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Heine RJSD, Mathijssen RHJ, Verbeek FAJ, Van Gils C, Uyl-de Groot CA. Market Entry Agreements for Innovative Pharmaceuticals Subject to Indication Broadening: A Case Study for Pembrolizumab in The Netherlands. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02738-4. [PMID: 38909683 DOI: 10.1016/j.jval.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/29/2024] [Accepted: 06/07/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Managed entry agreements and especially financial-based agreements are commonly used in European countries for innovative cancer pharmaceuticals. These agreements facilitate access to innovative treatments while mitigating financial risks for payers. This study focuses on the confidential price agreement made by the Dutch government for the reimbursement of pembrolizumab, the implications of broadening indications on cost-effectiveness, and the viability or desirability of said agreement. METHODS We selected 5 indications in which pembrolizumab was deemed effective and developed portioned survival models for each indication. Survival and progression-free survival data from the published trials were utilized to recreate individual patient data, and we extrapolated-using parametric models-to a time horizon of 30 years. Inputs for both quality of life and costs were derived from the available literature and were indexed. RESULTS The incremental cost-effectiveness ratios ranged between €35 313 and €322 349 per quality-adjusted life-year, depending on the indication. Only 1 indication fell under the €80 000 (or €100 000) cost-effectiveness threshold. When applying the average reported discount on intramural pharmaceuticals in The Netherlands, incremental cost-effectiveness ratios ranged between €20 881 and €252 934 per quality-adjusted life-year gained, and the €80 000 (or €100 000) threshold was met in 3 indications out of 5. CONCLUSIONS Our results show that pembrolizumab could be cost-effective in some indications, depending on the confidential price agreement established. However, the possibility of reimbursing not cost-effective care when the price is anchored in 1 indication remains possible. Indication-based pricing could help align value and price for innovative pharmaceuticals that are subject to indication broadening.
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Affiliation(s)
- Renaud J S D Heine
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus Center for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Floor A J Verbeek
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Carin A Uyl-de Groot
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus Center for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
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Fernandes AS, Obeid G, Laureno TJN, Correra TC. Protonated and Sodiated Cyclophosphamide Fragmentation Pathways Evaluation by Infrared Multiple Photon Dissociation Spectroscopy. J Phys Chem A 2023. [PMID: 37285455 DOI: 10.1021/acs.jpca.3c01323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Cyclophosphamide (CP or CTX) is a widely used antineoplastic agent, and the evaluation of its efficacy and its impacts on the environment are dependent on tandem mass spectrometry (MSn) techniques. Because there is no dedicated experimental study to characterize the actual molecular nature of the CP fragments upon collision-induced dissociation, this work evaluated the chemical structure of the fragments of protonated and sodiated CP and CP protonation sites by infrared multiple photon dissociation spectroscopy supported by density functional theory calculations. This study allowed us to propose a new fragment structure and confirm the nature of multiple fragments, including those relevant for transitions used for CP quantitative and qualitative analyses. Our results also show that there is no spectroscopic evidence that can rule out the existence of aziridinium fragments, making it clear that further studies on the nature of iminium/aziridinium fragments in the gas phase are necessary.
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Affiliation(s)
- André S Fernandes
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes, 748, Cidade Universitária, São Paulo 05508-000, São Paulo, Brazil
| | - Guilherme Obeid
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes, 748, Cidade Universitária, São Paulo 05508-000, São Paulo, Brazil
| | - Tiago J N Laureno
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes, 748, Cidade Universitária, São Paulo 05508-000, São Paulo, Brazil
| | - Thiago C Correra
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo, Av. Prof. Lineu Prestes, 748, Cidade Universitária, São Paulo 05508-000, São Paulo, Brazil
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Carroll CE, Landrum MB, Wright AA, Keating NL. Adoption of Innovative Therapies Across Oncology Practices-Evidence From Immunotherapy. JAMA Oncol 2023; 9:324-333. [PMID: 36602811 PMCID: PMC9857528 DOI: 10.1001/jamaoncol.2022.6296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/03/2022] [Indexed: 01/06/2023]
Abstract
Importance Immunotherapies reflect an important breakthrough in cancer treatment, substantially improving outcomes for patients with a variety of cancer types, yet little is known about which practices have adopted this novel therapy or the pace of adoption. Objective To assess adoption of immunotherapies across US oncology practices and examine variation in adoption by practice type. Design, Setting, and Participants This cohort study used data from Medicare fee-for-service beneficiaries undergoing 6-month chemotherapy episodes between 2010 and 2017. Data were analyzed January 19, 2021, to September 28, 2022, for patients with cancer types for which immunotherapy was approved by the US Food and Drug Administration (FDA) during the study period: melanoma, kidney cancer, lung cancer, and head and neck cancer. Exposures Oncology practice location (rural vs urban), affiliation type (academic system, nonacademic system, independent), and size (1 to 5 physicians vs 6 or more physicians). Main Outcomes and Measures The primary outcome was whether a practice adopted immunotherapy. Adoption rates for each practice type were estimated using multivariate linear models that adjusted for patient characteristics (age, sex, race and ethnicity, cancer type, Charlson Comorbidity Index, and median household income). Results Data included 71 659 episodes at 1732 oncology practices. Of these, 264 practices (15%) were rural, 900 (52%) were independent, and 492 (28%) had 1 to 5 physicians. Most practices adopted immunotherapy within 2 years of FDA approval, but there was substantial variation in adoption rates across practice types. After FDA approval, adoption of immunotherapy was 11 (95% CI, -16 to -6) percentage points lower at rural practices than urban practices and 27 (95% CI, -32 to -22) percentage points lower at practices with 1 to 5 physicians than practices with 6 or more physicians. Adoption rates were similar at independent practices and nonacademic systems; however, both practice types had lower adoption than academic systems (independent practice difference, -6 [95% CI, -9 to -3] percentage points; nonacademic systems difference, -9 [95% CI, -11 to -6] percentage points). Conclusions and Relevance In this cohort study of Medicare claims, practice characteristics, especially practice size and rural location, were associated with adoption of immunotherapy. These findings suggest that there may be geographic disparities in access to important innovations for treating patients with cancer.
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Affiliation(s)
- Caitlin E. Carroll
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alexi A. Wright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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Hillis C, Flynn KE, Goldman EH, Moreira-Lucas TS, Visentini J, Dorman S, Ballinger R, Byrnes HF, De Palma A, Barbier V, Machado L, Atallah E. A Survey of Patient Experience in CML: American and Canadian Perspectives. Patient Prefer Adherence 2023; 17:331-347. [PMID: 36760231 PMCID: PMC9904222 DOI: 10.2147/ppa.s394332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
PURPOSE With treatment, chronic myeloid leukemia (CML) has a favorable prognosis, however, individuals with CML experience impairment to their quality of life (QoL). The aim of this study was to examine the perspectives and experiences of individuals with CML and to understand their challenges communicating with their CML physician. PATIENTS AND METHODS An online survey in adults with CML (n=100) in the US and Canada assessed QoL, patient-provider relationships, treatment satisfaction, and understanding of CML and treatment goals via the MD Anderson Symptom Inventory, the Cancer Therapy Satisfaction Questionnaire and de novo survey questions. Participants were recruited via an external patient recruiter and CML Patient Groups. RESULTS Many participants reported hardships due to CML and its treatment. The main impacts were on the ability to work (21%), engage in personal activities (e.g., hobbies, 28%), and to enjoy sexual relations (median=2.00, IQR=8.50). A substantial proportion (21-39%) wished to discuss additional topics with their providers (e.g., management of CML and/or its impacts). While participants reported satisfaction with therapy overall (median=85.71, IQR=17.86), they indicated low to moderate treatment satisfaction with specific components, including concerns regarding side effects (median=43.75, IQR=43.75). Participants generally had a good understanding of CML (97%) and its treatment goals (92%). CONCLUSION These findings advance our understanding of issues that need improvement to support QoL for individuals living with CML. Future work is needed to improve patient-provider relationships, address treatment-related side effects, and provide clinical information that is easier for patients to understand.
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Affiliation(s)
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Josie Visentini
- Medical Affairs, Pfizer Canada Inc., Kirkland, Quebec, Canada
| | | | - Rachel Ballinger
- Patient Centred Outcomes (PCO), ICON Clinical Research Inc., Reading, UK
| | - Hilary F Byrnes
- Patient Centred Outcomes (PCO), ICON Clinical Research Inc., Blue Bell, PA, USA
| | - Andrea De Palma
- Patient Centred Outcomes (PCO), ICON Clinical Research Inc., Milan, Italy
- Correspondence: Andrea De Palma, Tel +39 06 45 20 8037, Email
| | - Valentin Barbier
- Patient Centred Outcomes (PCO), ICON Clinical Research Inc., Lyon, France
| | - Lisa Machado
- The Canadian CML Network, Toronto, Ontario, Canada
| | - Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Healthcare costs and resource utilization associated with renal cell carcinoma among older Americans: A longitudinal case-control study using the SEER-Medicare data. Urol Oncol 2022; 40:347.e17-347.e27. [DOI: 10.1016/j.urolonc.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 11/19/2022]
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O'Mahony C, Murphy KD, Byrne S. A mixed methods analysis of the monitoring of oral anti-cancer therapies. Eur J Oncol Nurs 2021; 54:102026. [PMID: 34487968 DOI: 10.1016/j.ejon.2021.102026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/01/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE Oral anti-cancer therapies offer advantages over parenteral therapies in terms of their non-invasive nature and reduced intrusiveness. However, the shift from directly observed administration of these therapies to home administration means that continuous monitoring is needed. The oral anti-cancer therapy market is rapidly growing, with an ever-increasing number of new medicines available for the patients presenting with cancer illnesses. This study aims to (i) evaluate both the cost of providing monitoring consultations of oral anti-cancer therapies, and (ii) to assess the experience of cancer therapy nurses responsible for the monitoring and their opinions of the quality of the service. METHODS This study provides a mixed methods evaluation of the monitoring of oral anti-cancer therapies. Nurses were asked to record the time taken for them to perform their monitoring duties, and staff related costs were calculated using publicly available salary data. Patient-related costs were calculated using the Human Capital method. Nurses were asked to discuss their experience of monitoring oral anti-cancer therapies in semi-structured interviews. These interviews were subsequently analysed using thematic analysis. RESULTS 201 recordings and their associated costs were documented. The median consultation time was 33 min, costing €22.10 using Clinical Nurse Specialist salary figures and €26.51 using Advanced Nurse Practitioner salary figures. The associated patient cost was €14.06. Themes of the effect of Covid-19 on the service, expanding and complicated care package requirements, the need for dedicated oral clinics and the future of the service emerged from the interview data. CONCLUSION The monitoring service provided by nurses may be undervalued. The commitment to fully dedicated oral anti-cancer therapy clinics and an increase in staff to align with the ongoing increase in service demand is seen as vital for the continued safe and effective delivery of this specialist cancer service.
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Affiliation(s)
- Cian O'Mahony
- Pharmaceutical Care Group, School of Pharmacy, University College Cork, College Road, Cork, Ireland.
| | - Kevin D Murphy
- Pharmaceutical Care Group, School of Pharmacy, University College Cork, College Road, Cork, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Group, School of Pharmacy, University College Cork, College Road, Cork, Ireland
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Understanding the Relationship between Breast Reconstruction Subtype and Risk of Financial Toxicity: A Single-Institution Pilot Study. Plast Reconstr Surg 2021; 148:1e-11e. [PMID: 34181599 DOI: 10.1097/prs.0000000000008015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of breast reconstruction on financial toxicity remains poorly understood despite growing awareness. The authors sought to illustrate the relationship between breast reconstruction subtypes and the risk of financial toxicity. METHODS The authors conducted a single-institution cross-sectional survey of all female breast cancer patients undergoing any form of breast reconstruction between January of 2018 and June of 2019. Financial toxicity was measured by means of the validated Comprehensive Score for Financial Toxicity instrument. Demographics, clinical course, and coping strategies were abstracted from a purpose-built survey and electronic medical records. Multivariable linear regression was performed to identify associations with financial toxicity. RESULTS The authors' analytical sample was 350 patients. One hundred eighty-four (52.6 percent) underwent oncoplastic reconstruction, 126 (36 percent) underwent implant-based reconstruction, and 40 (11.4 percent) underwent autologous reconstruction. Oncoplastic reconstruction recipients were older, had a higher body mass index, and were more likely to have supplemental insurance and receive adjuvant hormonal therapy. No significant differences in the risk of financial toxicity were uncovered across breast reconstruction subtypes (p = 0.53). Protective factors against financial toxicity were use of supplemental insurance (p = 0.0003) and escalating annual household income greater than $40,000 (p < 0.0001). Receipt of radiation therapy was positively associated with worsening financial toxicity (-2.69; 95 CI percent, -5.22 to -0.15). Financial coping strategies were prevalent across breast reconstruction subtypes. CONCLUSIONS Breast reconstruction subtype does not differentially impact the risk of financial toxicity. Increasing income and supplemental insurance were found to be protective, whereas receipt of radiation therapy was positively associated with financial toxicity. Prospective, multicenter studies are needed to identify the main drivers of out-of-pocket costs and financial toxicity in breast cancer care.
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Li M, Goldman DP, Chen AJ. Spending On Targeted Therapies Reduced Mortality In Patients With Advanced-Stage Breast Cancer. Health Aff (Millwood) 2021; 40:763-771. [PMID: 33939503 DOI: 10.1377/hlthaff.2020.01714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Costly targeted therapies are playing an increasingly important role in treating cancer. To characterize trends in spending on targeted therapies for breast cancer and to estimate the association of these therapies with cancer mortality, we analyzed cancer diagnoses in the Surveillance, Epidemiology, and End Results Program-Medicare linked database. We categorized total cancer spending into spending on targeted therapies, spending on nontargeted therapies, and spending on other cancer care. Diagnosis-year spending on targeted therapies increased from $1,024 per patient in 2000 to $18,809 per patient in 2015 for patients with advanced-stage cancer and from $82 to $3,289 for patients with early-stage cancer. For patients with advanced-stage cancer, a $1,000 increase in spending on targeted therapies in the diagnosis year was associated with a 0.55-percentage-point decrease in adjusted three-year cancer mortality, whereas for patients with early-stage cancer, there was no association. The other two types of spending (on nontargeted therapies and other cancer care) were not associated with mortality among patients with either advanced- or early-stage cancer. Our results indicate that among various types of cancer treatments, only targeted therapies generated meaningful survival gains for patients with advanced-stage breast cancer.
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Affiliation(s)
- Meng Li
- Meng Li is an assistant professor at the University of Texas MD Anderson Cancer Center, in Houston, Texas, and a nonresident fellow at the Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California (USC), in Los Angeles, California
| | - Dana P Goldman
- Dana P. Goldman is the interim dean of and the Leonard D. Schaeffer Chair and Distinguished Professor of Public Policy, Pharmacy, and Economics in the Sol Price School of Public Policy and School of Pharmacy, USC
| | - Alice J Chen
- Alice J. Chen is an associate professor in the Sol Price School of Public Policy and senior fellow at the Leonard D. Schaeffer Center for Health Policy and Economics, USC
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Howard DH, Quek RGW, Fox KM, Arondekar B, Filson CP. The value of new drugs for advanced prostate cancer. Cancer 2021; 127:3457-3465. [PMID: 34062620 DOI: 10.1002/cncr.33662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/12/2021] [Accepted: 04/29/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The US Food and Drug Administration has recently approved a number of new cancer drugs. The clinical trials that serve as the basis for new cancer drug approvals may not reflect how the drugs will perform in routine practice and do not measure the impact of the drugs on spending. The authors sought to evaluate the real-world effectiveness and value of drugs recently approved for advanced prostate cancer. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, the authors identified fee-for-service Medicare beneficiaries aged 65 years or older who began treatment with a drug approved for metastatic castration-resistant prostate cancer in 2007-2009, when only 1 drug was approved for metastatic castration-resistant prostate cancer, and in 2014-2016, when 5 additional drugs were approved. They calculated life expectancy and lifetime medical costs (ie, Medicare reimbursements) for each group. RESULTS Between 2007-2009 and 2014-2016, life expectancy increased by 12.6 months. Lifetime medical costs increased by $87,000. The incremental cost per life-year gained was $83,000. CONCLUSION The release of 5 new drugs coincided with increases in survival rates and spending. This study's estimates indicate that the new drugs collectively were cost-effective.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory Healthcare, Atlanta, Georgia
| | | | - Kathleen M Fox
- Strategic Healthcare Solutions, LLC, Aiken, South Carolina
| | | | - Christopher P Filson
- Winship Cancer Institute, Emory Healthcare, Atlanta, Georgia.,Department of Urology, Emory University, Atlanta, Georgia
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Youn B, Wilson IB, Mor V, Trikalinos NA, Dahabreh IJ. Population-level changes in outcomes and Medicare cost following the introduction of new cancer therapies. Health Serv Res 2021; 56:486-496. [PMID: 33682120 PMCID: PMC8143675 DOI: 10.1111/1475-6773.13624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To examine the population-level impacts of the introduction of novel cancer therapies with high cost in the United States, using immunotherapies in advanced nonsmall cell lung cancer (NSCLC) as an example. DATA SOURCES Surveillance, Epidemiology, and End Results data in 2012-2015 linked to Medicare fee-for-service claims until 2016. STUDY DESIGN We examined population-level trends in treatment patterns, survival, and Medicare spending in patients diagnosed with advanced NSCLC, the leading cause of cancer death in the United States, between 2012 and 2015. We estimated the percentage of patients who received any antineoplastic therapy within two years of diagnosis, including novel immunotherapies. We compared the trends in overall survival and mean two-year Medicare spending per each patient before and after the introduction of immunotherapies in 2015. DATA COLLECTION/EXTRACTION METHODS Not Applicable. PRINCIPAL FINDINGS The percentage of patients treated with any antineoplastic therapy remained the same at 46.7% in 2012 and 2015, whereas the use of immunotherapies increased from 0% to 15.2%. The two-year survival rate and median survival increased by 3.3 percentage points (95% CI: 2.0, 4.5) and 0.4 months (CI: 0.0, 0.9), respectively, during the same period. The mean two-year total Medicare spending and outpatient spending per patient increased by $5735 (CI: 3479, 8040) and $7661 (CI: 5902, 9311), respectively, which were largely attributable to the increases in immunotherapy spending by $5806 (CI: 5165, 6459). CONCLUSIONS The introduction of lung cancer immunotherapies was accompanied by improvements in survival and increases in spending between 2012 and 2015 in the Medicare population. As novel immunotherapies and other target therapies continue to change the clinical management of various cancers, further efforts are needed to ensure their effective and efficient use, and to understand their population-level impacts in the United States.
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Affiliation(s)
- Bora Youn
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Nikolaos A Trikalinos
- Department of Medicine, Washington University in St. Louis, St Louis, Missouri, USA.,Siteman Cancer Center, St Louis, Missouri, USA
| | - Issa J Dahabreh
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Malignancy. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 23:59-65. [DOI: 10.1016/j.carrev.2020.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 11/22/2022]
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Tandar A, Catino A, Sharma V. Aortic Stenosis and Malignancy-A Shift in Trajectory: Management of Aortic Stenosis in Cancer Patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:66-67. [PMID: 33250407 DOI: 10.1016/j.carrev.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Anwar Tandar
- Division Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Anna Catino
- Division Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Vikas Sharma
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Buxbaum JD, Chernew ME, Fendrick AM, Cutler DM. Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015. Health Aff (Millwood) 2020; 39:1546-1556. [PMID: 32897792 DOI: 10.1377/hlthaff.2020.00284] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and -7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.
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Affiliation(s)
- Jason D Buxbaum
- Jason D. Buxbaum is a student in the Program in Health Policy at Harvard University, in Cambridge, Massachusetts
| | - Michael E Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy and director of the Healthcare Markets and Regulation (HMR) Lab in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - A Mark Fendrick
- A. Mark Fendrick is a professor in the Department of Internal Medicine and director of the Center for Value-Based Insurance Design at the University of Michigan, in Ann Arbor, Michigan
| | - David M Cutler
- David M. Cutler is the Otto Eckstein Professor of Applied Economics in the Department of Economics at Harvard University and a research associate at the National Bureau of Economic Research, in Cambridge, Massachusetts
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Abstract
BACKGROUND There is a concern that the Oncology Care Model (OCM), a voluntary bundled payment program, may incentivize mergers and acquisitions among physician practices leading to reduced competition and price increases. These concerns are heightened if OCM is preferentially adopted in competitive health care markets because it could result in reduced competition, but little is known about the characteristics of markets where OCM is adopted. OBJECTIVE To measure the association between regional market competition among medical oncologists with the initial adoption of OCM. RESEARCH DESIGN The Herfindahl-Hirschman Index (HHI), a measure of competition, was calculated for hospital referral regions (HRRs) using secondary data from the Centers for Medicare and Medicaid Services. The relationship between HHI and OCM adoption was assessed using a 2-part regression model adjusting for the market-level number of practices, physician density, average practice size, sociodemographic characteristics, and medical resources. A count model on all HRRs was also estimated to assess an overall effect. SUBJECTS A total of 10,788 physicians in 3,537 practices who billed Medicare for oncology services in 2015. RESULTS OCM was adopted in 114 (37%) of the 306 HRRs. We found that practices in competitive health care markets were more likely to adopt OCM than in noncompetitive markets. Two-part regression analysis indicated a nonlinear relationship between HHI and OCM adoption. Average practice size, number of practices in an HRR, and the hospital bed rate were positively associated with adoption, whereas the rate of full-time equivalent hospital employees to 1000 residents was negatively associated with adoption. CONCLUSIONS OCM adoption was higher in HRRs with greater competition. Careful monitoring of market-level changes among OCM adopters should be undertaken to ensure that the benefits of the OCM outweigh the negative consequences of possible changes in competition.
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Sussell JA, Sheinson D, Wu N, Shah-Manek B, Seetasith A. HER2-Positive Metastatic Breast Cancer: A Retrospective Cohort Study of Healthcare Costs in the Targeted-Therapy Age. Adv Ther 2020; 37:1632-1645. [PMID: 32172510 DOI: 10.1007/s12325-020-01283-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Claims data (IBM MarketScan Commercial and MarketScan Medicare Supplemental databases) from June 30, 2011 to September 30, 2017 were used to evaluate the cost impact of human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) in this retrospective cohort study. METHODS The primary analysis compared short-term costs for patients diagnosed with HER2+ MBC at least 180 days after the end of first HER2-targeted treatment (MBC+ cohort) versus a propensity score matched cohort of patients with breast cancer who did not develop MBC (MBC- cohort). A pseudo-post period for patients in the HER2+ MBC- cohort was defined by indexing to the HER2+ treatment completion-MBC diagnosis time interval of the matched pair in the HER2+ MBC+ cohort; we then compared average monthly cost differences between these groups for the year preceding and following MBC diagnosis. In secondary analyses, we estimated medium-term aggregate and categorical healthcare costs for patients with HER2+ MBC up to 3 years post-diagnosis. RESULTS In the short-term primary analysis, costs for the HER2+ MBC+ and HER2+ MBC- cohorts were largely comparable in the year preceding MBC diagnosis. Monthly direct costs were significantly higher for the HER2+ MBC+ cohort in the months immediately preceding MBC diagnosis, with differences in the range of $500-5000. Following diagnosis, total monthly costs were $13,000-34,000 higher for patients in the HER2+ MBC+ cohort vs. the HER2+ MBC- cohort. In the medium-term secondary analysis, mean per patient total costs were $218,171 [standard error (SE) $5450] in the first year following MBC diagnosis and $412,903 (SE $13,034) cumulatively over 3 years following diagnosis (among patients with complete follow-up). Primary cost contributors were outpatient visits ($195,162; SE $8043) and HER2-targeted therapy drug costs ($177,489; SE $8120). CONCLUSIONS HER2+ MBC is associated with high short-term and medium-term direct healthcare costs. These could be alleviated with early diagnosis and optimal standard-of-care treatment for early breast cancer, which can significantly reduce the risk of recurrence.
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Baumgardner JR, Brauer MS, Zhang J, Hao Y, Liu Z, Lakdawalla DN. CAR-T therapy and historical trends in effectiveness and cost–effectiveness of oncology treatments. J Comp Eff Res 2020; 9:327-340. [DOI: 10.2217/cer-2019-0065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Aim: This study examines how chimeric antigen receptor T-cell (CAR-T) therapy’s incremental effectiveness and cost–effectiveness profile fits into the recent history of anticancer treatments. Materials & methods: We conducted graphical and multivariable analyses using data from the Cost–Effectiveness Analysis Registry of the Tufts Medical Center and the Institute for Clinical and Economic Review’s analysis of CAR-T therapies. We collected additional information including the US FDA approval years for pharmacologic innovations. Results: CAR-T provided 5.03 (95% CI: 3.88–6.18) more incremental quality-adjusted life-years than the average pharmaceutical intervention and 4.61 (95% CI: 1.67–7.56) more than the average nonpharmaceutical intervention, while retaining similar cost–effectiveness. There was evidence of worsening cost–effectiveness by approval year for pharmaceutical interventions. Limitations: Analysis is limited to anticancer treatments studied in cost–utility analyses, estimated to cover approximately 60% of FDA-approved antineoplastic agents. Conclusion: CAR-T therapy breaks a pattern of stagnant efficacy growth in pharmaceutical innovation and demonstrates significantly greater incremental effectiveness and similar cost–effectiveness to prior innovations.
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Affiliation(s)
| | | | - Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
| | - Yanni Hao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
| | - Zhimei Liu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
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17
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Hertler A, Chau S, Khetarpal R, Bassin E, Dang J, Koppel D, Damarla V, Wade J. Utilization of Clinical Pathways Can Reduce Drug Spend Within the Oncology Care Model. JCO Oncol Pract 2020; 16:e456-e463. [PMID: 32196401 PMCID: PMC7224689 DOI: 10.1200/jop.19.00753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Reducing drug spend is one of the greatest challenges for practices participating in the Oncology Care Model (OCM). Evidence-based clinical pathways have the potential to decrease drug spend while maintaining clinical outcomes consistent with published evidence. The goal of this study was to determine whether voluntary use of clinical pathways by a practice can maximize OCM episodic cost savings. METHODS AND MATERIALS: A community oncology practice used evidence-based clinical pathways for OCM-attributed patients. All treatment plans were submitted to the pathway vendor in real time for clinical pathway adherence measurement. Analysis was conducted before implementation and on an ongoing daily and weekly basis to identify cases in which higher cost drugs or regimens were ordered. A clinical data governance committee met biweekly to review clinical pathway performance metrics and drug utilization. RESULTS: From quarter 1 of 2017 to quarter 1 of 2019, the median drug spend increased less rapidly for Cancer Care Specialists of Illinois (CCSI; 18.6%) compared with OCM (34.4%). Furthermore, the percent difference in drug spend for CCSI relative to OCM decreased from 13.5% to 0.1% (P < .001). Each quarter, there was approximately a 1.7% decrease (95% CI, 1.0% to 2.4%) in drug spend for CCSI relative to OCM. Additional analyses found that, over a 15-month period (October 2017 through December 2019), CCSI achieved an increase in pathway adherence from 69% to 81%. CONCLUSION: Reduction in drug spend is possible within a value-based care model, using evidence-based clinical pathways.
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Affiliation(s)
| | | | | | | | | | | | | | - James Wade
- Cancer Care Specialists of Illinois, Decatur, IL
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18
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Chen AJ, Hu X, Conti RM, Jena AB, Goldman DP. Trends in the Price per Median and Mean Life-Year Gained Among Newly Approved Cancer Therapies 1995 to 2017. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1387-1395. [PMID: 31806195 PMCID: PMC7589784 DOI: 10.1016/j.jval.2019.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/22/2019] [Accepted: 08/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The prices of newly approved cancer drugs have risen over the past decades. A key policy question is whether the clinical gains offered by these drugs in treating specific cancer indications justify the price increases. OBJECTIVES To evaluate the price per median and mean life year gained among newly approved cancer therapies from 1995 to 2017. METHODS We collected data on the price (in 2017 USD) per life-year gained among cancer drug-indication pairs approved by the US Food and Drug Administration (FDA) between 1995 and 2017. We modeled trends using fractional polynomial and linear spline regression models that controlled for route of administration and cancer type fixed effects. RESULTS We found that between 1995 and 2012, price increases outstripped median survival gains, a finding consistent with previous literature. Nevertheless, price per mean life-year gained increased at a considerably slower rate, suggesting that new drugs have been more effective in achieving longer-term survival. Between 2013 and 2017, price increases reflected equally large gains in median and mean survival, resulting in a flat profile for benefit-adjusted launch prices in recent years. CONCLUSIONS Although drug costs have been rising more rapidly than median survival gains, they have been rising at about the same rate as mean survival gains. This suggests that when accounting for longer-term survival gains, the benefits of new drugs are roughly keeping pace with their costs, despite rapid cost growth.
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Affiliation(s)
- Alice J Chen
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Xiaohan Hu
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Rena M Conti
- Questrom School of Business, Boston University, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; National Bureau of Economic Research, Cambridge, MA, USA
| | - Dana P Goldman
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA; National Bureau of Economic Research, Cambridge, MA, USA
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Nogueira LM, Yabroff KR, Siegel RL, Jemal A. Data challenges for evaluating new treatments. Cancer 2019; 125:2528-2531. [PMID: 31095739 DOI: 10.1002/cncr.32157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/20/2019] [Accepted: 03/23/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Leticia M Nogueira
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Rebecca L Siegel
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
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20
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Pulte D, Weberpals J, Jansen L, Brenner H. Changes in population-level survival for advanced solid malignancies with new treatment options in the second decade of the 21st century. Cancer 2019; 125:2656-2665. [PMID: 31095726 DOI: 10.1002/cncr.32160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/13/2018] [Accepted: 12/11/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Several new treatments that improve survival in clinical trials have been developed for various solid malignancies in advanced stages. The effect of these options on survival in the general population is currently unknown. METHODS Cancers for which 2 or more new treatment options have been approved by the US Food and Drug Administration during the years 2009 through 2011 for the treatment of advanced disease were identified, including adenocarcinoma of the lung, melanoma, breast cancer, prostate cancer, and renal cell carcinoma. Kaplan-Meier analysis was used to compare overall survival for these conditions in the Surveillance, Epidemiology, and End Results database for the periods 2007 to 2008, 2009 to 2010, and 2011 to 2012. Hazard ratios derived from adjusted, shared frailty models for cancer-specific survival were calculated as well for the years of diagnosis (2007-2008, 2009-2010, and 2011-2012). RESULTS Two-year survival increased for patients with advanced-stage lung adenocarcinoma (+3.0 percentage points), melanoma (+3.4 percentage points), and breast cancer (+2.7 percentage points). When only patients aged 15 to 64 years were included, 2-year survival for those with melanoma increased by +6.7 percentage points. No change in survival was observed for renal cell carcinoma. Decreases in the hazard ratio for cancer-specific mortality were observed during the period 2011 to 2012 compared with 2007 to 2008 for lung adenocarcinoma, melanoma, and breast cancer. CONCLUSIONS Small increases in 2-year survival were observed between the periods 2007 to 2008 and 2011 to 2012 for lung adenocarcinoma, melanoma, and prostate cancer. Cancer-specific mortality decreased for each of these cancers among patients who were diagnosed between the periods 2007 to 2008 and 2011 to 2013. These findings suggest that newer treatment options are beginning to increase survival for stage IV cancers at the population level.
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Affiliation(s)
- Dianne Pulte
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Janick Weberpals
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg, Germany.,German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
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Segel JE, Schaefer EW, Raman JD, Hollenbeak CS. Association Between Hospitals' Risk-Adjusted Emergency Department Visits and Survival and Costs in Kidney Cancer Patients Undergoing Nephrectomy. Clin Genitourin Cancer 2019; 17:e650-e657. [PMID: 31000485 DOI: 10.1016/j.clgc.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/09/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To estimate the association between a hospital's risk-adjusted emergency department (ED) visit rate and its risk-adjusted mortality rate and costs among kidney cancer patients undergoing initial nephrectomy. PATIENTS AND METHODS Using 2007-2012 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we used logistic regression to model ED visit occurrence within 30 and 365 days for all kidney cancer patients receiving initial surgery. Our model controlled for demographics, stage, histology, systemic targeted therapy, and comorbidities. Based on model predictions, we created a ratio of actual versus predicted ED visits for hospitals to identify hospitals with higher and lower than predicted ED visit rates. We estimated the association between the hospitals' ED visit ratio and hospitals' risk-adjusted 365-day mortality rates, and 6- and 12-month total costs and total costs (less ED visits). RESULTS In our sample of 6078 patients, 15.5% had an ED visit within 30 days of surgery and 43.5% within 365 days. For hospitals with ≥ 11 patients, we found no statistically significant association between 30-day or 365-day risk-adjusted ED visit rate and their 365-day risk-adjusted mortality rate. Hospitals' 30-day ED visit rates were not significantly associated with either 6- or 12-month costs. However, hospitals' 365-day ED visit rates were significantly associated with 12-month costs, even when excluding the cost of the ED visit. CONCLUSION Our results suggest hospitals' risk-adjusted ED visit rates capture a qualitatively different measure of quality than the more commonly reported mortality rates. Longer term ED visit rates are significantly associated with increased costs while 30-day ED visits are not.
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Affiliation(s)
- Joel E Segel
- Department of Health Policy and Administration, Pennsylvania State University, University Park, PA; Penn State Cancer Institute, Hershey, PA; Department of Public Health Sciences, Pennsylvania State University, Hershey, PA.
| | - Eric W Schaefer
- Department of Public Health Sciences, Pennsylvania State University, Hershey, PA
| | - Jay D Raman
- Division of Urology, Penn State College of Medicine, Hershey, PA
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, Pennsylvania State University, University Park, PA; Department of Public Health Sciences, Pennsylvania State University, Hershey, PA; Department of Surgery, Penn State College of Medicine, Hershey, PA
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22
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Hochheiser L, Hornberger J, Turner M, Lyman GH. Multi-gene assays: effect on chemotherapy use, toxicity and cost in estrogen receptor-positive early stage breast cancer. J Comp Eff Res 2019; 8:289-304. [DOI: 10.2217/cer-2018-0137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Aim: To assess multi-gene assay (MGA) effects on chemotherapy use, toxicities, recurrences, and costs in estrogen receptor-positive early breast cancer. Methods: Meta-analysis performed using data from public databases. Results: Studies included 12,202 women. Relative to no testing, chemotherapy use was higher with 12-gene and 70-gene and lower with PAM50 (commercial) and 21-gene MGAs. Overall, 1643 distant recurrences occurred with no testing, declining by 231 (21-gene), 121 (70-gene), 54 (12-gene) and 94 (PAM50); only the 21-gene assay resulted in no risk of increasing the number of distant recurrences. Relative to ‘no testing’, total cost of care declined only with 21-gene MGA. Conclusion: MGAs differ in chemotherapy use and related outcomes for women with estrogen receptor-positive early breast cancer.
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Affiliation(s)
- Lou Hochheiser
- Professor Emeritus, Department of Family Practice, University of Vermont, Burlington, VT 83001, USA
| | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Center & The University of Washington, Seattle, WA 98109, USA
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Ramos-Peñafiel C, Olarte-Carrillo I, Cerón-Maldonado R, Rozen-Fuller E, Kassack-Ipiña JJ, Meléndez-Mier G, Collazo-Jaloma J, Martínez-Tovar A. Effect of metformin on the survival of patients with ALL who express high levels of the ABCB1 drug resistance gene. J Transl Med 2018; 16:245. [PMID: 30176891 PMCID: PMC6122769 DOI: 10.1186/s12967-018-1620-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/25/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In acute lymphoblastic leukemia (ALL), high ABCB1 gene expression has been associated with treatment resistance, which affects patient prognosis. Many preclinical reports and retrospective population studies have shown an anti-cancer effect of metformin. Therefore, the objective of this study was to assess the effect of metformin on the treatment regimen in patients with ALL who exhibited high levels of ABCB1 gene expression and to determine its impact on overall survival. METHODS A total of 102 patients with ALL were recruited; one group (n = 26) received metformin, and the other received chemotherapy (n = 76). Measurement of ABCB1 transcript expression was performed using qRT-PCR prior to treatment initiation. Survival analysis was performed using Kaplan-Meier curves. The impact of both the type of treatment and the level of expression on the response (remission or relapse) was analyzed by calculating the odds ratio. RESULTS The survival of patients with high ABCB1 expression was lower than those with low or absent ABCB1 gene expression (p = 0.030). In the individual analysis, we identified a benefit to adding metformin in the group of patients with high ABCB1 gene expression (p = 0.025). In the metformin user group, the drug acted as a protective factor against both therapeutic failure (odds ratio [OR] 0.07, 95% confidence interval [CI] 0.0037-1.53) and early relapse (OR 0.05, 95% CI 0.0028-1.153). CONCLUSION The combined use of metformin with chemotherapy is effective in patients with elevated levels of ABCB1 gene expression. Trial registration NCT 03118128: NCT.
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Affiliation(s)
- Christian Ramos-Peñafiel
- Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Irma Olarte-Carrillo
- Laboratorio de Biología Molecular, Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Rafael Cerón-Maldonado
- Laboratorio de Biología Molecular, Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Etta Rozen-Fuller
- Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Juan Julio Kassack-Ipiña
- Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Guillermo Meléndez-Mier
- Dirección de Investigación, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Juan Collazo-Jaloma
- Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México
| | - Adolfo Martínez-Tovar
- Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México. .,Laboratorio de Biología Molecular, Servicio de Hematología, Hospital General de México, "Dr. Eduardo Liceaga", Ciudad de México, México.
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Vyas A, Madhavan SS, Sambamoorthi U, Pan XL, Regier M, Hazard H, Kalidindi S. Healthcare Utilization and Costs During the Initial Phase of Care Among Elderly Women With Breast Cancer. J Natl Compr Canc Netw 2018; 15:1401-1409. [PMID: 29118232 DOI: 10.6004/jnccn.2017.0167] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/06/2017] [Indexed: 12/21/2022]
Abstract
Background: Understanding the patterns of healthcare utilization and costs during the initial phase of care (12 months after breast cancer [BC] diagnosis) in older women (aged ≥65 years) is crucial in the allocation of Medicare resources. The objective of this study was to determine healthcare utilization and costs during the initial phase of care in older, female, Medicare fee-for-service beneficiaries diagnosed with BC, and to determine the factors associated with higher costs. Methods: A retrospective observational study using the SEER-Medicare linked database was conducted in 69,307 women aged ≥66 years diagnosed with primary incident BC in 2003-2009 to determine healthcare utilization, average costs, and costs for specific services during the initial phase of care. Generalized linear model regression was conducted to identify the factors associated with higher costs in a multivariate framework. Results: A total of 96% of women were treated with surgery during the initial phase of BC care, whereas 21% and 54% underwent chemotherapy and radiotherapy, respectively. Costs during the initial phase of care totalled $28,075 in 2012 USD, comprising $13,344 for physician services and $7,456 for outpatient services. Factors associated with higher costs during the initial phase of care were younger age (66-69 years), African American race, higher household income, advanced stages of BC, initial BC treatment, higher number of primary care physician visits, and presence of comorbidities and/or a mental condition. Conclusions: The economic burden of BC is substantial during the initial phase of care. Physician and outpatient services accounted for the highest proportion of costs. Predisposing factors, need-related factors, healthcare use, and external environmental healthcare factors significantly predicted costs during the initial phase of care.
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Affiliation(s)
- Ami Vyas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
| | - S Suresh Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, West Virginia
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, West Virginia
| | | | - Michael Regier
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, West Virginia
| | - Hannah Hazard
- Department of Surgery, School of Medicine, Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, West Virginia
| | - Sita Kalidindi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, West Virginia
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Rotenstein LS, Dusetzina SB, Keating NL. Out-of-Pocket Spending Not Associated with Oral Oncolytic Survival Benefit. J Manag Care Spec Pharm 2018; 24:494-502. [PMID: 29799324 PMCID: PMC6052860 DOI: 10.18553/jmcp.2018.24.6.494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND With total and out-of-pocket spending for oral oncolytics rising, there is increased interest in choosing oncology treatments based on their clinical value relative to cost. OBJECTIVE To determine if out-of-pocket spending varied for higher versus lower benefit oral oncology drugs reimbursed by commercial insurers. METHODS This study was a retrospective analysis of commercial insurer prescription drug claims filed between 2007 and 2014 for 13 oral oncolytics approved before 2009. We calculated mean monthly out-of-pocket payment for each fill by patient. We then categorized oral oncolytics by their overall and progression-free survival benefits for each FDA-approved indication, using evidence from published studies. We assessed the relationship of survival benefit with mean monthly out-of-pocket payment, adjusting for demographic and plan characteristics. RESULTS Our population included 44,113 patients aged 18-65 years (mean 52.5 [SD 9.4]) with a cancer diagnosis who filled 731,354 prescriptions. The most commonly represented oncolytics were imatinib (37.4% of fills), lenalidomide (17.7% of fills), and dasatinib (10.0% of fills). Approximately 32.3% of fills were for drug-indication pairs with an overall survival benefit of 4+ years. In adjusted analyses, there was no clear pattern to suggest that out-of-pocket payments differed with drug indication-specific survival benefits. Drugs for indications providing > 0 to 1 year of overall survival benefit were significantly more likely to have a lower out-of-pocket payment versus those prescribed off-label, but there were no significant differences in out-of-pocket payments between drugs and associated indications in any other survival category versus drugs used off-label. CONCLUSIONS Out-of-pocket payments for oral oncolytics were not clearly related to indication-specific value in commercially insured patients. This finding suggests that despite increased attention to value- and indication-based drug pricing, cost sharing for oral oncolytics does not currently reflect these goals. DISCLOSURES This project was supported by Research Scholar Grant RSGI-14-030-01-CPHPS from the American Cancer Society; the NIH Building Interdisciplinary Research Careers in Women's Health (BIRCWH) K12 Program; the North Carolina Translational and Clinical Sciences Institute (UL1TR001111) Grant; and K24CA181510 from the National Cancer Institute. The authors have no disclosures. Data from this study were presented at the 2017 American Society for Clinical Oncology Annual Meeting on June 5, 2017, in Chicago, Illinois.
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Affiliation(s)
- Lisa S Rotenstein
- 1 Department of Health Care Policy, Harvard Medical School, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stacie B Dusetzina
- 2 Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy and Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Nancy L Keating
- 1 Department of Health Care Policy, Harvard Medical School, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Muldoon LD, Pelizzari PM, Lang KA, Vandigo J, Pyenson BS. Assessing Medicare’s Approach To Covering New Drugs In Bundled Payments For Oncology. Health Aff (Millwood) 2018; 37:743-750. [DOI: 10.1377/hlthaff.2017.1552] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- L. Daniel Muldoon
- L. Daniel Muldoon is a health care consultant at Milliman, Inc., in New York City
| | - Pamela M. Pelizzari
- Pamela M. Pelizzari is a senior health care consultant at Milliman, Inc., in New York City
| | - Kelsey A. Lang
- Kelsey A. Lang is deputy vice president for policy and research, Pharmaceutical Research and Manufacturers of America, in Washington, D.C
| | - Joe Vandigo
- Joe Vandigo is director for policy and research, Pharmaceutical Research and Manufacturers of America
| | - Bruce S. Pyenson
- Bruce S. Pyenson is a principal and consulting actuary at Milliman, Inc., in New York City, and a commissioner on the Medicare Payment Advisory Commission
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Liu W, Patil D, Howard DH, Moore RH, Wang H, Sanda MG, Filson CP. Adoption of Prebiopsy Magnetic Resonance Imaging for Men Undergoing Prostate Biopsy in the United States. Urology 2018; 117:57-63. [PMID: 29679601 DOI: 10.1016/j.urology.2018.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/28/2018] [Accepted: 04/05/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess adoption of prebiopsy prostate magnetic resonance imaging (MRI) in the United States and to evaluate factors associated with magnetic resonance imaging-guided prostate biopsy (MRI-Bx) use. Prior reports have shown improved cancer detection with MRI-Bx vs transrectal ultrasound-guided methods (transrectal ultrasound-guided biopsy [TRUS-Bx]). Population-based trends of their use and outcomes have not been previously characterized. MATERIALS AND METHODS Using private insurance claims (2009-2015), we identified men who underwent prostate biopsy. Exposures were biopsy year and geographic region defined by metropolitan statistical area. Outcomes included biopsy type (MRI-Bx, TRUS-Bx, or transperineal biopsy) based on procedure codes and cancer detection based on a new diagnosis for prostate cancer (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] 185). Hierarchical mixed-effects multivariable regression estimated odds of undergoing MRI-Bx. RESULTS We identified 241,681 men (mean age 57.5 ± 5.4 years) who underwent biopsy. The use of MRI-Bx rose rapidly (0.2% in 2009 to 6.5% in 2015, P <.001). Overall, 3429 men underwent MRI before biopsy, more commonly in metropolitan statistical areas (odds ratio 1.90, 95% confidence interval 1.66-2.19). In 2015, nearly 18% of men with prior negative biopsy underwent a prebiopsy MRI. Patients with prior negative biopsies were over 4 times more likely to use MRI guidance (vs no prior biopsies, odds ratio 4.63, 95% confidence interval 4.27-5.02) and had a greater chance of cancer detection with MRI-Bx (25.2%) vs TRUS-Bx (19.7%, P = .010). CONCLUSION Among men undergoing prostate biopsy, prebiopsy prostate MRI utilization was concentrated within urban areas and among patients with prior negative biopsies, where its use was associated with superior cancer detection compared with traditional TRUS-Bx.
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Affiliation(s)
- Wen Liu
- Emory University School of Medicine, Atlanta, GA; Rollins School of Public Health, Emory University, Atlanta, GA
| | - Dattatraya Patil
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - David H Howard
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Renee H Moore
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Heqiong Wang
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Martin G Sanda
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - Christopher P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, GA; Atlanta Veterans Administration Medical Center, Decatur, GA.
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Abstract
The economic burden of cancer on the national health expenditure is billions of dollars. The economic cost is measured on direct and indirect medical costs, which vary depending on stage at diagnosis, patient age, type of medical services, and site of service. Costs vary by region, physician behavior, and patient preferences. When analyzing the economic burden of survivors of colon cancer, we cannot forget the societal burden. Post-acute care and readmissions are major economic burdens. People with colon cancer have to be followed for their lifetime. Economic models are being studied to give cost-effective solutions to this problem.
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Affiliation(s)
- Guy R Orangio
- LSU Department of Surgery, 1542 Tulane Avenue, Suite 758, New Orleans, LA 70112, USA.
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Tannenbaum S, Soulos PR, Herrin J, Mougalian S, Long JB, Wang R, Ma X, Gross CP, Xu X. Regional Medicare Expenditures and Survival Among Older Women With Localized Breast Cancer. Med Care 2017; 55:1030-1038. [PMID: 29068906 PMCID: PMC5863278 DOI: 10.1097/mlr.0000000000000822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes. OBJECTIVES To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival. RESEARCH DESIGN A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients' HRR quintile and survival. SUBJECTS In total, 12,610 Medicare beneficiaries diagnosed with stage II-III breast cancer during 2005-2008 who underwent surgery. MEASURES Outcome measures for our analysis were 3- and 5-year overall survival. RESULTS Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients' 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results. CONCLUSIONS For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer-related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.
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Affiliation(s)
| | - Pamela R. Soulos
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Jeph Herrin
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Division of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Health Research & Educational Trust, Chicago, IL
| | - Sarah Mougalian
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jessica B. Long
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cary P. Gross
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Xiao Xu
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
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Awortwe C, Kaehler M, Rosenkranz B, Cascorbi I, Bruckmueller H. MicroRNA-655-3p regulates Echinacea purpurea mediated activation of ABCG2. Xenobiotica 2017; 48:1050-1058. [PMID: 28990842 DOI: 10.1080/00498254.2017.1390624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1. The aim of this study was to investigate the regulatory effect of Echinacea purpurea (EP) on efflux transporters ABCB1 and ABCG2 and to identify specific microRNAs contributing to their post-transcriptional regulation. 2. ABCB1 and ABCG2 levels were assessed in human hepatoblastoma HepG2 cells treated with 50 µg/mL methanolic extract of commercial EP capsules for different durations. The microRNA expression profile of HepG2 cells after EP treatment was evaluated and in silico target prediction was subsequently conducted to identify specific microRNAs with binding sites in the 3'-UTR of ABCB1 and ABCG2. Luciferase reporter gene assays and site-directed mutagenesis were used to confirm the binding site of identified microRNA within the 3'-UTR of the target gene. 3. EP increased ABCB1 (10-fold ± 3.4, p < 0.001) and ABCG2 (2.7-fold ± 0.5, p < 0.01) mRNA levels after 12 h exposure. Twenty-four microRNAs showed significant expression differences at all durations of exposure to EP. MiR-655-3p showed a 6.79-fold decrease in expression after 12 h exposure compared to 0 h, was predicted in silico to bind ABCG2 3'-UTR and showed a significant negative correlation (p = 0.01) to ABCG2 expression level. The binding of miR-655-3p to ABCG2 3'-UTR was confirmed by reporter gene assays (reduction of reporter gene activity to 60%; p = 0.0001). 4. These results suggest that EP regulates ABCG2 expression via downregulation of miR-655-3p in the liver cells. Thus, miR-655-3p downregulation could be applied to predict EP mediated drug interactions.
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Affiliation(s)
- Charles Awortwe
- a Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, University of Stellenbosch , Tygerberg , South Africa.,b Institute for Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein , Kiel , Germany , and.,c Biomedical Research and Innovation Platform, South African Medical Research Council , Tygerberg , South Africa
| | - Meike Kaehler
- b Institute for Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein , Kiel , Germany , and
| | - Bernd Rosenkranz
- a Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, University of Stellenbosch , Tygerberg , South Africa
| | - Ingolf Cascorbi
- b Institute for Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein , Kiel , Germany , and
| | - Henrike Bruckmueller
- b Institute for Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein , Kiel , Germany , and
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van der Gronde T, Uyl-de Groot CA, Pieters T. Addressing the challenge of high-priced prescription drugs in the era of precision medicine: A systematic review of drug life cycles, therapeutic drug markets and regulatory frameworks. PLoS One 2017; 12:e0182613. [PMID: 28813502 PMCID: PMC5559086 DOI: 10.1371/journal.pone.0182613] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
CONTEXT Recent public outcry has highlighted the rising cost of prescription drugs worldwide, which in several disease areas outpaces other health care expenditures and results in a suboptimal global availability of essential medicines. METHOD A systematic review of Pubmed, the Financial Times, the New York Times, the Wall Street Journal and the Guardian was performed to identify articles related to the pricing of medicines. FINDINGS Changes in drug life cycles have dramatically affected patent medicine markets, which have long been considered a self-evident and self-sustainable source of income for highly profitable drug companies. Market failure in combination with high merger and acquisition activity in the sector have allowed price increases for even off-patent drugs. With market interventions and the introduction of QALY measures in health care, governments have tried to influence drug prices, but often encounter unintended consequences. Patent reform legislation, reference pricing, outcome-based pricing and incentivizing physicians and pharmacists to prescribe low-cost drugs are among the most promising short-term policy options. Due to the lack of systematic research on the effectiveness of policy measures, an increasing number of ad hoc decisions have been made with counterproductive effects on the availability of essential drugs. Future challenges demand new policies, for which recommendations are offered. CONCLUSION A fertile ground for high-priced drugs has been created by changes in drug life-cycle dynamics, the unintended effects of patent legislation, government policy measures and orphan drug programs. There is an urgent need for regulatory reform to curtail prices and safeguard equitable access to innovative medicines.
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Affiliation(s)
- Toon van der Gronde
- Department of Pharmaceutical Sciences, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Carin A. Uyl-de Groot
- Institute for Medical Technology Assessment, Department of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Toine Pieters
- Department of Pharmaceutical Sciences, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
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Taylor D. The reality of economics for oncologists. Breast 2017; 33:183-190. [DOI: 10.1016/j.breast.2017.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/15/2017] [Accepted: 03/27/2017] [Indexed: 11/15/2022] Open
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Jackman DM, Zhang Y, Dalby C, Nguyen T, Nagle J, Lydon CA, Rabin MS, McNiff KK, Fraile B, Jacobson JO. Cost and Survival Analysis Before and After Implementation of Dana-Farber Clinical Pathways for Patients With Stage IV Non-Small-Cell Lung Cancer. J Oncol Pract 2017; 13:e346-e352. [PMID: 28260402 DOI: 10.1200/jop.2017.021741] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Increasing costs and medical complexity are significant challenges in modern oncology. We explored the use of clinical pathways to support clinical decision making and manage resources prospectively across our network. MATERIALS AND METHODS We created customized lung cancer pathways and partnered with a commercial vendor to provide a Web-based platform for real-time decision support and post-treatment data aggregation. Dana-Farber Cancer Institute (DFCI) Pathways for non-small cell lung cancer (NSCLC) were introduced in January 2014. We identified all DFCI patients who were diagnosed and treated for stage IV NSCLC in 2012 (before pathways) and 2014 (after pathways). Costs of care were determined for 1 year from the time of diagnosis. RESULTS Pre- and postpathway cohorts included 160 and 210 patients with stage IV NSCLC, respectively. The prepathway group had more women but was otherwise similarly matched for demographic and tumor characteristics. The total 12-month cost of care (adjusted for age, sex, race, distance to DFCI, clinical trial enrollment, and EGFR and ALK status) demonstrated a $15,013 savings after the implementation of pathways ($67,050 before pathways v $52,037 after pathways). Antineoplastics were the largest source of cost savings. Clinical outcomes were not compromised, with similar median overall survival times (10.7 months before v 11.2 months after pathways; P = .08). CONCLUSION After introduction of a clinical pathway in metastatic NSCLC, cost of care decreased significantly, with no compromise in survival. In an era where comparative outcomes analysis and value assessment are increasingly important, the implementation of clinical pathways may provide a means to coalesce and disseminate institutional expertise and track and learn from care decisions.
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Affiliation(s)
| | | | | | - Tom Nguyen
- Dana-Farber Cancer Institute, Boston, MA
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