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Banerjee S. Cost-Effectiveness and the Economics of Genomic Testing and Molecularly Matched Therapies. Surg Oncol Clin N Am 2024; 33:231-242. [PMID: 38401907 DOI: 10.1016/j.soc.2023.12.010] [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] [Indexed: 02/26/2024]
Abstract
Cost-effectiveness analysis of precision oncology can help guide value-driven care. Next-generation sequencing is increasingly cost-efficient over single gene testing because diagnostic algorithms require multiple individual gene tests to determine biomarker status. Matched targeted therapy is often not cost-effective due to the high cost associated with drug treatment. However, genomic profiling can promote cost-effective care by identifying patients who are unlikely to benefit from therapy. Additional applications of genomic profiling such as universal testing for hereditary cancer syndromes and germline testing in patients with cancer may represent cost-effective approaches compared with traditional history-based diagnostic methods.
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Affiliation(s)
- Sudeep Banerjee
- Division of Colorectal Surgery, Department of General Surgery, Kaiser Permanente San Jose Medical Center, Kaiser Permanente Northern California, 280 Hospital Parkway, Building B, San Jose, CA 95119, USA.
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Sasaki K, Haddad FG, Short NJ, Jain N, Issa G, Jabbour E, Kantarjian H. Outcome of Philadelphia chromosome-positive chronic myeloid leukemia in the United States since the introduction of imatinib therapy-The Surveillance, Epidemiology, and End Results database, 2000-2019. Cancer 2023; 129:3805-3814. [PMID: 37769040 DOI: 10.1002/cncr.35038] [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: 04/05/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Since the introduction of BCR::ABL1 tyrosine kinase inhibitors (TKIs) in 2000, the treatment of Philadelphia chromosome (Ph)-positive chronic myeloid leukemia (CML) has improved significantly. METHODS This study aimed to evaluate Ph-positive CML outcomes in the TKI therapy era, considering factors like age, ethnicity, and income. Using the Surveillance, Epidemiology, and End Results (SEER) database, 2857 patients with Ph-positive CML diagnosed from 2000 to 2019 were analyzed. RESULTS The overall 5-year survival rates in Ph-positive CML increased to above 80%, compared with pre-TKIs historical data reporting 5-year overall survival (OS) rates of less than 50%. The 5-year OS rate was 73% for patients diagnosed in 2000-2004, 82% in 2005-2009, and 78% in 2010-2014; the 4-year OS rate was 83% in 2015-2019. The 5-year OS rate for younger patients (<60 years old) was 88% in 2000-2009 and 90% in 2010-2019 (p value .426). In older patients (60+ years old), the 5-year OS rates were 64% and 65%, respectively (p value, .303). Lower household income was associated with inferior survival across the 2000-2019. These results are inferior to European studies where TKIs are universally available and affordable, and relative OS in CML is similar to age-matched normal populations. CONCLUSIONS Although the outcome of Ph-positive CML has improved significantly since 2000, the SEER data still shows differences in outcomes among patient subsets, some anticipated (worse OS in older patients accounted by the relative OS), but others that suggest less than universal access and affordability of this therapy (among poorer patients) in the United States.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Joyce DD, Dusetzina SB. Financial toxicity of oral therapies in advanced prostate cancer. Urol Oncol 2023; 41:363-368. [PMID: 37029039 DOI: 10.1016/j.urolonc.2023.03.002] [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: 09/25/2022] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
The treatment landscape of advanced prostate cancer (CaP) has evolved significantly over the past 20 years. As the number of oral anticancer treatment options continues to increase, so do the costs of these drugs. Furthermore, payment responsibility for these treatments is increasingly shifted from insurers to patients. In this narrative review, we sought to summarize existing assessments of financial toxicity (FT) associated with oral advanced CaP treatments, describe efforts targeted at limiting FT from these agents, and identify areas in need of further investigation. FT is understudied in advanced CaP. Oral treatment options are associated with significantly higher direct costs to patients compared to standard androgen deprivation therapy or chemotherapy. Financial assistance programs, Medicare low-income subsidies, and recent health policy changes help offset these costs for some patients. Physicians are reluctant to discuss treatment costs with patients and further work is needed to better understand best practices for inclusion of FT discussions in shared decision-making. Oral therapies for advanced CaP are associated with significantly higher patient out-of-pocket costs which may contribute to FT. Currently, little is known regarding the extent and severity of these costs on patients' lives. While recent policy changes have helped reduce these costs for some patients, more work is needed to better characterize FT in this population to inform interventions that improve access to care and lessen the harms associated with the cost of novel treatments.
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Affiliation(s)
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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Jenei K, Lythgoe MP, Prasad V. CostPlus and implications for generic imatinib. LANCET REGIONAL HEALTH. AMERICAS 2022; 13:100317. [PMID: 36777318 PMCID: PMC9903877 DOI: 10.1016/j.lana.2022.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kristina Jenei
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada,Corresponding author at: 2206 East Mall, Vancouver, British Columbia, V6T 1Z3, Canada.
| | - Mark P. Lythgoe
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, United States
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Sun Y, Hendrix A, Muluneh B, Ozawa S. Online Pharmacy Accessibility of Imatinib, An Oral Chemotherapy Medication. J Natl Compr Canc Netw 2022; 20:808-814. [PMID: 35830891 DOI: 10.6004/jnccn.2022.7007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Since prices of imatinib (Gleevec) remain high, patients on oral chemotherapy are looking for alternative methods to access this life-saving medication. We assessed the accessibility of imatinib through online pharmacies and analyzed each website for medication safety, price, and marketing tactics. METHODS We searched the term "buy imatinib online" using 4 commonly used internet search engines (Google, Bing, Yahoo!, and DuckDuckGo) and screened web pages displayed in the first 10 pages. Websites were included if they were published in English, sold imatinib, were free to access, and offered shipping in the United States. Websites were classified using LegitScript's categorization as "certified," "unclassified," "unapproved," or "rogue." We analyzed information on websites' patient safety characteristics, marketing techniques, pricing, domain registration information, and IP addresses. RESULTS Of the 44 online pharmacies identified, only 3 (7%) were certified, and the remainder were classified as rogue (52%; n=23), unapproved (30%; n=13), or unclassified (11%; n=5). Thirteen online pharmacies (30%; 9 rogue, 4 unclassified) sold imatinib without a prescription. Nearly one-quarter (n=10) of online pharmacies selling imatinib did not include drug-related warnings on their websites, and nearly half (n=21) did not limit the purchasable quantity. More than three-quarters (n=34) of online pharmacies selling imatinib did not offer pharmacist consultations, even though nearly all websites extended offers to speak with sales associates (91%; n=40). Most online pharmacies selling imatinib claimed price discounts (95%; n=42), but fewer provided bulk discounts (23%; n=10) or coupons (34%; n=15). One-third of rogue pharmacies selling imatinib (n=7) claimed to be registered or accredited on their websites. CONCLUSIONS The lack of safety measures taken by illegitimate online pharmacies endangers patient safety because they allow patients to purchase imatinib without appropriate evaluation for response, drug interactions, and adverse effects. Healthcare providers need to be aware of this practice and should assure patient access to imatinib through safe and legitimate pharmacies.
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Affiliation(s)
- Yujiao Sun
- Division of Practice Advancement and Clinical Education, and
| | - Adam Hendrix
- Division of Practice Advancement and Clinical Education, and
| | - Benyam Muluneh
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, and
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, and.,Department of Maternal Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
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Rivera DR, Enewold L, Barrett MJ, Banegas MP, Filipski KK, Freedman AN, Lam CK, Mariotto A. Population-based utilization and costs associated with tyrosine kinase inhibitors for first-line treatment of chronic myelogenous leukemia among elderly patients. J Manag Care Spec Pharm 2020; 26:1494-1504. [PMID: 33251998 PMCID: PMC10391029 DOI: 10.18553/jmcp.2020.26.12.1494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Following approval of imatinib, a breakthrough tyrosine kinase inhibitor (TKI), survival significantly improved by more than 20% since 2001 among treated chronic myelogenous leukemia (CML) patients. Subsequently, more expensive second-generation TKIs with varying selectivity profiles have been approved. Population-based studies are needed to evaluate the real-world utilization of TKI therapies, particularly given their escalating costs and recommendations for maintenance therapy. OBJECTIVE: To assess the utilization patterns of first-line TKIs, overall and by specific agent, among elderly CML patients in the United States, and the cost implications. METHODS: CML patients aged 65 years and older at diagnosis between 2007 and 2015 were identified from population-based cancer registries in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The percentage of CML patients receiving imatinib, dasatinib, or nilotinib within the first year of diagnosis was calculated along with time to first-line treatment initiation. Bivariate comparisons and Cox proportional hazards models were used to identify factors associated with TKI initiation. Average monthly patient responsibility, including patient out-of-pocket (OOP) costs, stratified by Part D low-income subsidy (LIS) status were also calculated. RESULTS: Among the 1,589 CML patients included, receipt of any TKI within 1 year of diagnosis increased from 66.2% to 78.9%. In 2015, the distribution of first-line TKI therapies was 41.3% imatinib, 28.3% dasatinib, and 9.3% nilotinib. Almost 60% of patients initiated TKI treatment within 3 months of diagnosis. Multivariable analysis indicated that TKI use in the first year was lower among the very elderly (aged > 75 years vs. 65-69 years: HR = 0.72; 95% CI = 0.63-0.83), patients with more comorbidities (Hierarchical Condition Category risk score > 2 vs. HR = 0.74, 95% CI = 0.62-0.88), and patients ineligible for LIS (HR = 0.75; 95% CI = 0.65-0.87). Average monthly patient OOP cost was significantly lower for LIS-eligible versus LIS-ineligible patients: imatinib (2016: $12 vs. $487), dasatinib (2016: $34 vs. $557), and nilotinib (2016: $1 vs. $526). CONCLUSIONS: TKI use has increased significantly since 2007. While imatinib remained the most frequently prescribed first-line agent, by 2015 newer TKIs represented one third of the market share. Utilization patterns indicated persistent age, comorbidity, and financial barriers. TKI use is indicated for long-term therapy, and increased adoption of newer, more expensive agents raises concerns about the sustained affordability of CML treatment, particularly among unsubsidized patients. DISCLOSURES: No outside funding supported this study. There are no reported conflicts of interest.
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Affiliation(s)
- Donna R Rivera
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Rockville, MD
| | - Lindsey Enewold
- National Cancer Institute, Division of Cancer Control and Population Sciences, Health Care Delivery Research Program, Rockville, MD
| | | | | | - Kelly K Filipski
- National Cancer Institute, Division of Cancer Control and Population Sciences, Epidemiology and Genomics Research Program, Rockville, MD
| | - Andrew N Freedman
- National Cancer Institute, Division of Cancer Control and Population Sciences, Epidemiology and Genomics Research Program, Rockville, MD
| | - Clara K Lam
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Rockville, MD
| | - Angela Mariotto
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Rockville, MD
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Banerjee S, Kumar A, Lopez N, Zhao B, Tang CM, Yebra M, Yoon H, Murphy JD, Sicklick JK. Cost-effectiveness Analysis of Genetic Testing and Tailored First-Line Therapy for Patients With Metastatic Gastrointestinal Stromal Tumors. JAMA Netw Open 2020; 3:e2013565. [PMID: 32986105 PMCID: PMC7522695 DOI: 10.1001/jamanetworkopen.2020.13565] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Gastrointestinal stromal tumor (GIST) is frequently driven by oncogenic KIT variations. Imatinib targeting of KIT marked a new era in GIST treatment and ushered in precision oncological treatment for all solid malignant neoplasms. However, studies on the molecular biological traits of GIST have found that tumors respond differentially to imatinib dosage based on the KIT exon with variation. Despite this knowledge, few patients undergo genetic testing at diagnosis, and empirical imatinib therapy remains routine. Barriers to genetic profiling include concerns about the cost and utility of testing. OBJECTIVE To determine whether targeted gene testing (TGT) is a cost-effective diagnostic for patients with metastatic GIST from the US payer perspective. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation developed a Markov model to compare the cost-effectiveness of TGT and tailored first-line therapy compared with empirical imatinib therapy among patients with a new diagnosis of metastatic GIST. The main health outcome, quality-adjusted life years (QALYs), and costs were obtained from the literature, and transitional probabilities were modeled from disease progression and survival estimates from randomized clinical trials of patients with metastatic GIST. Data analyses were conducted October 2019 to January 2020. EXPOSURE TGT and tailored first-line therapy. MAIN OUTCOMES AND MEASURES The primary outcome was QALYs and cost. Cost-effectiveness was defined using an incremental cost-effectiveness ratio, with an incremental cost-effectiveness ratio less than $100 000/QALY considered cost-effective. One-way and probabilistic sensitivity analyses were conducted to assess model stability. RESULTS Therapy directed by TGT was associated with an increase of 0.10 QALYs at a cost of $9513 compared with the empirical imatinib approach, leading to an incremental cost-effectiveness ratio of $92 100. These findings were sensitive to the costs of TGT, drugs, and health utility model inputs. Therapy directed by TGT remained cost-effective for genetic testing costs up to $3730. Probabilistic sensitivity analysis found that TGT-directed therapy was considered cost-effective 70% of the time. CONCLUSIONS AND RELEVANCE These findings suggest that using genetic testing to match treatment of KIT variations to imatinib dosing is a cost-effective approach compared with empirical imatinib.
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Affiliation(s)
- Sudeep Banerjee
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego
- Department of Surgery, University of California, Los Angeles
| | - Abhishek Kumar
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego
| | - Nicole Lopez
- Department of Surgery, Division of Colorectal Surgery, University of California, San Diego
| | - Beiqun Zhao
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego
| | - Chih-Min Tang
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego
| | - Mayra Yebra
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego
| | - Hyunho Yoon
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego
| | - James D. Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego
| | - Jason K. Sicklick
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego
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8
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Wilkes JJ, Lyman GH, Doody DR, Chennupati S, Becker LK, Morin PE, Winestone LE, Henk HJ, Chow EJ. Health Care Cost Associated With Contemporary Chronic Myelogenous Leukemia Therapy Compared With That of Other Hematologic Malignancies. JCO Oncol Pract 2020; 17:e406-e415. [PMID: 32822255 DOI: 10.1200/op.20.00143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Given the widespread introduction of tyrosine kinase inhibitors (TKIs), we evaluated the cost associated with chronic myelogenous leukemia (CML) care compared with the cost of care for patients with hematologic malignancies (HEM) and for patients without cancer (GEN), to aid with resource allocation and clinical decision making. METHODS A retrospective cohort was constructed from the OptumLabs Data Warehouse using claims from 2000 to 2016. Eligible patients had ≥ 2 CML claims and were enrolled continuously for ≥ 6 months before diagnosis and ≥ 1 year afterward (n = 1,909). Patients with CML were frequency matched 4:1 with HEM and GEN cohorts and were observed through October 2017. We used generalized linear models to assess the variation in total mean annualized health care costs in the 3 cohorts and to examine the influence of factors associated with costs. RESULTS Mean annualized costs for CML were $82,054 (ie, $25,471 [95% CI, $20,808 to $30,133] more than those for HEM and $74,993 [95% CI, $70,818 to $79,167] more than those for GEN); these differences were driven by pharmacy costs in the CML group. The cost of CML care exceeded that for HEM and GEN for all index years in this study and increased over each diagnostic interval until 2015, peaking at $91,990. The mean annual cost of all TKIs increased. Imatinib's mean annualized cost was $41,546 in the period 2000-2004 but increased to $105,069 in the period 2015-2017. In multivariable analysis, percent days on TKIs had the greatest influence on cost: ≥ 75% of the time versus none showed a difference in cost of $108,716 (95% CI, $99,193 to $118,239). CONCLUSION Contemporary CML costs exceeded the cost of treatment of other hematologic malignancies. Cost was primarily driven by TKIs, whose cost continued to increase over time.
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Affiliation(s)
- Jennifer J Wilkes
- Center for Clinical and Translational Research, Seattle, WA.,Department of Pediatrics, University of Washington, Seattle, WA.,OptumLabs, Eden Prairie, MN
| | - Gary H Lyman
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA.,Department of Medicine, University of Washington, Seattle, WA
| | - David R Doody
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Shasank Chennupati
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | - Lena E Winestone
- University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Eric J Chow
- Center for Clinical and Translational Research, Seattle, WA.,Department of Pediatrics, University of Washington, Seattle, WA.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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Smy L, Sadler AJ, McMillin GA. Evaluation of Imatinib Concentrations in Samples Submitted for BCR-ABL1 or Imatinib Testing-Evidence to Support Therapeutic Drug Monitoring for Dose Optimization? Ther Drug Monit 2020; 42:559-564. [PMID: 32697563 DOI: 10.1097/ftd.0000000000000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Imatinib is one of the first-line therapies for chronic myeloid leukemia. Achieving a major molecular response early in treatment, as indicated by a BCR-ABL1 major international scale result of ≤0.1% within 6 months, is associated with better patient outcomes and is statistically associated with a trough imatinib concentration of approximately 1000 ng/mL. Adherence to therapy, drug resistance, drug-drug interactions, and pharmacokinetic/pharmacodynamic factors may hinder attaining this target. Therapeutic drug monitoring of imatinib is not currently standard-of-care, but may help to evaluate adherence and optimize treatment of patients with chronic myeloid leukemia. This study aimed to evaluate imatinib concentrations in real-world patient plasma samples to identify the proportion of imatinib-treated patients who achieved the therapeutic target of 1000 ng/mL. METHODS This was a retrospective, observational study that measured imatinib in residual plasma samples used for BCR-ABL1 tests (n = 1022) and analyzed clinician-ordered imatinib tests for therapeutic drug monitoring (n = 116). Imatinib was measured by competitive immunoassay. The frequency of imatinib concentrations achieving the therapeutic target was determined and correlated with BCR-ABL1 major international scale, age, and sex. RESULTS Seventy-two percent of patients tested for BCR-ABL1 may not have been prescribed or were not adherent to imatinib therapy. In the 29% of patients who did not achieve major molecular response, but had quantifiable imatinib concentrations, the therapeutic concentration was not met. For clinician-ordered imatinib tests, 45% of samples did not exceed the therapeutic target and 4% had potentially toxic plasma concentrations (>3000 ng/mL). CONCLUSIONS Therapeutic drug monitoring for imatinib may assist clinicians in the identification of patients who may not be adherent to therapy, display variable pharmacokinetics or pharmacodynamics, or may be experiencing toxicity or treatment failure.
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Affiliation(s)
- Laura Smy
- *Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah. Dr. Smy is now with Department of Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and †ARUP Laboratories, Inc, Salt Lake City, Utah. The authors declare no conflict of interest
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Comparable Efficacy and Safety of Generic Imatinib and Branded Imatinib in Patients With Newly Diagnosed Chronic Myeloid Leukemia With a Consideration of Socioeconomic Characteristics: A Retrospective Study From a Single Center. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e304-e315. [PMID: 32209331 DOI: 10.1016/j.clml.2020.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/10/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION To compare the efficacy and safety of generic and branded imatinib in adults with newly diagnosed chronic myeloid leukemia in the chronic phase (CML-CP), we retrospectively reviewed data from patients CML-CP who received generic or branded imatinib. PATIENTS AND METHODS A propensity score matching (PSM) study was performed. A Cox regression model was used to identify factors associated with responses and outcomes. RESULTS Four hundred forty-two adults receiving generic imatinib (n = 236) or Glivec (Novartis, Basel, Switzerland; n = 206) were included. There were more patients with rural household registration (P < .001), lower education level (P < .001), divorced or widowed status (P = .009), higher white blood cell counts (P = .019), splenomegaly (P < .001), and longer intervals from diagnosis to imatinib initiation (P = .033) in the generic cohort. During the follow-up, there was no significant difference between the 2 cohorts in the 4-year probabilities of achieving a complete cytogenetic response (97.0% vs. 97.3%; P = .736), major molecular response (87.8% vs. 90.1%; P = .113), and molecular response4.5 (32.5% vs. 38.8%; P = .186), as well as failure-free survival (77.3% vs. 81.4%; P = .313), progression-free survival (94.4% vs. 95.8%; P = .489), and overall survival (96.8% vs. 98.3%; P = .088). Multivariate analyses showed that the drug type was not associated with responses and outcomes. After the PSM procedure, 177 pairs of patients with comparable baseline characteristics were reanalyzed. Multivariate analyses confirmed that generic or branded imatinib used as first-line therapy was not associated with either responses or outcomes. CONCLUSION Sociodemographic characteristics might influence the tyrosine kinase inhibitor that patients chose. Generic and branded imatinib as first-line therapy had comparable efficacy and safety in CML-CP patients.
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Shroff GS, Truong MT, Carter BW, Benveniste MF, Kanagal-Shamanna R, Rauch G, Viswanathan C, Boddu PC, Daver N, Wu CC. Leukemic Involvement in the Thorax. Radiographics 2020; 39:44-61. [PMID: 30620703 DOI: 10.1148/rg.2019180069] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Leukemias are malignancies in which abnormal white blood cells are produced in the bone marrow, resulting in compromise of normal bone marrow hematopoiesis and subsequent cytopenias. Leukemias are classified as myeloid or lymphoid depending on the type of abnormal cells produced and as acute or chronic according to cellular maturity. The four major types of leukemia are acute myeloid leukemia, chronic myeloid leukemia, acute lymphoblastic leukemia, and chronic lymphocytic leukemia. Clinical manifestations are due to either bone marrow suppression (anemia, thrombocytopenia, or neutropenia) or leukemic organ infiltration. Imaging manifestations of leukemia in the thorax are myriad. While lymphadenopathy is the most common manifestation of intrathoracic leukemia, leukemia may also involve the lungs, pleura, heart, and bones and soft tissues. Myeloid sarcomas occur in 5%-7% of patients with acute myeloid leukemia and represent masses of myeloid blast cells in an extramedullary location. ©RSNA, 2019.
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Affiliation(s)
- Girish S Shroff
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Mylene T Truong
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Brett W Carter
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Marcelo F Benveniste
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Rashmi Kanagal-Shamanna
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Greg Rauch
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Chitra Viswanathan
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Prajwal C Boddu
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Naval Daver
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Carol C Wu
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
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Gajski G, Gerić M, Domijan AM, Golubović I, Garaj-Vrhovac V. Evaluation of oxidative stress responses in human circulating blood cells after imatinib mesylate treatment - Implications to its mechanism of action. Saudi Pharm J 2019; 27:1216-1221. [PMID: 31885482 PMCID: PMC6921178 DOI: 10.1016/j.jsps.2019.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/19/2019] [Indexed: 02/02/2023] Open
Abstract
Imatinib mesylate (IM) is the first developed protein kinase inhibitor and recently it has topped consumption rates among targeted and total anticancer drugs. Although there are indications that IM possesses cyto/genotoxic activities against normal non-target cells as well, there is a lack of information regarding the underlying mechanism involved in those actions. Therefore, we aimed to evaluate the response of human circulating blood cells towards oxidative stress after IM treatment (0.0001–10 µg/mL) in vitro. Based on the results, IM had an influence on all of the oxidative stress parameters tested. Lower concentrations of IM induced an increase of glutathione level, following its decrease at higher IM concentrations indicating impairment in oxidative stress defences. Concomitant to a glutathione decrease, an increase of malondialdehyde and protein carbonyls level was observed indicating oxidative damage of lipids and proteins. The observed effects overlapped with the observed formation of oxidative base damage detected by formamidopyrimidine-DNA glycosylase modified-comet assay indicating that IM managed to induce oxidative DNA damage. Our results provide novelty in their mechanistic approach to IM-induced toxicity in non-target cells and suggest that IM can affect blood cells and induce oxidative stress.
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Affiliation(s)
- Goran Gajski
- Institute for Medical Research and Occupational Health, Mutagenesis Unit, 10000 Zagreb, Croatia
- Corresponding author at: Institute for Medical Research and Occupational Health, Mutagenesis Unit, Ksaverska cesta 2, 10000 Zagreb, Croatia.
| | - Marko Gerić
- Institute for Medical Research and Occupational Health, Mutagenesis Unit, 10000 Zagreb, Croatia
| | - Ana-Marija Domijan
- University of Zagreb, Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Ivana Golubović
- University of Zagreb, Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Vera Garaj-Vrhovac
- Institute for Medical Research and Occupational Health, Mutagenesis Unit, 10000 Zagreb, Croatia
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13
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Abou Dalle I, Kantarjian H, Burger J, Estrov Z, Ohanian M, Verstovsek S, Ravandi F, Borthakur G, Garcia-Manero G, Jabbour E, Cortes J. Efficacy and safety of generic imatinib after switching from original imatinib in patients treated for chronic myeloid leukemia in the United States. Cancer Med 2019; 8:6559-6565. [PMID: 31502383 PMCID: PMC6825993 DOI: 10.1002/cam4.2545] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/03/2019] [Accepted: 08/23/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction Imatinib is standard therapy for patients with chronic myeloid leukemia (CML). In February 2016, a generic formulation entered the US market. Physicians and patients are frequently concerned about whether switching from original to generic drugs may affect the efficacy and/or safety. Materials and methods This is an observational retrospective study using medical charts of patients diagnosed with CML in the chronic phase who were treated with original imatinib from the year 2000 to 2017 and who were subsequently switched to generic imatinib. Results In this study, 38 patients have switched to generic imatinib. Before the switch, responses were assessed on all patients, all of them were in CCyR and 36 (95%) were in MMR, including 28 (74%) with MR4.5. Patients have received generic imatinib for a median of 19.4 (range, 3.4‐46.3) months. Molecular responses after switching were stable in 89%, improved in 8%, and worsened in 3% of patients. After switching, 15 (39%) patients reported new or worsening adverse events, including 5 (13%) patients with edema, 8 (21%) muscle cramps, 7 (18%) nausea, 6 (16%) diarrhea, and 5 (13%) fatigue. Discussion Bioequivalence studies demonstrated the same rate and extent of absorption of generic imatinib compared to the original form, which led to the FDA approval. In our observational series, most of the patients maintained their responses and none lost MMR. Adverse events noted were mild and well tolerated. Conclusion A change from original to generic imatinib appears to maintain efficacy and be generally safe. More patients and longer follow‐up are required to confirm these observations.
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Affiliation(s)
- Iman Abou Dalle
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Hagop Kantarjian
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Jan Burger
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Zeev Estrov
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Maro Ohanian
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Srdan Verstovsek
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Farhad Ravandi
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Gautam Borthakur
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | | | - Elias Jabbour
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Jorge Cortes
- Department of leukemia, MD Anderson Cancer Center, The University of Texas, Houston, Texas
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14
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Cost-effectiveness of abiraterone versus docetaxel in the treatment of metastatic hormone naïve prostate cancer. Urol Oncol 2019; 37:688-695. [PMID: 31399302 DOI: 10.1016/j.urolonc.2019.05.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/14/2019] [Accepted: 05/26/2019] [Indexed: 01/23/2023]
Abstract
PURPOSE Prostate cancer is the second leading cause of cancer death in men in the US. Since 2015, landmark studies have demonstrated improved survival outcomes with the use of docetaxel (DCT) or abiraterone (AA) in addition to androgen deprivation therapy (ADT) in the metastatic hormone-naïve setting. These treatment strategies have not been prospectively compared but have similar overall survival benefits despite differing mechanisms of action, toxicity, and cost. We performed a cost-effectiveness analysis to provide insight into the value of AA vs. DCT in the first-line treatment of metastatic prostate cancer. MATERIALS AND METHODS We developed Markov models by using a US-payer perspective and a 3-year time horizon to estimate costs (2018 US$) and progression-free quality-adjusted life years (PF-QALYs) for ADT alone, DCT, and AA. Health states were defined as initial state, treatment states according to experience of an adverse event, and progressed disease/death. State transition probabilities were derived from rates for drug discontinuation, frequency of adverse events, disease progression, and death from the randomized phase III trials ChemoHormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) and LATITUDE. Univariate and probabilistic sensitivity analyses were conducted to evaluate model uncertainty. RESULTS DCT resulted in an increase of 0.32 PF-QALYs and $16,100 in cost and AA resulted in an increase of 0.52 PF-QALYs and $215,800 in cost compared to ADT alone. The incremental cost-effectiveness ratio for DCT vs. ADT was $50,500/PF-QALY and for AA vs. DCT was $1,010,000/PF-QALY. Probabilistic sensitivity analysis demonstrated that at a willingness-to-pay threshold of $150,000/PF-QALY AA was highly unlikely to be cost-effective. CONCLUSION DCT is substantially more cost-effective than AA in the treatment of metastatic hormone naïve prostate cancer.
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15
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Kenzik KM, Bhatia R, Williams GR, Bhatia S. Medicare and patient spending among beneficiaries diagnosed with chronic myelogenous leukemia. Cancer 2019; 125:2570-2578. [PMID: 30973642 DOI: 10.1002/cncr.32137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/04/2019] [Accepted: 03/11/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The authors examined Medicare spending and patient spending in older patients with chronic myelogenous leukemia (CML) over the first 5 years from the time of CML diagnosis in the tyrosine kinase inhibitor (TKI) era. METHODS Medicare beneficiaries with CML who were diagnosed between 2007 and 2012 at age >65 years were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (805 beneficiaries). A noncancer Medicare beneficiary sample was frequency-matched based on age, sex, and race/ethnicity (805 individuals). Patients were followed until 5 years from diagnosis, disenrollment, death, or December 31, 2014, whichever came first. Total Medicare spending, service-specific spending, and amount owed by patients was estimated monthly and then summed over 60 months and averaged to generate annual spending. RESULTS The median age at the time of diagnosis of CML was 76 years (range, 66-102 years). Overall, 51.4% of patients received TKIs (27.8% received imatinib alone), 28% received non-TKI therapy, and 21% received no treatment. The 5-year survival rate for patients with ≥85% time receiving TKIs was 79% compared with 76% for noncancer controls versus 62% for those with <85% time receiving TKIs. Annual Medicare spending was found to be significantly higher for patients treated with TKIs ($143,053) compared with those treated without TKIs ($41,268 vs $10,498 for noncancer controls). Annual patient cost responsibility was $11,712 per patient receiving any TKIs versus $7330 for those receiving non-TKI outpatient chemotherapy versus $3561 for noncancer controls. CONCLUSIONS Older patients with CML with adequate time receiving TKI therapy have 5-year survival rates that are comparable to those of their counterparts without cancer. However, TKI use is accompanied with significant Medicare and patient spending; patients receiving multiple TKIs (ie, dasatinib or nilotinib along with imatinib) constitute the group with the highest spending.
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Affiliation(s)
- Kelly M Kenzik
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ravi Bhatia
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Grant R Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pediatric Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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How I treat chronic myeloid leukemia in children and adolescents. Blood 2019; 133:2374-2384. [PMID: 30917954 DOI: 10.1182/blood.2018882233] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/21/2019] [Indexed: 12/15/2022] Open
Abstract
Evidence-based recommendations have been established for treatment of chronic myeloid leukemia (CML) in adults treated with tyrosine kinase inhibitors (TKIs), but the rarity of this leukemia in children and adolescents makes it challenging to develop similar recommendations in pediatrics. In addition to imatinib, which was approved for pediatric CML in 2003, the second-generation TKIs dasatinib and nilotinib were recently approved for use in children, expanding the therapeutic options and pushing allogeneic stem cell transplantation to a third-line treatment of most pediatric cases. Yet, without sufficient data on efficacy and safety specific to pediatric patients, the selection of a TKI continues to rely on clinical experience in adults. Here, we present 4 case scenarios highlighting common yet challenging issues encountered in the treatment of pediatric CML (suboptimal response, poor treatment adherence, growth retardation, and presentation in advanced phases). Limited experience with very young children, the transition of teenagers to adult medicine, and the goal of achieving treatment-free remission for this rare leukemia are additional significant obstacles that require further clinical investigation through international collaboration.
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Lightfoot HL, Goldberg FW, Sedelmeier J. Evolution of Small Molecule Kinase Drugs. ACS Med Chem Lett 2019; 10:153-160. [PMID: 30783496 DOI: 10.1021/acsmedchemlett.8b00445] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
The development of small molecule kinase drugs is a rapidly evolving field and represents one of the most important research areas within oncology. This innovation letter provides an overview and analysis of approved kinase drugs according to their WHO registration (INN) dates, primary biological targets, and selectivity and structural similarities, which are also depicted in an associated poster. It also discusses new trends in kinase drug discovery programs such as new kinase targets, novel mechanisms of action, and diverse indications.
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Affiliation(s)
- Helen L. Lightfoot
- IMED Biotech Unit,Discovery Sciences, AstraZeneca, Alderley Park SK10 4TG, U.K
| | - Frederick W. Goldberg
- Oncology, IMED Biotech Unit, Medicinal Chemistry, AstraZeneca, Cambridge CB4 0WG, U.K
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Cole AL, Dusetzina SB. Generic Price Competition For Specialty Drugs: Too Little, Too Late? Health Aff (Millwood) 2019; 37:738-742. [PMID: 29733710 DOI: 10.1377/hlthaff.2017.1684] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The case of generic imatinib demonstrates several potential barriers to effective generic price competition for specialty prescription drugs, including fewer market entrants, smaller-than-expected price reductions, shifts in prescribing toward more expensive brand-name treatments, and limited uptake of the generic product.
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Affiliation(s)
- Ashley L Cole
- Ashley L. Cole is a doctoral candidate in the Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, and a predoctoral fellow at the Cecil G. Sheps Center for Health Services Research, both at the University of North Carolina at Chapel Hill
| | - Stacie B Dusetzina
- Stacie B. Dusetzina ( ) is an associate professor in the Department of Health Policy and Ingram Associate Professor of Cancer Research at Vanderbilt University School of Medicine, in Nashville, Tennessee
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Leighow SM, Pritchard JR. The risks of perpetuating an evolutionary arms race in drug discovery. Evol Med Public Health 2019; 2019:64-65. [PMID: 31186898 PMCID: PMC6536724 DOI: 10.1093/emph/eoz013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Scott M Leighow
- Department of Biomedical Engineering, Pennsylvania State University
| | - Justin R Pritchard
- Department of Biomedical Engineering, Pennsylvania State University
- The Huck Institute for the Life Sciences, University Park, PA, USA
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Fachi MM, Tonin FS, Leonart LP, Aguiar KS, Lenzi L, Figueiredo BC, Fernandez-Llimos F, Pontarolo R. Comparative efficacy and safety of tyrosine kinase inhibitors for chronic myeloid leukaemia: A systematic review and network meta-analysis. Eur J Cancer 2018; 104:9-20. [DOI: 10.1016/j.ejca.2018.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 12/21/2022]
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Abstract
INTRODUCTION Dysregulated B cell receptor (BCR) signaling has been identified as a potent contributor to tumor survival in B cell non-Hodgkin lymphomas (NHLs). This pathway's emergence as a rational therapeutic target in NHL led to development of BCR-directed agents, including inhibitors of Bruton's tyrosine kinase (BTK), spleen tyrosine kinase (SYK), and phosphatidylinositol 3 kinase (PI3K). Several drugs have become valuable assets in the anti-lymphoma armamentarium. AREAS COVERED We provide an overview of the BCR pathway, its dysregulation in B cell NHL, and the drugs developed to target BCR signaling in lymphoma. Mechanisms, pharmacokinetics, pharmacodynamics, efficacy, and toxicity of currently available BTK, SYK, and PI3K inhibitors are described. EXPERT OPINION While the excellent response rates and favorable toxicity profile of the BTK inhibitor ibrutinib in certain NHL subtypes have propelled it to consideration as frontline therapy in selected populations, additional data and clinical studies are needed before other agents targeting BCR signaling influence clinical practice similarly. PI3K inhibitors remain an option for some relapsed indolent lymphomas and chronic lymphocytic leukemia, but their widespread use may be limited by adverse effects. Future research should include efforts to overcome resistance to BTK inhibitors, combination therapy using BCR-targeted agents, and exploration of novel agents.
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Affiliation(s)
- Kelly Valla
- Winship Cancer Institute of Emory University - Department of Hematology and Medical Oncology, 1365 C Clifton Rd NE, Atlanta, Georgia 30322, United States
| | - Christopher R. Flowers
- Emory University - Winship Cancer Institute, School of Medicine, 1365 Clifton Road, N.E. Building B, Atlanta, Georgia 30322, United States
| | - Jean L. Koff
- Emory University - Winship Cancer Institute, School of Medicine, 1365 Clifton Road, N.E. Building B, Atlanta, Georgia 30322, United States
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Kavanagh S, Nee A, Lipton JH. Emerging alternatives to tyrosine kinase inhibitors for treating chronic myeloid leukemia. Expert Opin Emerg Drugs 2018; 23:51-62. [PMID: 29480034 DOI: 10.1080/14728214.2018.1445717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION BCR-ABL-directed tyrosine kinase inhibitors (TKIs) have revolutionised therapy for chronic myeloid leukemia. However, despite the availability and efficacy of this class of agents, lifelong treatment is still required in a significant proportion of patients Areas covered: We give an overview of the currently available BCR-ABL-directed TKIs and other conventional therapies for CML. We proceed to review the current market and some of the scientific rationale for new drug development before outlining a number of novel therapies, considered broadly as immunotherapies and targeted agents. Published English-language literature was reviewed regarding currently available TKIs; clinical trials repositories were reviewed to identify novel agents recently investigated or under active study. Expert opinion: We recommend discussion with patients and enrolment on an appropriate clinical trial where feasible. In situations where no trials are available, or if patients decline enrolment, we recommend use of an appropriate BCR-ABL directed TKI, selected on the basis of an evaluation of patient risk factors and side effect profile. Allogeneic stem cell transplant continues to have a role though this is generally limited to cases with advanced phases of disease or in cases with resistance-conferring mutations.
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Affiliation(s)
- Simon Kavanagh
- a Princess Margaret Cancer Centre , University Health Network , Toronto , ON , Canada
| | - Aisling Nee
- a Princess Margaret Cancer Centre , University Health Network , Toronto , ON , Canada
| | - Jeffrey H Lipton
- a Princess Margaret Cancer Centre , University Health Network , Toronto , ON , Canada
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Abstract
India has a large share of the hepatitis C virus (HCV) burden of the world. Unsafe medical practices and blood transfusions are the leading modes of transmission of HCV in India. The commonest HCV genotype in India is genotype 3 followed by genotype 1. While directly acting antivirals (DAAs) agents have become available at reasonable rates in India, cost of therapy remains a major barrier for control of HCV in India. Generic DAAs have been proven to be cost-saving in prior studies. We examined data from various studies in India and elsewhere using generic DAAs, and evaluated whether they are equally efficacious as the branded drugs. Since the availability of generic DAAs in the Indian market, there is a lot of real life data as well as prospective studies in special patient populations such as hematological disorders (thalassemia and hemophilia), chronic kidney disease, hemodialysis patients, post liver and renal transplant patients on immunosuppression, intravenous drug users, confections and other high risk groups. Control of HCV infection in India requires multi pronged approach. There is a need to formulate a health educational curriculum targeting not only the high-risk population but also the general population regarding the transmission of HCV. Adopting the dual approach of treating the old cases (decreasing the reservoir pool of HCV) and decreasing the incidence of new ones would help curtail the disease and decrease liver related mortality. In this scenario, the role of efficacious low cost generic medications is essential.
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Key Words
- ALT, alanine aminotransferase
- CHC, chronic hepatitis C
- CI, confidence interval
- DAAs
- DAAs, direct-acting antiviral agents
- DCV, daclatasvir
- EASL, The European Association for the Study of the Liver
- GT, Genotype
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- IL, interleukin
- INASL, Indian National Association for study of the Liver
- LDV, ledipasvir
- Peg-IFN, pegylated interferon
- RBV, ribavirin
- SOF, sofosbuvir
- SVR, sustained virologic response
- VEL, velpatasvir
- chronic hepatitis C
- generic direct antivirals
- real life efficacy study
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | | | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India,Address for correspondence: Radha K. Dhiman, Professor, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.Department of Hepatology, Postgraduate Institute of Medical Education and ResearchChandigarh160012India
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