA
| | - Camillo Porta
- Interdisciplinary Department of Medicine, University of Bari "Aldo Moro" and A.O.U. Consorziale Policlinico di Bari, Bari, Italy.
| | - Steven G Gray
- Thoracic Oncology Research Group, Trinity St James's Cancer Institute, St James's Hospital, Dublin, Ireland.
| | - Luciano Mutti
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, USA. .,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, Coppito 2, 67100, L'Aquila, Italy.
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