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Gueiderikh A, Tarabay A, Abdelouahab M, Smolenschi C, Tanguy ML, Valery M, Malka D, Pudlarz T, Fuerea A, Boige V, Hollebecque A, Ducreux M, Boilève A. Pancreatic adenocarcinoma third line systemic treatments: a retrospective cohort study. BMC Cancer 2024; 24:272. [PMID: 38408958 PMCID: PMC10898186 DOI: 10.1186/s12885-024-12016-z] [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: 11/02/2023] [Accepted: 02/16/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Chemotherapy for metastatic pancreatic adenocarcinoma (PDAC) primarily relies on FOLFIRINOX (LV5FU- irinotecan - Oxaliplatine) and Gemcitabine - Nab-Paclitaxel in the first-line setting. However, second-lines remain less well-defined and there is limited data regarding third-line treatments. The objective of our study was to determine the proportion of patients advancing to third line chemotherapy, to outline the various third-line chemotherapy regimens used in routine practice and to evaluate their respective efficacy. METHODS A retrospective single-center cohort from 2010-2022 compiled baseline characteristics, treatment outcomes and survival of PDAC patients who received at least one chemotherapy line in a French tertiary-center. Overall survivals (OS) were analyzed using a Cox multivariable model. RESULTS In total, 676 patients were included, with a median follow-up time of 69.4 months, (Interquartile Range (IQR) = 72.1). Of these, 251 patients (37%) that proceeded to 3rd-line chemotherapy. The median PFS in 3rd line was 2.03 months, [CI95%: 1.83, 2.36]. The median 3rd line overall survival was 5.5 months, [CI95%: 4.8, 6.3]. In multivariable analysis erlotinib-based chemotherapy was found to be deleterious (HR=2.38, [CI95%: 1.30, 4.34], p=0.005) compared to fluoropyrimidine-based chemotherapy in terms of 3rd line overall survival while gemcitabine monotherapy showed a tendency towards negative outcomes. First and 2nd line chemotherapies sequence didn't influence 3rd line outcome. CONCLUSION In our cohort, one-third of treated patients proceeded to 3rd line chemotherapy resulting in a 5.5 months median 3rd line OS, consistent with treatments at advanced stage. Our results argue against the use of erlotinib and gemcitabine monotherapy.
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Affiliation(s)
- A Gueiderikh
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
- Université Paris Saclay, 91471, Orsay, France
| | - A Tarabay
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
| | - M Abdelouahab
- Département de statistiques, Gustave Roussy, 94800, Villejuif, France
| | - C Smolenschi
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
- Gustave Roussy, DITEP, 94800, Villejuif, France
| | - M L Tanguy
- Département de statistiques, Gustave Roussy, 94800, Villejuif, France
| | - M Valery
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
| | - D Malka
- Département d'oncologie médicale, Institut Mutualiste Montsouris, 75014, Paris, France
| | - T Pudlarz
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
| | - A Fuerea
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
| | - V Boige
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
| | - A Hollebecque
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
- Gustave Roussy, DITEP, 94800, Villejuif, France
| | - M Ducreux
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France
- Université Paris Saclay, 91471, Orsay, France
| | - A Boilève
- Département de médecine oncologique, Gustave Roussy, 94800, Villejuif, France.
- Université Paris Saclay, 91471, Orsay, France.
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Treatment Response and Conditional Survival in Advanced Pancreatic Cancer Patients Treated with FOLFIRINOX: A Multicenter Cohort Study. JOURNAL OF ONCOLOGY 2022; 2022:8549487. [PMID: 35847365 PMCID: PMC9283068 DOI: 10.1155/2022/8549487] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022]
Abstract
Background FOLFIRINOX chemotherapy is the current Dutch standard of care for locally advanced (LAPC) and metastatic pancreatic cancer (PDAC) patients with good performance status. The objective of this study was to evaluate real-world response rates and survival in advanced PDAC and to assess conditional survival after FOLFIRINOX. Methods A multicenter, retrospective cohort study was conducted in four hospitals in the Netherlands. Consecutive patients with LAPC or metastatic PDAC, treated with FOLFIRINOX, were included. Results Between 2012 and 2018, 284 patients were included: n = 136 with LAPC and n = 148 with metastatic PDAC. Objective response rates were similar in both the groups: 14.0% in LAPC and 18.2% in metastatic patients. The disease control rate was higher in LAPC patients (77.2%) compared to metastatic PDAC (51.4%, P < 0.001). Median overall survival (OS) in LAPC patients was 12.7 months (95% CI 11.4–14.1 months). Their 2-year survival probability increased from 14% to 26% one year after the completion of FOLFIRINOX. Median OS in metastatic PDAC patients was 8.1 months (95% CI 6.5–9.6 months); 2-year survival probability increased from 10% to 29% after one year. Discussion. Our study provides real-world estimates of response rates, survival, and conditional survival in patients with advanced PDAC treated with FOLFIRINOX. These results are useful for patient counseling and clinical decision making.
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Arciero V, Luo J, Parmar A, Dai WF, Beca JM, Raphael MJ, Isaranuwatchai W, Habbous S, Tadrous M, Earle CC, Biagi JJ, Mittmann N, Arias J, Gavura S, Chan KKW. Real-World Cost-Effectiveness of First-Line Gemcitabine Plus Nab-Paclitaxel vs FOLFIRINOX in Patients With Advanced Pancreatic Cancer. JNCI Cancer Spectr 2022; 6:pkac047. [PMID: 35758620 PMCID: PMC9346632 DOI: 10.1093/jncics/pkac047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/08/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There are no randomized control trials (RCTs) comparing gemcitabine and nab-paclitaxel (Gem-Nab) and fluorouracil, folinic acid, irinotecan, oxaliplatin (FOLFIRINOX) for advanced pancreatic cancer (APC). Although it is well known that RCT-based efficacy often does not translate to real-world effectiveness, there is limited literature investigating comparative cost-effectiveness of Gem-Nab vs FOLFIRINOX for APC. We aimed to examine the real-world cost-effectiveness of Gem-Nab vs FOLFIRINOX for APC in Ontario, Canada. METHODS This study compared patients treated with first-line Gem-Nab or FOLFIRINOX for APC in Ontario from April 2015 to March 2019. Patients were linked to administrative databases. Using propensity scores and a stabilizing weights method, an inverse probability of treatment weighted cohort was developed. Mean survival and total costs were calculated over a 5-year time horizon, adjusted for censoring, and discounted at 1.5%. Incremental cost-effectiveness ratio and net monetary benefit were computed to estimate cost-effectiveness from the public health-care payer's perspective. Sensitivity analysis was conducted using the propensity score matching method. RESULTS A total of 1988 patients were identified (Gem-Nab: n = 928; FOLFIRINOX: n = 1060). Mean survival was lower for patients in the Gem-Nab than the FOLFIRINOX group (0.98 vs 1.26 life-years; incremental effectiveness = -0.28 life-years [95% confidence interval = -0.47 to -0.13]). Patients in the Gem-Nab group incurred greater mean 5-year total costs (Gem-Nab: $103 884; FOLFIRINOX: $101 518). Key cost contributors include ambulatory cancer care, acute inpatient hospitalization, and systemic therapy drug acquisition. Gem-Nab was dominated by FOLFIRINOX, as it was less effective and more costly. Results from the sensitivity analysis were similar. CONCLUSIONS Gem-Nab is likely more costly and less effective than FOLFIRINOX and therefore not considered cost-effective at commonly accepted willingness-to-pay thresholds.
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Affiliation(s)
- Vanessa Arciero
- Department of Medicine, Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Ambica Parmar
- Department of Medicine, Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wei Fang Dai
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
| | - Jaclyn M Beca
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
- Ontario Health, Cancer Care Ontario, Toronto, ON, Canada
| | - Michael J Raphael
- Department of Medicine, Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wanrudee Isaranuwatchai
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
- St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Steven Habbous
- Ontario Health, Cancer Care Ontario, Toronto, ON, Canada
| | | | - Craig C Earle
- Department of Medicine, Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - Jim J Biagi
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Nicole Mittmann
- Canadian Agency for Drugs and Technologies in Health, Toronto, ON, Canada
| | - Jessica Arias
- Ontario Health, Cancer Care Ontario, Toronto, ON, Canada
| | - Scott Gavura
- Ontario Health, Cancer Care Ontario, Toronto, ON, Canada
| | - Kelvin K W Chan
- Department of Medicine, Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
- Ontario Health, Cancer Care Ontario, Toronto, ON, Canada
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Pembrolizumab Alone or with Chemotherapy for Metastatic Non-Small-Cell Lung Cancer: A Systematic Review and Network Meta-Analysis. Crit Rev Oncol Hematol 2022; 173:103660. [PMID: 35341985 DOI: 10.1016/j.critrevonc.2022.103660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 02/08/2023] Open
Abstract
Pembrolizumab monotherapy has replaced chemotherapy as first-line treatment for patients with metastatic non-small-cell lung cancer with tumor programmed death-ligand 1 expression ≥50%. The benefit of chemotherapy combined with pembrolizumab, as compared to pembrolizumab monotherapy, remains uncertain. This systematic review and network meta-analysis aimed to compare these therapies through a network of randomized controlled trials. Endpoints evaluated were progression-free survival (PFS) and overall survival (OS) expressed as hazard ratio (HR) and restricted mean survival time (RMST) through reconstruction of individual patient data from Kaplan-Meier curves, and objective response rate and adverse events. Four trials were included. Through HR and RMST, combination therapy demonstrated longer PFS and similar OS as compared to pembrolizumab monotherapy. Combination therapy was associated with an increase in response rate and adverse events. Thus, combination therapy can be considered when rapid response or prevention of rapid progression is needed. Further evidence to directly compare these therapies is required.
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Quality of life of locally advanced pancreatic cancer patients after FOLFIRINOX treatment. Support Care Cancer 2021; 30:2407-2415. [PMID: 34762217 PMCID: PMC8794891 DOI: 10.1007/s00520-021-06648-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/21/2021] [Indexed: 01/17/2023]
Abstract
Background Quality of life in cancer patients might be affected by chemotherapy-induced toxicity. Especially in patients with pancreatic ductal adenocarcinoma (PDAC), with a short life expectancy, fear of poor quality of life is often a reason for both patients and medical oncologists to refrain from further treatment. In this study, we investigated quality of life (QoL), pain, sleep, and activity levels in locally advanced pancreatic cancer (LAPC) patients after FOLFIRINOX treatment. Methods A total of 41 LAPC patients with stable disease or partial response were included after completion of at least four cycles of FOLFIRINOX. QoL was measured with the EORTC QLQ-C30 and NRS pain scores. Patients completed the Richards-Campbell Sleep Questionnaire (RCSQ) for five consecutive nights and wore a GENEActiv tri-axial accelerometer (Actiwatch) for 7 days, registering sleep duration, efficiency, and activity. Results Mean EORTC QLQ-C30 score for global health status was 78.3 (± 17.3), higher than reference values for cancer patients (P < 0.001) and general population (P = 0.045). LAPC patients reported few disease-related symptoms. Two patients (5%) reported pain scores > 3. Mean sleep duration was 8 h/night (± 1.2 h) and sleep efficiency 70% (± 9%) with high patient-reported quality of sleep (mean RCSQ score 72.0 ± 11.4). Mean duration of moderate-vigorous activity was 37 min/week (± 103 min/week). Conclusions QoL is very good in most LAPC patients with disease control after FOLFIRINOX, measured with validated questionnaires and Actiwatch registration. The fear of clinical deterioration after FOLFIRINOX is not substantiated by this study and should not be a reason to refrain from treatment. Trial registration Dutch trial register NL7578. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-021-06648-1.
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Equivalent Efficacy but Different Safety Profiles of Gemcitabine Plus Nab-Paclitaxel and FOLFIRINOX in Metastatic Pancreatic Cancer. Biomolecules 2021; 11:biom11060780. [PMID: 34067288 PMCID: PMC8224606 DOI: 10.3390/biom11060780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
FOLFIRINOX (FFX) and gemcitabine + nab-paclitaxel (GN) are the most common chemotherapy regimens in first-line treatment of metastatic pancreatic cancer (PC). They have not been compared each other in a prospective trial, but only in retrospective studies, which can thus be affected by several biases. In order to overcome these biases, we took advantage of matching-adjusted indirect comparison (MAIC), that allows an indirect comparison by reducing cross-trial differences, and compared data from 268 patients treated with GN in a real-world setting with data from the 171 patients included in the FFX arm of the PRODIGE trial. Survival outcomes did not differ between the two populations. Overall survival was 11.1 months for both treatments (hazard ratio (HR) of FFX 1.10, 95% confidence interval (CI) 0.81–1.49; p = 0.527). Progression-free survival was 6.0 months with GN and 6.4 months with FFX (HR of FFX 1.11, 95% CI 0.82–1.50; p = 0.520). On the other hand, we observed a difference in the toxicity profiles: grade 3/4 anemia was more frequent with GN, whereas a higher occurrence of grade 3/4 vomiting and diarrhea was reported with FFX. FFX and GN show an equivalent efficacy but different safety profiles in the first-line therapy of metastatic pancreatic cancer. Searching for reliable predictive biomarkers is advised in order to improve therapeutic strategy in metastatic PC.
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Sigel K, Zhou M, Park YHA, Mutetwa T, Nadkarni G, Yeh C, Polak P, Sigel C, Conroy T, Juzyna B, Ychou M, Fojo T, Wisnivesky JP, Bates SE. Gemcitabine plus nab-paclitaxel versus FOLFIRINOX for unresected pancreatic cancer: Comparative effectiveness and evaluation of tumor growth in Veterans. Semin Oncol 2021; 48:69-75. [PMID: 33714591 PMCID: PMC9703645 DOI: 10.1053/j.seminoncol.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Advanced, unresectable pancreatic cancer is often treated with either gemcitabine plus nab-paclitaxel (Gem/NabP) or FOLFIRINOX, although these regimens have never been compared in a head-to-head trial. In this study, we compared these two regimens using Veterans Administration (VA) data and evaluated the use of a novel tumor growth formula to predict outcomes. METHODS We identified 670 Veterans from national VA data with unresected stage II-IV pancreatic adenocarcinoma diagnosed between 2003 and 2016 who were treated with either first-line Gem/NabP or FOLFIRINOX. We compared overall survival (OS) and adverse events by treatment using propensity scores (PS) to account for allocation bias. Using longitudinal CA19-9 biomarker information we then fit the data to a novel tumor growth equation, comparing growth with OS. RESULTS We found no difference in PS-adjusted (hazard ratio [HR] 1.00; 95% confidence interval [95% CI] 0.84-1.20) or PS-matched (HR: 0.93; 95% CI: 0.76-1.13) OS between the two treatment groups. Tumor growth analysis revealed similar growth parameter values for Gem/NabP and FOLFIRINOX (P = .074 for difference). CONCLUSIONS Gem/NabP appeared noninferior to FOLFIRINOX for survival outcomes for advanced pancreatic adenocarcinoma based on national VA data. Biomarker-based growth equations may be useful for monitoring treatment response and predicting prognosis for pancreatic cancer.
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Affiliation(s)
- Keith Sigel
- The Mount Sinai School of Medicine, New York, NY.
| | - Mengxi Zhou
- The College of Physicians and Surgeons at Columbia University, New York, NY
| | | | | | - Girish Nadkarni
- The College of Physicians and Surgeons at Columbia University, New York, NY
| | - Celine Yeh
- The College of Physicians and Surgeons at Columbia University, New York, NY
| | - Paz Polak
- The Mount Sinai School of Medicine, New York, NY; The College of Physicians and Surgeons at Columbia University, New York, NY
| | - Carlie Sigel
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thierry Conroy
- Institut de cancerologie de Lorraine, Vandouevre de Nancy, France
| | | | - Mark Ychou
- Institut de cancer de Montpellier, Montpellier, France
| | - Tito Fojo
- James J. Peters VA Medical Center, Bronx, NY; The College of Physicians and Surgeons at Columbia University, New York, NY
| | | | - Susan E Bates
- James J. Peters VA Medical Center, Bronx, NY; The College of Physicians and Surgeons at Columbia University, New York, NY
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A multicenter propensity score analysis of FOLFIRINOX vs gemcitabine plus nab-paclitaxel administered to patients with metastatic pancreatic cancer: results from the NAPOLEON study. Int J Clin Oncol 2021; 26:941-950. [PMID: 33483857 DOI: 10.1007/s10147-021-01859-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/20/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX, FFX) and gemcitabine plus nab-paclitaxel (GnP) are considered standard treatments for patients with metastatic pancreatic cancer. Direct comparisons are not available that establish which is optimal. METHODS We conducted a propensity score-adjusted analysis of patients with metastatic pancreatic cancer to identify the therapeutic advantages of these standard therapies. We used clinical data as part of a multicenter retrospective study of patients with unresectable or recurrent pancreatic cancer treated with FFX or GnP (NAPOLEON study). RESULTS FFX and GnP were initially administered to 102 and 153 patients, respectively. The GnP group comprised more patients of advanced age, worse performance status, lower body mass index, recurrence, and lower albumin concentrations. Median overall survival (OS) and progression-free survival (PFS) were 11.5 months and 5.8 months in the FFX group and 11.1 months and 5.9 months in the GnP group, respectively. Propensity score-adjusted analysis indicated that the administration of FFX or GnP was not independently associated with OS (adjusted hazard ratio [HR] 1.06; 95% confidence interval [CI] 0.76-1.47; P = 0.73). Similarly, the difference in PFS was not significant between groups (adjusted HR 0.93; 95% CI 0.68-1.26; P = 0.62). Gastrointestinal disorders were more common in the FFX group, whereas the frequencies of hematological, nervous system, and skin disorders were higher in the GnP group. CONCLUSION The efficacies of FFX and GnP were comparable, although safety profiles differed and should be considered in selecting treatment.
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Delos Santos S, Udayakumar S, Nguyen A, Ko YJ, Berry S, Doherty M, Chan KKW. A systematic review and network meta-analysis of second-line therapy in hepatocellular carcinoma. Curr Oncol 2020; 27:300-306. [PMID: 33380861 PMCID: PMC7755448 DOI: 10.3747/co.27.6583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background In patients with advanced hepatocellular carcinoma (hcc) following sorafenib failure, it is unclear which treatment is most efficacious, as treatments in the second-line setting have not been directly compared and no standard therapy exists. This systematic review and network meta-analysis (nma) aimed to compare the clinical benefits and toxicities of these treatments. Methods A systematic review of randomized controlled trials (rcts) was conducted to identify phase iii rcts in advanced hcc following sorafenib failure. Baseline characteristics and outcomes of placebo were examined for heterogeneity. Primary outcomes of interest were extracted for results, including overall survival (os), progression-free survival (pfs), objective response rate (orr), grade 3/4 toxicities, and subgroups. An nma was conducted to compare both drugs through the intermediate placebo. Comparisons were expressed as hazard ratios (hrs) for os and pfs, and as risk difference (rd) for orr and toxicities. Subgroup analyses for os and pfs were also performed. Results Two rcts were identified (1280 patients) and compared through an indirect network; celestial (cabozantinib vs. placebo) and resorce (regorafenib vs. placebo). Baseline characteristics of patients in both trials were similar. Both trials also had similar placebo outcomes. Cabozantinib, compared with regorafenib, showed similar os [hazard ratio (hr): 1.21; 95% confidence interval (ci): 0.90 to 1.62], pfs (hr: 1.02; 95% ci: 0.78 to 1.34) and orr (-3.0%; 95% ci: -7.6% to 1.7%). Both treatments showed similar toxicities, but there were marginally higher risks of grade 3/4 hand-foot syndrome (5%; 95% ci: 0.1% to 9.8%), diarrhea (4.8%; 95% ci: 1.1% to 8.5%), and anorexia (4.4%; 95% ci: 0.8% to 8.0%) for cabozantinib. Subgroup results for os and pfs were consistent with overall results. Conclusions Overall, this nma determined that cabozantinib and regorafenib have similar clinical benefits and toxicities for second-line hcc.
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Affiliation(s)
- S Delos Santos
- Sunnybrook Research Institute, University of Toronto, Toronto, ON
| | - S Udayakumar
- Sunnybrook Research Institute, University of Toronto, Toronto, ON
| | - A Nguyen
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Y J Ko
- Sunnybrook Research Institute, University of Toronto, Toronto, ON
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
- Department of Medicine, University of Toronto, Toronto, ON
| | - S Berry
- Sunnybrook Research Institute, University of Toronto, Toronto, ON
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
- Department of Medicine, University of Toronto, Toronto, ON
| | - M Doherty
- Sunnybrook Research Institute, University of Toronto, Toronto, ON
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
- Department of Medicine, University of Toronto, Toronto, ON
| | - K K W Chan
- Sunnybrook Research Institute, University of Toronto, Toronto, ON
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
- Department of Medicine, University of Toronto, Toronto, ON
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON
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Wu B, Shi L. Cost-Effectiveness of Maintenance Olaparib for Germline BRCA-Mutated Metastatic Pancreatic Cancer. J Natl Compr Canc Netw 2020; 18:1528-1536. [DOI: 10.6004/jnccn.2020.7587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 05/08/2020] [Indexed: 11/17/2022]
Abstract
Background: Maintenance therapy with the PARP inhibitor olaparib for metastatic pancreatic cancer (MPC) with a germline BRCA1 or BRCA2 mutation has been shown to be effective. We aimed to evaluate the cost-effectiveness of maintenance olaparib for MPC from the US payer perspective. Materials and Methods: A partitioned survival model was adopted to project the disease course of MPC. Efficacy and toxicity data were gathered from the Pancreas Cancer Olaparib Ongoing (POLO) trial. Transition probabilities were estimated from the reported survival probabilities in each POLO group. Cost and health preference data were derived from the literature. The incremental cost-utility ratio, incremental net-health benefit, and incremental monetary benefit were measured. Subgroup analysis, one-way analysis, and probabilistic sensitivity analysis were performed to explore the model uncertainties. Results: Maintenance olaparib had an incremental cost-utility ratio of $191,596 per additional progression-free survival (PFS) quality-adjusted life-year (QALY) gained, with a high cost of $132,287 and 0.691 PFS QALY gained, compared with results for a placebo. Subgroup analysis indicated that maintenance olaparib achieved at least a 16.8% probability of cost-effectiveness at the threshold of $200,000/QALY. One-way sensitivity analyses revealed that the results were sensitive to the hazard ratio of PFS and the cost of olaparib. When overall survival was considered, maintenance olaparib had an incremental cost-utility ratio of $265,290 per additional QALY gained, with a high cost of $128,266 and 0.483 QALY gained, compared with results for a placebo. Conclusions: Maintenance olaparib is potentially cost-effective compared with placebo for patients with a germline BRCA mutation and MPC. Economic outcomes could be improved by tailoring treatment based on individual patient factors.
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Affiliation(s)
- Bin Wu
- 1Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China; and
| | - Lizheng Shi
- 2Department of Global Health Management and Policy, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
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Franco F, Camara JC, Martín-Valadés JI, López-Alfonso A, Marrupe D, Gutiérrez-Abad D, Martínez-Amores B, León A, Juez I, Pérez M, Royuela A, Ruiz-Casado A. Clinical outcomes of FOLFIRINOX and gemcitabine-nab paclitaxel for metastatic pancreatic cancer in the real world setting. Clin Transl Oncol 2020; 23:812-819. [PMID: 32857340 DOI: 10.1007/s12094-020-02473-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES The incidence of pancreatic cancer is increasing in developed countries. The incorporation of new therapies, to the first-line treatment of patients with good performance status led to better survival in clinical trials. However, there is a wide variability in their use and some concerns about the treatment of elderly patients who were not included in the clinical trials. METHODS This is a retrospective multicenter study. Data from consecutive patients diagnosed with metastatic pancreatic cancer (mPC) treated with FOLFIRINOX (FFX) or gemcitabine plus nab-paclitaxel (GnP) were analysed to evaluate efficacy (overall survival-OS) and toxicity. RESULTS A total of 119 patients were included. 49.6% were treated with FFX and 50.4% with GNP in first-line. The median OS was 12 months with no statistically significant differences between both regimens (12.7 m for FFX vs 10.2 m for GnP). Elevated Ca 19.9 levels and neutrophil-lymphocyte ratio (NLR) increased the risk of death. Patients who received both regimens in first/second line had a median OS longer than 15 months whichever the sequence. 32 patients (27%) were older than 70-y. 54% patients received a second-line treatment, 56% in the FFX group and 44% in the GnP group. The median OS for patients older than 70 was 9.5 m versus 12.3 m for patients younger than 70. Progression of the disease was the cause of death in 67.6% of the patients. CONCLUSIONS In our setting, the use of FFX and GnP for treating mPC is quite similar, but superiority could not be demonstrated for any of the schemes in the first line. OS was determined by basal levels of Ca 19.9 and NLR. Patients receiving both regimens in first/second line whichever the sequence, exhibited the best survival rates. In our series, elderly patients had poorer survival rates.
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Affiliation(s)
- F Franco
- Department of Medical Oncology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain.
| | - J C Camara
- Department of Medical Oncology, Fundación Hospital Alcorcón, Alcorcón, Spain
| | | | - A López-Alfonso
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - D Marrupe
- Department of Medical Oncology, Hospital Universitario de Móstoles, Móstoles, Spain
| | - D Gutiérrez-Abad
- Department of Medical Oncology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - B Martínez-Amores
- Department of Medical Oncology, Hospital Universitario Rey Juan Carlos, Móstoles, Spain
| | - A León
- Department of Medical Oncology, Fundación Jiménez Díaz, Madrid, Spain
| | - I Juez
- Department of Medical Oncology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - M Pérez
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - A Royuela
- Department of Biostatistics, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - A Ruiz-Casado
- Department of Medical Oncology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
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12
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Chan KKW, Guo H, Cheng S, Beca JM, Redmond-Misner R, Isaranuwatchai W, Qiao L, Earle C, Berry SR, Biagi JJ, Welch S, Meyers BM, Mittmann N, Coburn N, Arias J, Schwartz D, Dai WF, Gavura S, McLeod R, Kennedy ED. Real-world outcomes of FOLFIRINOX vs gemcitabine and nab-paclitaxel in advanced pancreatic cancer: A population-based propensity score-weighted analysis. Cancer Med 2019; 9:160-169. [PMID: 31724340 PMCID: PMC6943167 DOI: 10.1002/cam4.2705] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In Ontario, FOLFIRINOX (FFX) and gemcitabine + nab-paclitaxel (GnP) have been publicly funded for first-line unresectable locally advanced pancreatic cancer (uLAPC) or metastatic pancreatic cancer (mPC) since April 2015. We examined the real-world effectiveness and safety of FFX vs GnP for advanced pancreatic cancer, and in uLAPC and mPC. METHODS Patients receiving first-line FFX or GnP from April 2015 to March 2017 were identified in the New Drug Funding Program database. Baseline characteristics and outcomes were obtained through the Ontario Cancer Registry and other population-based databases. Overall survival (OS) was assessed using Kaplan-Meier and weighted Cox proportional hazard models, weighted by the inverse propensity score adjusting for baseline characteristics. Weighted odds ratio (OR) for hospitalization and emergency department visits (EDV) were estimated from weighted logistic regression models. RESULTS For 1130 patients (632 FFX, 498 GnP), crude median OS was 9.6 and 6.1 months for FFX and GnP, respectively. Weighted OS was improved for FFX vs GnP (HR = 0.77, 0.70-0.85). Less frequent EDV and hospitalization were observed in FFX (EDV: 67.8%; Hospitalization: 49.2%) than GnP (EDV: 77.7%; Hospitalization: 59.3%). More frequent febrile neutropenia-related hospitalization was observed in FFX (5.8%) than GnP (3.3%). Risk of EDV and hospitalization were significantly lower for FFX vs GnP (EDV: OR = 0.68, P = .0001; Hospitalization: OR = 0.76, P = .002), whereas the risk of febrile neutropenia-related hospitalization was significantly higher (OR = 2.12, P = .001). Outcomes for uLAPC and mPC were similar. CONCLUSION In the real world, FFX had longer OS, less frequent all-cause EDV and all-cause hospitalization, but more febrile neutropenia-related hospitalization compared to GnP.
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Affiliation(s)
- Kelvin K W Chan
- Cancer Care Ontario, Toronto, ON, Canada.,Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.,Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
| | - Helen Guo
- Cancer Care Ontario, Toronto, ON, Canada
| | - Sierra Cheng
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jaclyn M Beca
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada.,Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, ON, Canada
| | | | - Wanrudee Isaranuwatchai
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada.,Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, ON, Canada
| | - Lucy Qiao
- Cancer Care Ontario, Toronto, ON, Canada
| | - Craig Earle
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.,Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Scott R Berry
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - James J Biagi
- Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
| | | | | | | | - Natalie Coburn
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Wei F Dai
- Cancer Care Ontario, Toronto, ON, Canada
| | | | | | - Erin D Kennedy
- Cancer Care Ontario, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada
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13
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Network Meta-Analysis of Efficacy and Safety of Chemotherapy and Target Therapy in the First-Line Setting of Advanced Pancreatic Cancer. Cancers (Basel) 2019; 11:cancers11111746. [PMID: 31703359 PMCID: PMC6895788 DOI: 10.3390/cancers11111746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/29/2019] [Accepted: 11/02/2019] [Indexed: 12/13/2022] Open
Abstract
Both gemcitabine and fluoropyrimidine are recommended backbones in the first-line treatment of pancreatic ductal adenocarcinoma (PDAC). To compare the efficacy and safety of these two therapeutic backbones, and to investigate the optimal therapies, we conducted a network meta-analysis. By retrospective analysis of randomized controlled trials (RCT), the most preferred therapeutic regimen may be predicted. The eligible RCTs of the gemcitabine-based therapies and fluoropyrimidine-based therapies were searched up to 31 August 2019. In a frequentist network meta-analysis, treatments were compared and ranked according to overall survival (OS) and progression-free survival (PFS). Thirty-two trials with 10,729 patients were included. The network meta-analyses results for overall survival and progression-free survival showed that fluoropyrimidine-based therapy seems to be the most effective treatment choice. Compared to gemcitabine combined with taxanes or immunotherapy, fluoropyrimidine-based therapy had comparable treatment effects (PFS: 0.67, p-Value = 0.11; 0.76, p-Value = 0.32; OS: 0.80, p-Value = 0.16; 0.77, p-Value = 0.21). Moreover, the combination of immunotherapy and gemcitabine had tolerable toxicities. Based on current evidence, fluoropyrimidine-based therapies and the combination of gemcitabine and taxanes were the most effective therapies in the advanced pancreatic cancer, and the combination of immunotherapy and gemcitabine can be developed into a new form of therapy.
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14
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Wang Y, Camateros P, Cheung WY. A Real-World Comparison of FOLFIRINOX, Gemcitabine Plus nab-Paclitaxel, and Gemcitabine in Advanced Pancreatic Cancers. J Gastrointest Cancer 2019; 50:62-68. [PMID: 29143916 DOI: 10.1007/s12029-017-0028-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE FOLFIRINOX (FFN), nab-paclitaxel plus gemcitabine (GN), and gemcitabine are three systemic therapies that provide clinically meaningful benefit to patients with unresectable pancreatic cancer (UPC). There are no clinical trials that directly compare the efficacy of all three regimens. In this study, we aim to examine and compare the real-world effectiveness of these treatments. METHODS Patients diagnosed with UPC who initiated palliative chemotherapy from August 2014 to January 2016 at any one of six cancer centers in British Columbia were identified from the provincial pharmacy. Clinical, pathological, treatment, and outcome characteristics were compared. RESULTS Two hundred twenty-five patients were included: 55% men, 68% Eastern Cooperative Oncology Group 0/1, 58% metastatic disease. Patients who received FFN were younger (p < 0.001) and in better performance status (p < 0.001). Patients treated with FFN or GN experienced significantly longer median overall survival (OS) when compared to those treated with gemcitabine (14.1 vs 10.5 vs 4.2 months, respectively, p < 0.001). Progression-free survival (PFS) was also longer among patients on FFN or GN in comparison to gemcitabine (FFN, HR 0.44, 95% CI 0.24 to 0.814, p = 0.008; GN, HR 0.30, 95% CI 0.19 to 0.47, p < 0.001). A significantly higher proportion of patients require two or more dose modifications on FFN (40%) compared to GN (14%) or gemcitabine (9%) (p < 0.001). CONCLUSIONS Receipt of modified FFN and GN portends a better prognosis than gemcitabine alone. In the absence of a randomized comparison of all three regimens, our population-based study reveals that the introduction of modified FFN and GN confers real-world effectiveness for UPC patients.
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Affiliation(s)
- Ying Wang
- Division of Medical Oncology, British Columbia Cancer Agency, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Pierre Camateros
- Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC, V5Z 1M9, Canada
| | - Winson Y Cheung
- Division of Medical Oncology, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB, T2N 4N2, Canada.
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15
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Li X, Guo C, Li Q, Wei S, Zhang Q, Chen Y, Shen Y, Ma T, Li G, Gao S, Que R, Lou J, Yu R, Yuan Y, Wei Q, Huang P, Liang T, Bai X. Association of Modified-FOLFIRINOX-Regimen-Based Neoadjuvant Therapy with Outcomes of Locally Advanced Pancreatic Cancer in Chinese Population. Oncologist 2019; 24:301-e93. [PMID: 30459238 PMCID: PMC6519772 DOI: 10.1634/theoncologist.2018-0696] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 10/08/2018] [Indexed: 12/27/2022] Open
Abstract
LESSONS LEARNED Modification of FOLFIRINOX significantly improves safety and tolerability in Chinese patients with locally advanced pancreatic cancer.Patients with locally advanced pancreatic cancer benefit from neoadjuvant therapy and experience a much better survival than patients with upfront surgery. BACKGROUND The objective of this study was to evaluate the efficacy of modified-FOLFIRINOX (mFOLFIRINOX) regimens in Chinese patients with locally advanced pancreatic cancer (LAPC) and to compare outcomes between patients with LAPC treated with mFOLFIRINOX-based neoadjuvant therapy (LAPC-N) and patients with LAPC who underwent upfront surgery (LAPC-S). METHODS Forty-one patients with LAPC-N were enrolled prospectively. Imaging features, chemotherapy response, adverse events, perioperative complications, histology, and survival were analyzed. Seventy-four patients with resectable pancreatic cancer (RPC) (from April 2012 to November 2017) and 19 patients with LAPC-S (from April 2012 to March 2014) were set as observational cohorts, and data were collected retrospectively. LAPC-N patients with adequate response underwent surgical treatment, whereas continuous chemotherapy was given to LAPC-N patients who were not deemed resectable after treatment, and the response was re-evaluated every 2 months. RESULTS Forty-one patients with LAPC received mFOLFIRINOX with a response rate of 37.1%. The most common severe adverse events were neutropenia and anemia. mFOLFIRINOX-based neoadjuvant therapy contributed to a remarkable decrease in CA19-9 level and tumor diameter. Fourteen LAPC-N patients underwent surgery (LAPC-N-S) after downstaging. Compared with LAPC-N-S cases, LAPC-S patients had longer operative time, more blood loss, and a higher risk of grade 5 complications. The median overall survival (OS) and progression-free survival (PFS) of LAPC-N-S patients were 27.7 months and 19.3 months, respectively, which were similar to those of patients with RPC (30.0 months and 23.0 months) and much longer than those of patients with LAPC-S (8.9 months and 7.6 months), respectively. CONCLUSION Neoadjuvant chemotherapy such as the mFOLFIRINOX regimen can be recommended for Chinese patients with LAPC after dose modification. Patients with LAPC-N who underwent surgery obtained significantly improved survival compared with patients in the observational LAPC-S cohort, who did not undergo neoadjuvant therapy.
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Affiliation(s)
- Xiang Li
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Chengxiang Guo
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Qinghai Li
- Department of Radiology, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Shumei Wei
- Department of Pathology, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Qi Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Yiwen Chen
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Yinan Shen
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Risheng Que
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Risheng Yu
- Department of Radiology, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Ying Yuan
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Qichun Wei
- Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Pintong Huang
- Department of Ultrasound Medicine, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
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16
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van der Sijde F, Vietsch EE, Mustafa DAM, Besselink MG, Groot Koerkamp B, van Eijck CHJ. Circulating Biomarkers for Prediction of Objective Response to Chemotherapy in Pancreatic Cancer Patients. Cancers (Basel) 2019; 11:cancers11010093. [PMID: 30650521 PMCID: PMC6356815 DOI: 10.3390/cancers11010093] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/03/2019] [Accepted: 01/11/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is a lethal disease with increasing incidence. Most patients present with advanced disease, for which palliative systemic chemotherapy is the only therapeutic option. Despite improved median survival rates with FOLFIRINOX or gemcitabine chemotherapy compared to the best supportive care, many individual patients may not benefit from chemotherapy. Biomarkers are needed to predict who will benefit from chemotherapy and to monitor a patient’s response to chemotherapy. This review summarizes current research and future perspectives on circulating biomarkers for systemic chemotherapy response.
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Affiliation(s)
- Fleur van der Sijde
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands.
| | - Eveline E Vietsch
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands.
| | - Dana A M Mustafa
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands.
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17
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Comparative Effectiveness of nab-Paclitaxel Plus Gemcitabine vs FOLFIRINOX in Metastatic Pancreatic Cancer: A Retrospective Nationwide Chart Review in the United States. Adv Ther 2018; 35:1564-1577. [PMID: 30209750 PMCID: PMC6182639 DOI: 10.1007/s12325-018-0784-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Indexed: 12/11/2022]
Abstract
Introduction nab-Paclitaxel plus gemcitabine (nab-P + G) and FOLFIRINOX (FFX) are among the most common first-line (1L) therapies for metastatic adenocarcinoma of the pancreas (MPAC), but real-world data on their comparative effectiveness are limited. Methods This retrospective cohort study compared the efficacy and safety of 1L nab-P + G versus FFX, overall and under specific treatment sequences. Medical records were reviewed by 215 US physicians who provided information on MPAC patients who initiated 1L therapy with nab-P + G or FFX between April 1, 2015 and December 31, 2015. Study outcomes were overall survival (OS) and tolerability. OS was compared using Kaplan–Meier curves and adjusted Cox proportional hazards models. Results In total, 654 medical records were reviewed, including those of 337 and 317 patients initiated on nab-P + G and FFX as 1L MPAC therapy, respectively. nab-P + G-initiated patients were older, less likely to have ECOG ≤ 1, and had more comorbidities than FFX-initiated patients. Median OS (mOS) was 12.1 and 13.8 months for nab-P + G- and FFX-initiated patients, respectively (HR = 0.99, P = 0.96). Among patients with ECOG ≤ 1, mOS was 14.1 and 13.7 months, respectively (HR = 1.00, P = 0.99). Among patients with 1L nab-P + G and FFX, 36.1% and 41.3% received 2L therapy and experienced mOS of 16.3 and 16.6 months, respectively (HR = 1.04, P = 0.76). The rates of diarrhea, fatigue, mucositis, and nausea and vomiting were significantly higher in the FFX than nab-P + G cohort. Conclusion The real-world survival was similar between patients receiving 1L nab-P + G or FFX both overall and among patients who received active 2L treatments. In addition, nab-P + G was associated with significantly lower rates of common AEs compared with FFX. Funding Celgene. Electronic supplementary material The online version of this article (10.1007/s12325-018-0784-z) contains supplementary material, which is available to authorized users.
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18
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Zhang S, Tian Y, Xie S, Zhang J, Zhao J, Chen Y, Wang C. Systemic Chemotherapy as First-line Treatment for Metastatic Pancreatic Adenocarcinoma: A Bayesian Analysis. Intern Med 2018. [PMID: 30146578 DOI: 10.2169/internalmedicine.1114-18] [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] [Indexed: 11/06/2022] Open
Abstract
Objective The preferred chemotherapy regimen for metastatic pancreatic cancer remains a matter of controversy. In the present study, we aimed to assess and rank the effectiveness and toxicity of all of the available chemotherapy regimens included in the last 15 years' randomized controlled trials (RCTs) for metastatic pancreatic adenocarcinomas objectively. Methods PubMed, Embase, Cochrane Collaboration database, and ClinicalTrials.gov were searched for RCTs comparing chemotherapy regimens as first-line treatment for metastatic pancreatic adenocarcinomas. Using a Bayesian network meta-analysis, we compared and ranked all included chemotherapy regimens in terms of the overall survival, progression-free survival, response rate, and hematological toxicity. Results We identified 2,206 articles and included in the analysis 46 eligible articles reporting 44 RCTs with a total of 9,133 patients and 48 first-line intravenous systemic chemotherapy regimens. The models showed a good fit to the data. The top-ranked chemotherapy regimen for the overall survival was FP (simplified leucovorin + fluorouracil + nab-paclitaxel), with a hazard ratio (HR) of 0.45 versus gemcitabine monotherapy (95% credible interval 0.28-0.71). The regimen ranked first for the progression-free survival was gemcitabine + erlotinib + bevacizumab (HR 0.39, 0.23-0.62). GS (gemcitabine + S-1) had the highest overall response rate [odds ratio (OR) versus gemcitabine monotherapy 7.06, 1.15-51.15]. GemCape (gemcitabine + capecitabine) + erlotinib was ranked the most hematologically toxic (OR 7.78, 0.75-95.60). Conclusion The available evidence suggests that FP ranked first for metastatic pancreatic cancer in terms of the overall survival. GemCape + erlotinib ranked the most toxic.
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Affiliation(s)
- Shuisheng Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
- Department of General Surgery, Peking University Third Hospital, China
| | - Yuan Tian
- Department of Radiation Oncology, Shandong Provincial Qianfoshan Hospital, China
| | - Shuanghua Xie
- Department of Cancer Epidemiology and Health Statistics, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Jianwei Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Jiuda Zhao
- Department of Medical Oncology, Affiliated Hospital of Qinghai University, China
| | - Yingtai Chen
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Chengfeng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
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19
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Hajatdoost L, Sedaghat K, Walker EJ, Thomas J, Kosari S. Chemotherapy in Pancreatic Cancer: A Systematic Review. ACTA ACUST UNITED AC 2018; 54:medicina54030048. [PMID: 30344279 PMCID: PMC6122094 DOI: 10.3390/medicina54030048] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/05/2018] [Indexed: 02/06/2023]
Abstract
Background and Aim: Pancreatic cancer is one of the most fatal cancers. Cytotoxic chemotherapy remains the mainstream treatment for unresectable pancreatic cancer. This systematic review evaluated and compared the overall survival (OS) and progression-free survival (PFS) outcomes obtained from recent phase 2 and 3 clinical trials of pancreatic cancer chemotherapy. Materials and methods: Thirty-two studies were included and compared based on chemotherapy agents or combinations used. Additionally, outcomes of first-line versus second-line chemotherapy in pancreatic cancer were compared. Results: In studies that investigated the treatments in adjuvant settings, the highest OS reported was for S-1 in patients, who received prior surgical resection (46.5 months). In neoadjuvant settings, the combination of gemcitabine, docetaxel, and capecitabine prior to the surgical resection had promising outcomes (OS of 32.5 months). In non-adjuvant settings, the highest OS reported was for the combination of temsirolimus plus bevacizumab (34.0 months). Amongst studies that investigated second-line treatment, the highest OS reported was for the combination of gemcitabine plus cisplatin (35.5 months), then temsirolimus plus bevacizumab (34.0 months). Conclusions: There is a need to develop further strategies besides chemotherapy to improve the outcomes in pancreatic cancer treatment. Future studies should consider surgical interventions, combination chemotherapy, and individualized second-line treatment based on the prior chemotherapy.
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Affiliation(s)
- Leva Hajatdoost
- Department of Pharmaceutical Sciences, Baha'i Institute for Higher Education (BIHE), Tehran 11369, Iran.
| | - Keyvan Sedaghat
- Department of Pharmaceutical Sciences, Baha'i Institute for Higher Education (BIHE), Tehran 11369, Iran.
| | - Erin J Walker
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, Canberra 2617 ACT, Australia.
| | - Jackson Thomas
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, Canberra 2617 ACT, Australia.
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, Canberra 2617 ACT, Australia.
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20
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The benefits of modified FOLFIRINOX for advanced pancreatic cancer and its induced adverse events: a systematic review and meta-analysis. Sci Rep 2018; 8:8666. [PMID: 29875415 PMCID: PMC5989209 DOI: 10.1038/s41598-018-26811-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 05/11/2018] [Indexed: 01/05/2023] Open
Abstract
FOLFIRINOX has been one of the first-line options for advanced pancreatic cancer, even though it induces significant adverse effects. Several institutions have begun using modified FOLFIRINOX to decrease its side effects and increase its tolerability. We systematically investigated the outcome from patients who initially received modified FOLFIRINOX as a chemotherapy regimen for advanced pancreatic cancer. We used the random-model generic inverse variance method to analyse the binary data with 95% confidence intervals (CIs). Eleven studies were included in the meta-analysis with 563 total patients. The 6-month and 1-year overall survival (OS) rates of locally advanced pancreatic cancer (LAPC) were 90.9% and 76.2%. The 6-month and 1-year progression-free survival (PFS) rates of LAPC were 81.5% and 48.5%. The 6-month and 1-year OS rates of metastatic pancreatic cancer (MPC) were 79.7% and 47.6%. The 6-month and 1-year PFS rates of MPC were 56.3% and 20.6%. The following rates were also calculated: complete response rate (CR): 2.9%; partial response rate (PR): 35.9%; stable disease rate (SD): 41.2%; overall response rate (OR): 34.6%; disease control rate (DCR): 76.7%; progressive disease: 23.1%; and grade III/IV adverse events (AEs): neutropenia 23.1%, febrile neutropenia 4.8%, thrombocytopenia 4.8%, anaemia 5.7%, fatigue 11.5%, nausea 9.1%, diarrhoea 10.1%, vomiting 5.7%, neuropathy 3.8%, and increased ALT 5.7%. In conclusion, modified FOLFIRINOX could provide comparative survival benefits with fewer adverse events compared to the conventional dosage.
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Chin V, Nagrial A, Sjoquist K, O'Connor CA, Chantrill L, Biankin AV, Scholten RJPM, Yip D. Chemotherapy and radiotherapy for advanced pancreatic cancer. Cochrane Database Syst Rev 2018; 3:CD011044. [PMID: 29557103 PMCID: PMC6494171 DOI: 10.1002/14651858.cd011044.pub2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cancer (PC) is a highly lethal disease with few effective treatment options. Over the past few decades, many anti-cancer therapies have been tested in the locally advanced and metastatic setting, with mixed results. This review attempts to synthesise all the randomised data available to help better inform patient and clinician decision-making when dealing with this difficult disease. OBJECTIVES To assess the effect of chemotherapy, radiotherapy or both for first-line treatment of advanced pancreatic cancer. Our primary outcome was overall survival, while secondary outcomes include progression-free survival, grade 3/4 adverse events, therapy response and quality of life. SEARCH METHODS We searched for published and unpublished studies in CENTRAL (searched 14 June 2017), Embase (1980 to 14 June 2017), MEDLINE (1946 to 14 June 2017) and CANCERLIT (1999 to 2002) databases. We also handsearched all relevant conference abstracts published up until 14 June 2017. SELECTION CRITERIA All randomised studies assessing overall survival outcomes in patients with advanced pancreatic ductal adenocarcinoma. Chemotherapy and radiotherapy, alone or in combination, were the eligible treatments. DATA COLLECTION AND ANALYSIS Two review authors independently analysed studies, and a third settled any disputes. We extracted data on overall survival (OS), progression-free survival (PFS), response rates, adverse events (AEs) and quality of life (QoL), and we assessed risk of bias for each study. MAIN RESULTS We included 42 studies addressing chemotherapy in 9463 patients with advanced pancreatic cancer. We did not identify any eligible studies on radiotherapy.We did not find any benefit for chemotherapy over best supportive care. However, two identified studies did not have sufficient data to be included in the analysis, and many of the chemotherapy regimens studied were outdated.Compared to gemcitabine alone, participants receiving 5FU had worse OS (HR 1.69, 95% CI 1.26 to 2.27, moderate-quality evidence), PFS (HR 1.47, 95% CI 1.12 to 1.92) and QoL. On the other hand, two studies showed FOLFIRINOX was better than gemcitabine for OS (HR 0.51 95% CI 0.43 to 0.60, moderate-quality evidence), PFS (HR 0.46, 95% CI 0.38 to 0.57) and response rates (RR 3.38, 95% CI 2.01 to 5.65), but it increased the rate of side effects. The studies evaluating CO-101, ZD9331 and exatecan did not show benefit or harm when compared with gemcitabine alone.Giving gemcitabine at a fixed dose rate improved OS (HR 0.79, 95% CI 0.66 to 0.94, high-quality evidence) but increased the rate of side effects when compared with bolus dosing.When comparing gemcitabine combinations to gemcitabine alone, gemcitabine plus platinum improved PFS (HR 0.80, 95% CI 0.68 to 0.95) and response rates (RR 1.48, 95% CI 1.11 to 1.98) but not OS (HR 0.94, 95% CI 0.81 to 1.08, low-quality evidence). The rate of side effects increased. Gemcitabine plus fluoropyrimidine improved OS (HR 0.88, 95% CI 0.81 to 0.95), PFS (HR 0.79, 95% CI 0.72 to 0.87) and response rates (RR 1.78, 95% CI 1.29 to 2.47, high-quality evidence), but it also increased side effects. Gemcitabine plus topoisomerase inhibitor did not improve survival outcomes but did increase toxicity. One study demonstrated that gemcitabine plus nab-paclitaxel improved OS (HR 0.72, 95% CI 0.62 to 0.84, high-quality evidence), PFS (HR 0.69, 95% CI 0.58 to 0.82) and response rates (RR 3.29, 95% CI 2.24 to 4.84) but increased side effects. Gemcitabine-containing multi-drug combinations (GEMOXEL or cisplatin/epirubicin/5FU/gemcitabine) improved OS (HR 0.55, 95% CI 0.39 to 0.79, low-quality evidence), PFS (HR 0.43, 95% CI 0.30 to 0.62) and QOL.We did not find any survival advantages when comparing 5FU combinations to 5FU alone. AUTHORS' CONCLUSIONS Combination chemotherapy has recently overtaken the long-standing gemcitabine as the standard of care. FOLFIRINOX and gemcitabine plus nab-paclitaxel are highly efficacious, but our analysis shows that other combination regimens also offer a benefit. Selection of the most appropriate chemotherapy for individual patients still remains difficult, with clinicopathological stratification remaining elusive. Biomarker development is essential to help rationalise treatment selection for patients.
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Affiliation(s)
- Venessa Chin
- Garvan Institute of Medical ResearchThe Kinghorn Cancer Centre384 Victoria Street DarlinghurstSydneyNSWAustralia2010
- St Vincent's HospitalSydneyNSWAustralia
| | - Adnan Nagrial
- Garvan Institute of Medical ResearchThe Kinghorn Cancer Centre384 Victoria Street DarlinghurstSydneyNSWAustralia2010
- The Crown Princess Mary Cancer CentreDarcy RoadWestmeadNSWAustralia2145
| | - Katrin Sjoquist
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation BuildingSydneyNSWAustralia2006
- Cancer Care Centre, St George HospitalMedical OncologySt George Hospital, Gray StKogarahAustraliaNSW 2217
| | - Chelsie A O'Connor
- St Vincent's HospitalSydneyNSWAustralia
- Genesis Cancer CareSydneyNSWAustralia
- Macquarie University HospitalSydneyAustralia
| | - Lorraine Chantrill
- The Kinghorn Cancer Centre, Garvan Institute of Medical ResearchDepartment of Pancreatic Cancer382 Victoria Street DarlinghurstSydneyNSWAustralia2010
| | - Andrew V Biankin
- University of GlasgowInstitute of Cancer SciencesWolfson Wohl Cancer Research CentreGarscube Estate, Switchback RoadGlasgowUKG61 1QH
- University of New South WalesSouth Western Sydney Clinical School, Faculty of MedicineLiverpoolNSWAustralia2170
- West of Scotland Pancreatic Unit and Glasgow Royal InfirmaryGlasgowUK
| | - Rob JPM Scholten
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtCochrane NetherlandsRoom Str. 6.126P.O. Box 85500UtrechtNetherlands3508 GA
| | - Desmond Yip
- The Canberra HospitalDepartment of Medical OncologyYamba DriveGarranACTAustralia2605
- Australian National UniversityANU Medical SchoolActonACTAustralia0200
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Chan KKW, Saluja R, Delos Santos K, Lien K, Shah K, Cramarossa G, Zhu X, Wong RKS. Neoadjuvant treatments for locally advanced, resectable esophageal cancer: A network meta-analysis. Int J Cancer 2018; 143:430-437. [PMID: 29441562 DOI: 10.1002/ijc.31312] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/06/2017] [Accepted: 01/09/2018] [Indexed: 02/06/2023]
Abstract
The relative survival benefits and postoperative mortality among the different types of neoadjuvant treatments (such as chemotherapy only, radiotherapy only or chemoradiotherapy) for esophageal cancer patients are not well established. To evaluate the relative efficacy and safety of neoadjuvant therapies in resectable esophageal cancer, a Bayesian network meta-analysis was performed. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched for publications up to May 2016. ASCO and ASTRO annual meeting abstracts were also searched up to the 2015 conferences. Randomized controlled trials that compared at least two of the following treatments for resectable esophageal cancer were included: surgery alone, surgery preceded by neoadjuvant chemotherapy, neoadjuvant radiotherapy or neoadjuvant chemoradiotherapy. The primary outcome assessed from the trials was overall survival. Thirty-one randomized controlled trials involving 5496 patients were included in the quantitative analysis. The network meta-analysis showed that neoadjuvant chemoradiotherapy improved overall survival when compared to all other treatments including surgery alone (HR 0.75, 95% CR 0.67-0.85), neoadjuvant chemotherapy (HR 0.83. 95% CR 0.70-0.96) and neoadjuvant radiotherapy (HR 0.82, 95% CR 0.67-0.99). However, the risk of postoperative mortality increased when comparing neoadjuvant chemoradiotherapy to either surgery alone (RR 1.46, 95% CR 1.00-2.14) or to neoadjuvant chemotherapy (RR 1.58, 95% CR 1.00-2.49). In conclusion, neoadjuvant chemoradiotherapy improves overall survival but may also increase the risk of postoperative mortality in patients locally advanced resectable esophageal carcinoma.
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Affiliation(s)
- Kelvin K W Chan
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, ON, Canada.,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON, Canada
| | - Ronak Saluja
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Keemo Delos Santos
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Kelly Lien
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Keya Shah
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Gemma Cramarossa
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Xiaofu Zhu
- Cross Cancer Institute, Edmonton, AB, Canada
| | - Rebecca K S Wong
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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Enzler T, Bates S. Clinical Trials in Pancreatic Cancer: A Long Slog. Oncologist 2017; 22:1424-1426. [PMID: 28982802 PMCID: PMC5728038 DOI: 10.1634/theoncologist.2017-0453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/07/2017] [Indexed: 12/27/2022] Open
Abstract
Many investigators have turned their efforts toward improving the gemcitabine/nab‐paclitaxel combination by the addition of a third agent. This commentary highlights efforts to date, including the Clinical Trial Results by Ko et al.: A Randomized Double‐Blinded Phase II Trial of Gemcitabine and Nab‐Paclitaxel Plus Apatorsen or Placebo in Patients with Metastati Pancreatic Cancer: The RAINIER Trial.
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Affiliation(s)
- Thomas Enzler
- Division of Hematology and Oncology, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Susan Bates
- Division of Hematology and Oncology, Department of Medicine, Columbia University Medical Center, New York, New York, USA
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Jerzak KJ, Delos Santos K, Saluja R, Lien K, Lee J, Chan KKW. A network meta-analysis of the sequencing and types of systemic therapies with definitive radiotherapy in locally advanced squamous cell carcinoma of the head and neck (LASCCHN)☆. Oral Oncol 2017; 71:1-10. [PMID: 28688674 DOI: 10.1016/j.oraloncology.2017.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 05/04/2017] [Accepted: 05/20/2017] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The current standard therapy for locally advanced squamous cell carcinoma of the head and neck (LASCCHN) is platinum-based chemotherapy plus concurrent radiotherapy (CRT), but several systemic therapies have been evaluated. We performed a Bayesian network meta-analysis (NMA) with random effects to enable direct and indirect comparisons of all existing treatment modalities for LASCCHN simultaneously. MATERIAL AND METHODS A systematic review was conducted using MEDLINE, EMBASE, ASCO abstracts, ASTRO abstracts and the Cochrane Central of Registered Trials using Cochrane methodology to identify randomized controlled trials (RCTs) up to June 2016. Only abstracts that involved the same definitive radiotherapy in the arms for the RCT were included. RESULTS Sixty-five RCTs involving 13,574 patients and 16 different treatment strategies were identified. Chemotherapy plus concurrent radiation (CRT) was superior to RT with a HR of 0.74 (95%CR 0.69-0.79) for OS in the NMA. Only 3 trials compared RT alone to concurrent therapy with an EGFR antibody (ERT), demonstrating a superior OS (HR 0.75, 95% CR 0.60-0.94), but this difference was not statistically significant when interpreted in a NMA (HR 0.84, 95%CR 0.65-1.08). ERT was not superior to CRT (HR 1.19, 95%CR 0.93-1.54), and the addition of neo-adjuvant taxane-based chemotherapy to CRT was not beneficial (HR 0.86, 95% CR 0.70-1.07). CONCLUSION The addition of either adjuvant or neoadjuvant chemotherapy to the CRT backbone does not confer an OS benefit in the treatment of LASCCHN. Similarly, ERT does not confer an OS benefit for patients who are eligible for CRT.
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Affiliation(s)
- Katarzyna J Jerzak
- Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Keemo Delos Santos
- Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Ronak Saluja
- Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Kelly Lien
- Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Justin Lee
- Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Kelvin K W Chan
- Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, 27 King's College Circle, Toronto, Ontario M5S 1A1, Canada; Canadian Centre for Applied Research in Cancer Control, Canada.
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Borazanci E, Dang CV, Robey RW, Bates SE, Chabot JA, Von Hoff DD. Pancreatic Cancer: “A Riddle Wrapped in a Mystery inside an Enigma”. Clin Cancer Res 2017; 23:1629-1637. [DOI: 10.1158/1078-0432.ccr-16-2070] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 12/27/2022]
Abstract
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most difficult-to-treat cancers. With an increasing incidence and inability to make major progress, it represents the very definition of unmet medical need. Progress has been made in understanding the basic biology—systematic genomic sequencing has led to the recognition that PDAC is not typically a heavily mutated tumor, although there are exceptions. The most consistently mutated genes are KRAS, CDKN2A, TP53, and SMAD4/DPC4. Study of familial PDAC has led to the recognition that a variety of defects in DNA repair genes can be associated with the emergence of pancreatic cancer. Recent studies suggest that epigenetics may play a larger role than previously recognized. A major new understanding is the recognition that PDAC should be considered a composite of tumor cells, as well as pancreatic stellate cells, immune cells, and extracellular matrix. The individual components contribute to metabolic aberration, immune dysfunction, and chemotherapy resistance, and therapeutic innovations may be needed to address them individually. It has also been recognized that metastatic seeding from PDAC occurs very early in the disease course—in an estimated 73% of cases, once the tumor reaches 2 cm. The implication of this is that therapies directed toward micrometastatic disease and increasing fractional cell kill are most needed. Neoadjuvant approaches have been taken to increase resectability and improve outcome. So much work remains, and most critical is the need to understand how this tumor originates and develops. Clin Cancer Res; 23(7); 1629–37. ©2017 AACR.
See all articles in this CCR Focus section, “Pancreatic Cancer: Challenge and Inspiration.”
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Affiliation(s)
- Erkut Borazanci
- 1HonorHealth, Scottsdale, Arizona and TGen, Phoenix, Arizona
| | - Chi V. Dang
- 2Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Susan E. Bates
- 4Columbia University Medical Center, New York, New York
- 5James J. Peters Bronx VA Medical Center, Bronx, New York
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Coyle D, Ko YJ, Coyle K, Saluja R, Shah K, Lien K, Lam H, Chan KKW. Cost-Effectiveness Analysis of Systemic Therapies in Advanced Pancreatic Cancer in the Canadian Health Care System. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:586-592. [PMID: 28408000 DOI: 10.1016/j.jval.2016.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 09/25/2016] [Accepted: 11/02/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness of gemcitabine (G), G + 5-fluorouracil, G + capecitabine, G + cisplatin, G + oxaliplatin, G + erlotinib, G + nab-paclitaxel (GnP), and FOLFIRINOX in the treatment of advanced pancreatic cancer from a Canadian public health payer's perspective, using data from a recently published Bayesian network meta-analysis. METHODS Analysis was conducted through a three-state Markov model and used data on the progression of disease with treatment from the gemcitabine arms of randomized controlled trials combined with estimates from the network meta-analysis for the newer regimens. Estimates of health care costs were obtained from local providers, and utilities were derived from the literature. The model estimates the effect of treatment regimens on costs and quality-adjusted life-years (QALYs) discounted at 5% per annum. RESULTS At a willingness-to-pay (WTP) threshold of greater than $30,666 per QALY, FOLFIRINOX would be the most optimal regimen. For a WTP threshold of $50,000 per QALY, the probability that FOLFIRINOX would be optimal was 57.8%. There was no price reduction for nab-paclitaxel when GnP was optimal. CONCLUSIONS From a Canadian public health payer's perspective at the present time and drug prices, FOLFIRINOX is the optimal regimen on the basis of the cost-effectiveness criterion. GnP is not cost-effective regardless of the WTP threshold.
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Affiliation(s)
- Doug Coyle
- University of Ottawa, Ottawa, Ontario, Canada; Health Economics Research Group, Brunel University, Uxbridge, UK
| | - Yoo-Joung Ko
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Kathryn Coyle
- Health Economics Research Group, Brunel University, Uxbridge, UK
| | - Ronak Saluja
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Keya Shah
- Queen's University, Kingston, Ontario, Canada
| | - Kelly Lien
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Lam
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada.
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Ghosn M, Ibrahim T, Assi T, El Rassy E, Kourie HR, Kattan J. Dilemma of first line regimens in metastatic pancreatic adenocarcinoma. World J Gastroenterol 2016; 22:10124-10130. [PMID: 28028360 PMCID: PMC5155171 DOI: 10.3748/wjg.v22.i46.10124] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 09/23/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is one of the deadliest cancers, ranking fourth among cancer-related deaths. Despite all the major molecular advances and treatment breakthroughs, mainly targeted therapies, the cornerstone treatment of metastatic pancreatic cancer (mPC) remains cytotoxic chemotherapy. In 2016, more than 40 years after the introduction of gemcitabine in the management of mPC, the best choice for first-line treatment has not yet been fully elucidated. Two main strategies have been adopted to enhance treatment efficacy. The first strategy is based on combining non-cross resistant drugs, while the second option includes the development of newer generations of chemotherapy. More recently, two new regimens, FOLFIRINOX and gemcitabine/nab-paclitaxel (GNP), have both been shown to improve overall survival in comparison with gemcitabine alone, at the cost of increased toxicity. Therefore, the best choice for first line therapy is a matter of debate. For some authors, FOLFIRINOX should be the first choice in patients with an Eastern Cooperative Oncology Group score (0-1) given its lower hazard ratio. However, others do not share this opinion. In this paper, we review the main comparison points between FOLFIRINOX and GNP. We analyze the two pivotal trials to determine the similarities and differences in study design. In addition, we compare the toxicity profile of the two regimens as well as the impact on quality of life. Finally, we present studies revealing real life experiences and review the advantages and disadvantages of possible second-line therapies including their cost effectiveness.
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GONG JUN, TULI RICHARD, SHINDE ARVIND, HENDIFAR ANDREWE. Meta-analyses of treatment standards for pancreatic cancer. Mol Clin Oncol 2016; 4:315-325. [PMID: 26998283 PMCID: PMC4774516 DOI: 10.3892/mco.2015.716] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 11/23/2015] [Indexed: 01/05/2023] Open
Abstract
Pancreatic cancer is the most lethal common cancer with an estimated 5-year survival rate of 6-7% (across all stages). The only potential curative therapy is surgical resection in those with localized disease. Adjuvant (postoperative) therapy confers a survival advantage over postoperative observation alone. Neoadjuvant (preoperative) therapy offers the potential to downstage initially unresectable tumors for resection, sterilize resection margins and decrease locoregional recurrence, and identify a subset of patients with aggressive disease for whom surgery will not be beneficial. Induction chemotherapy followed by consolidation chemoradiation is another recommended approach in those with locally advanced disease. For those who cannot be downstaged, cannot tolerate surgery, or were diagnosed with metastatic disease, treatment remains palliative with chemotherapy being a critical component of this approach. Recently, intensive combination chemotherapy has been shown to improve survival rates in comparison to gemcitabine alone in advanced disease. The past few decades have afforded an accumulation of high-level evidence regarding neoadjuvant, adjuvant and palliative therapies in pancreatic cancer. There are numerous reviews discussing recent retrospective studies, prospective studies and randomized controlled trials in each of these areas. However, reviews of optimal and recommended treatment strategies across all stages of pancreatic cancer that focus on the highest levels of hierarchical evidence, such as meta-analyses, are limited. The discussion of novel therapeutics is beyond the scope of this review. However, an extensive and the most current collection of meta-analyses of first-line systemic and locoregional treatment options for all stages of pancreatic cancer to date has been accumulated.
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Affiliation(s)
- JUN GONG
- Department of Internal Medicine, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - RICHARD TULI
- Department of Radiation Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - ARVIND SHINDE
- Department of Hematology and Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - ANDREW E. HENDIFAR
- Gastrointestinal and Neuroendocrine Malignancies, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Hingorani SR, Harris WP, Beck JT, Berdov BA, Wagner SA, Pshevlotsky EM, Tjulandin SA, Gladkov OA, Holcombe RF, Korn R, Raghunand N, Dychter S, Jiang P, Shepard HM, Devoe CE. Phase Ib Study of PEGylated Recombinant Human Hyaluronidase and Gemcitabine in Patients with Advanced Pancreatic Cancer. Clin Cancer Res 2016; 22:2848-54. [PMID: 26813359 DOI: 10.1158/1078-0432.ccr-15-2010] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/24/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE This phase Ib study evaluated the safety and tolerability of PEGylated human recombinant hyaluronidase (PEGPH20) in combination with gemcitabine (Gem), and established a phase II dose for patients with untreated stage IV metastatic pancreatic ductal adenocarcinoma (PDA). Objective response rate and treatment efficacy using biomarker and imaging measurements were also evaluated. EXPERIMENTAL DESIGN Patients received escalating intravenous doses of PEGPH20 in combination with Gem using a standard 3+3 dose-escalation design. In cycle 1 (8 weeks), PEGPH20 was administrated twice weekly for 4 weeks, then once weekly for 3 weeks; Gem was administrated once weekly for 7 weeks, followed by 1 week off treatment. In each subsequent 4-week cycle, PEGPH20 and Gem were administered once weekly for 3 weeks, followed by 1 week off. Dexamethasone (8 mg) was given pre- and post-PEGPH20 administration. Several safety parameters were evaluated. RESULTS Twenty-eight patients were enrolled and received PEGPH20 at 1.0 (n = 4), 1.6 (n = 4), or 3.0 μg/kg (n = 20), respectively. The most common PEGPH20-related adverse events were musculoskeletal and extremity pain, peripheral edema, and fatigue. The incidence of thromboembolic events was 29%. Median progression-free survival (PFS) and overall survival (OS) rates were 5.0 and 6.6 months, respectively. In 17 patients evaluated for pretreatment tissue hyaluronan (HA) levels, median PFS and OS rates were 7.2 and 13.0 months for "high"-HA patients (n = 6), and 3.5 and 5.7 months for "low"-HA patients (n = 11), respectively. CONCLUSIONS PEGPH20 in combination with Gem was well tolerated and may have therapeutic benefit in patients with advanced PDA, especially in those with high HA tumors. Clin Cancer Res; 22(12); 2848-54. ©2016 AACR.
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Affiliation(s)
- Sunil R Hingorani
- Fred Hutchinson Cancer Research Center, Seattle, Washington. University of Washington School of Medicine, Seattle, Washington.
| | - William P Harris
- Fred Hutchinson Cancer Research Center, Seattle, Washington. University of Washington School of Medicine, Seattle, Washington
| | | | - Boris A Berdov
- Medical Radiological Research Center, Obninsk, Russian Federation
| | - Stephanie A Wagner
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
| | - Eduard M Pshevlotsky
- Omsk Regional Budget Medical Institution: Clinical Oncological Center, Omsk, Russian Federation
| | - Sergei A Tjulandin
- Russian Oncology Research Center n.a. N.N. Blokhin, Moscow, Russian Federation
| | - Oleg A Gladkov
- Chelyabinsk Regional Clinical Oncology Center, Chelyabinsk, Russian Federation
| | | | | | | | | | - Ping Jiang
- Halozyme Therapeutics, San Diego, California
| | | | - Craig E Devoe
- Hofstra North Shore-LIJ School of Medicine, Hempstead, New York
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Colloca G, Venturino A, Guarneri D. Analysis of Response-Related and Time-to-event Endpoints in Randomized Trials of Gemcitabine-Based Treatment Versus Gemcitabine Alone as First-Line Treatment of Patients With Advanced Pancreatic Cancer. Clin Colorectal Cancer 2015; 15:264-76. [PMID: 26776098 DOI: 10.1016/j.clcc.2015.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/03/2015] [Accepted: 11/23/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gemcitabine-based combinations in advanced pancreatic cancer have been reported to have superior activity compared with gemcitabine alone. The results of the commonly used endpoints of clinical trials after chemotherapy or targeted therapy have been poorly reported. METHODS AND MATERIALS We performed a search of randomized trials of systemic treatment that included gemcitabine plus chemotherapy or targeted therapy versus gemcitabine alone. For selected trials, the differences between the treatment arms for every endpoint were calculated, and a correlation analysis between these differences and the differences in overall survival was performed for every intermediate endpoint. Whenever a correlation coefficient was significant, regression analysis was performed. Finally, an analysis was performed to evaluate the factors that could mediate and moderate the effect of progression-free survival on overall survival. RESULTS In addition to overall survival, progression-free survival, the overall response rate, and the disease control rate were the most frequently reported endpoints. Of the possible surrogate endpoints of overall survival, progression-free survival appears to be a reliable endpoint to assess chemotherapy (R(2) = 0.646) and chemotherapy plus targeted therapy (R(2) = 0.530) regimens and the disease control rate to assess chemotherapy (R(2) = 0.569). Of the factors that could limit the effect of progression-free survival on overall survival, the interval of radiologic evaluation could play a role. CONCLUSION In the selected trials, progression-free survival and the disease control rate were the most reliable surrogate endpoints of overall survival. Similar to the time-to-event endpoints, a standardization of response-related endpoints is strongly recommended.
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Kumachev A, Yan M, Berry S, Ko YJ, Martinez MCR, Shah K, Chan KKW. A Systematic Review and Network Meta-Analysis of Biologic Agents in the First Line Setting for Advanced Colorectal Cancer. PLoS One 2015; 10:e0140187. [PMID: 26474403 PMCID: PMC4608731 DOI: 10.1371/journal.pone.0140187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/22/2015] [Indexed: 12/20/2022] Open
Abstract
Background Epithelial growth factor receptor inhibitors (EGFRis) and bevacizumab (BEV) are used in combination with chemotherapy for the treatment of metastatic colorectal cancer (mCRC). However, few randomized controlled trials (RCTs) have directly compared their relative efficacy on progression-free survival (PFS) and overall survival (OS). Methods We conducted a systematic review of first-line RCTs comparing (1) EGFRis vs. BEV, with chemotherapy in both arms (2) EGFRis + chemotherapy vs. chemotherapy alone, or (3) BEV + chemotherapy vs. chemotherapy alone, using Cochrane methodology. Data on and PFS and OS were extracted using the Parmar method. Pairwise meta-analyses and Bayesian network meta-analyses (NMA) were conducted to estimate the direct, indirect and combined PFS and OS hazard ratios (HRs) comparing EGFRis to BEV. Results Seventeen RCTs contained extractable data for quantitative analysis. Combining direct and indirect data using an NMA did not show a statistical difference between EGFRis versus BEV (PFS HR = 1.11 (95% CR: 0.92–1.36) and OS HR = 0.91 (95% CR: 0.75–1.09)). Direct meta-analysis (3 RCTs), indirect (14 RCTs) and combined (17 RCTs) NMA of PFS HRs were concordant and did not show a difference between EGFRis and BEV. Meta-analysis of OS using direct evidence, largely influenced by one trial, showed an improvement with EGFRis therapy (HR = 0.79 (95% CR: 0.65–0.98)), while indirect and combined NMA of OS did not show a difference between EGFRis and BEV Successive inclusions of trials over time in the combined NMA did not show superiority of EGFRis over BEV. Conclusions Our findings did not support OS or PFS benefits of EGFRis over BEV in first-line mCRC.
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Affiliation(s)
| | - Marie Yan
- Faculty of Medicine, University of Toronto, Toronto Canada
| | - Scott Berry
- Faculty of Medicine, University of Toronto, Toronto Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Yoo-Joung Ko
- Faculty of Medicine, University of Toronto, Toronto Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | | | - Keya Shah
- Faculty of Medicine, Queens University, Kingston, Canada
| | - Kelvin K. W. Chan
- Faculty of Medicine, University of Toronto, Toronto Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- * E-mail:
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Wang SL, Cao S, Wu R, Chi F, Tang MY, Jin XY, Chen XD. Serum ferritin predicted prognosis in patients with locally advanced pancreatic cancer. Future Oncol 2015; 11:2905-10. [PMID: 26436474 DOI: 10.2217/fon.15.186] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIM The present study evaluated the value of serum ferritin (SF) level for the prognosis of patients with locally advanced pancreatic cancer (LAPC). PATIENTS & METHODS A total of 79 patients with LAPC treated by chemoradiotherapy were reviewed retrospectively. Pretreatment and post-treatment levels of SF were obtained. RESULTS Median progression-free survival (PFS) was 11.8 months; median overall survival was 18.3 months. A total of 36 patients with elevated SF level showed significantly worse overall survival and PFS than patients with low SF level (p = 0.002 and p = 0.004, respectively). In total, 17 patients showed normal SF level after chemoradiotherapy, and their median PFS was 3.2 months longer than that of patients whose SF levels were not restored after chemoradiotherapy. CONCLUSION SF may serve as a valuable tool to assess prognosis and monitor chemoradiotherapy response in patients with LAPC.
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Affiliation(s)
- Si-Liang Wang
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
| | - Shuo Cao
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
| | - Rong Wu
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
| | - Feng Chi
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
| | - Mei-Yue Tang
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
| | - Xue-Ying Jin
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
| | - Xiao-Dong Chen
- Department of Medical Oncology, Shengjing Hospital of China Medical University, 36 Sanhao Road, Shenyang 110004, China
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Baldo P, Giacomin E, Cecco S, D'Amico R, Cannizzaro R, Balduzzi S. Erlotinib for advanced pancreatic cancer. Hippokratia 2015. [DOI: 10.1002/14651858.cd011463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Paolo Baldo
- CRO Aviano - Centro di Riferimento Oncologico IRCCS; Pharmacy Unit, Drug Information Centre; Via Franco Gallini, 2 Aviano (PN) Friuli-Venezia-Giulia Italy 33081
| | - Elisa Giacomin
- CRO Aviano - Centro di Riferimento Oncologico IRCCS; Via Pedemontana Occidentale, 2 33081 Aviano (PN) Italy
| | - Sara Cecco
- CRO Aviano - Centro di Riferimento Oncologico IRCCS; Pharmacy Unit, Drug Information Centre; Via Franco Gallini, 2 Aviano (PN) Friuli-Venezia-Giulia Italy 33081
| | - Roberto D'Amico
- University of Modena and Reggio Emilia; Italian Cochrane Centre, Department of Diagnostic, Clinical and Public Health Medicine; Via del Pozzo 71 Modena Italy 41124
| | - Renato Cannizzaro
- CRO Aviano - Centro di Riferimento Oncologico IRCCS; Gastroenterology Unit; Via Franco Gallini, 2 Aviano (PN) Italy 33081
| | - Sara Balduzzi
- University of Modena and Reggio Emilia; Italian Cochrane Centre, Department of Diagnostic, Clinical and Public Health Medicine; Via del Pozzo 71 Modena Italy 41124
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