Redefining adjuvant chemotherapy in patients with stage III colon cancer: X-ACT trial

Pharmacoeconomics Evaluations of Oral Anticancer Agents: Systematic Review of Characteristics, Methodological Trends, and Reporting Quality

OBJECTIVES

To review literature characteristics, describe methodological trends, and assess the reporting quality of the economic evaluations of oral anticancer drugs (OACDs).

METHODS

The review included comparative economic evaluations of OACDs. The search was conducted via PubMed, Embase, EconLit, and Economic Evaluation Database, and studies till December 2017 were included. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, literature inclusion and data extraction were performed in duplicate by separate investigators. Outcome measures were literature characteristics, gaps and methodological trends, and reporting quality using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data were summarized on the basis of methodological themes of interest. Descriptive statistics and tabulations were used for result presentation.

RESULTS

Out of 241 found articles, 21 were included. There is a recent increasing interest in the economics of OACDs, whereby the cost per quality-adjusted life-year, via cost-utility analysis, is the most used for decision making. Most of the studies were from the payer perspective, and the primary sources of data were clinical trials, expert panels, and medical charts. The dominance status (higher effect, lower cost) was a commonly reported outcome. Decision-analytic modeling was used in most of the studies, mostly including Markov modeling. Studies were highly heterogeneous in methodological aspects, and the included studies did not meet most of the reporting quality criteria.

CONCLUSIONS

High heterogeneity in methods in studies may limit the robustness and transferability of results, potentially misleading decision makers toward wrong decisions on OACDs. The transferability and generalizability of results are further limited by a "less than ideal" adherence to current reporting standards.

The value of oxaliplatin in the systemic treatment of locally advanced rectal cancer

BACKGROUND

To evaluate, in a context of innovative multidisciplinary clinical practice, the efficacy of oxaliplatin in adjuvant administration (chemotherapy, CT) in relation to the total administered dose, in terms of prognosis with other clinical and therapeutic factors, in the heterogeneous model of locally advanced rectal cancer (LARC), which is characterized by a risk pattern of dominant systemic progression.

METHODS

Observational-analytical, retrospective, unicentric, non-randomized study of two cohorts of patients receiving FOLFOX-4 induction CT in neoadjuvancy, radiochemotherapy and surgery, differing in that one cohort did not receive any adjuvant post-surgical treatment and the other one received adjuvant CT with FOLFOX-4 cycles. A total of 212 patients from the Radiotherapy Oncology Service at the University Hospital Gregorio Marañon were studied: the neoadjuvant CT treatment group with oxaliplatin consisted of 110 patients and adjuvant CT treatment group with oxaliplatin consisted of 102 patients. The median follow-up time for the whole study population was 72 months (6 years).

RESULTS

The sociodemographic, clinical and diagnostic characteristics were very similar in both cohorts of patients, but with a pattern of therapeutic selection towards elements of adversity in pathological post-neoadjuvant staging. The dose of oxaliplatin in adjuvance (postoperative) superior to 6 cycles was positively associated with the locoregional control (LRC) at 5 years (P=0.012) and with the overall survival (OS) (P=0.048) at 5 years. In the responders to neoadjuvance with oxaliplatin [patients with tumor regression grade (TRG 3-4)], the dose of oxaliplatin greater than 5 cycles in adjuvance (postoperative) was positively associated with OS (P=0.06). And the dose of oxaliplatin in the range of 4-5 cycles in adjuvance (postoperative) was positively associated with distant metastasis-free survival (DMFS) and disease-free survival (DFS) in the cohort of responding patients (P=0.015 and 0.004, respectively).

CONCLUSIONS

The contribution of adjuvant oxaliplatin in the oncological evolution shows a favorable effect of LRC, DMFS, DFS and OS in the subgroups of patients that exhibit elements of response to neoadjuvant oxaliplatin (categories TRG 3-4, and pN0, downstaging T, downstaging N). Therefore, this neoadjuvant response profile with oxaliplatin, measured with highly reliable methodology (validated microscopic pathological response scales), defines a population of oxaliplatin-sensitive patients who benefits significantly from the administration of adjuvant oxaliplatin in sufficient cumulative doses (more of 5 cycles).

Neoadjuvant 5-FU or Capecitabine Plus Radiation With or Without Oxaliplatin in Rectal Cancer Patients: A Phase III Randomized Clinical Trial

BACKGROUND

National Surgical Adjuvant Breast and Bowel Project R-04 was designed to determine whether the oral fluoropyrimidine capecitabine could be substituted for continuous infusion 5-FU in the curative setting of stage II/III rectal cancer during neoadjuvant radiation therapy and whether the addition of oxaliplatin could further enhance the activity of fluoropyrimidine-sensitized radiation.

METHODS

Patients with clinical stage II or III rectal cancer undergoing preoperative radiation were randomly assigned to one of four chemotherapy regimens in a 2x2 design: CVI 5-FU or oral capecitabine with or without oxaliplatin. The primary endpoint was local-regional tumor control. Time-to-event endpoint distributions were estimated using the Kaplan-Meier method. Hazard ratios were estimated from Cox proportional hazard models. All statistical tests were two-sided.

RESULTS

Among 1608 randomized patients there were no statistically significant differences between regimens using 5-FU vs capecitabine in three-year local-regional tumor event rates (11.2% vs 11.8%), 5-year DFS (66.4% vs 67.7%), or 5-year OS (79.9% vs 80.8%); or for oxaliplatin vs no oxaliplatin for the three endpoints of local-regional events, DFS, and OS (11.2% vs 12.1%, 69.2% vs 64.2%, and 81.3% vs 79.0%). The addition of oxaliplatin was associated with statistically significantly more overall and grade 3-4 diarrhea (P < .0001). Three-year rates of local-regional recurrence among patients who underwent R0 resection ranged from 3.1 to 5.1% depending on the study arm.

CONCLUSIONS

Continuous infusion 5-FU produced outcomes for local-regional control, DFS, and OS similar to those obtained with oral capecitabine combined with radiation. This study establishes capecitabine as a standard of care in the pre-operative rectal setting. Oxaliplatin did not improve the local-regional failure rate, DFS, or OS for any patient risk group but did add considerable toxicity.

A path for diagnosis and therapy of colon cancer: a continuous quality improvement

OBJECTIVE

Prognosis of colorectal cancer strongly depends on stage at diagnosis, which can be cured in most cases at an early stage. The results were supported by different screening programmes. Few data concerning analysis of different phases of Colorectal Cancer Program were reported in literature. The aim of this study is to analyze "step by step", from a longitudinal type, the Colorectal Cancer Program, active at our Institution, verifying compliance with standards of care.

METHODS

We compared two different populations during the same period: patients referring to our Clinical Oncology Unit coming from Regional Colorectal Cancer Screening Program and the other population that was not in any Colorectal Cancer Program.

RESULTS

Considering patients from the Regional Colorectal Cancer Screening Program (19 patients, corresponding to 24.0% of the general case study), 3 (15.8%) were deceased and 16 (84.2%) were alive without evidence of the disease (NED). Concerning patients that are not coming from Regional Colorectal Cancer Screening Program (61 patients, corresponding to 76.0% of the general case study), 9 (14.8%) were deceased, 43 (70.5%) were NED, 8 (13.1%) were alive with metastases and 1 (1.6%) was lost during follow-up (PFU).

CONCLUSIONS

On the basis of this experience, we concluded for high-quality care for both populations. Any critical point should be carefully analyzed in order to implement quality of care.

At cancer diagnosis: a 'window of opportunity' for behavioural change towards physical activity. A randomised feasibility study in patients with colon and breast cancer

INTRODUCTION

Challenges exist in identifying, recruiting and motivating sedentary patients with cancer to initiate physical activity towards recommended levels. We hypothesise that the onset period of adjuvant chemotherapy can be 'the open window of opportunity' to identify and motivate sedentary patients with breast and colon cancers, at risk for developing coronary heart disease, to initiate and sustain lifestyle changes.

AIMS

To investigate the feasibility of oncologists/nurses screening for physical inactivity, in order to identify and recruit an at-risk population of sedentary patients with breast or colon cancer at the onset of adjuvant chemotherapy. Furthermore, the study will examine the adherence to one of two multimodal exercise interventions lasting 12 weeks; (1) hospital-based, high intensity, group exercise intervention (2) home-based, low intensity, individual, pedometer intervention. Both arms will be compared with a control group.

METHODS AND ANALYSES

All newly referred patients will be screened for sedentary behaviour, using national recommendations. Testing at baseline, 6, 12 and 39 weeks will include; (1) physiological testing (VO2-peak, one repetition maximum muscle strength and lung function (2) fasting full body dual-energy X-ray absorptiometry scan (3) fasting blood glucose, insulin, lipids and cholesterols, (4) psychometric questionnaires (general well-being, quality of life, anxiety and depression, motivational readiness). The randomised controlled trial feasibility design is selected in order to examine barriers for recruitment, programme adherence, safety aspects and potential efficacy to the interventions during adjuvant chemotherapy.

ETHICS AND DISSEMINATION

The Scientific Committee of the Capital Region (case No. H-1-2011-131) and the Danish Data Protection Agency (j. No. 2011-41-6349) approved the study. Data will be entered and locked into a database hosted by the Copenhagen Trial Unit, Rigshosptialet. Data will be available for analyses to project members and the trial statistician after the 45 included patients have completed the 12-week test. Results will be published in peer-reviewed scientific journals.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24901641.

XELOX versus FOLFOX6 as an adjuvant treatment in colorectal cancer: an economic analysis

OBJECTIVES

An economic analysis (based on interim data from a long-term, randomised, multi-centre, controlled, clinical trial) to evaluate chemotherapy with XELOX (capecitabine/oxaliplatin) versus FOLFOX6 (5Fluorouracil/leucovorin/oxaliplatin) as an adjuvant treatment for high risk colorectal cancer patients in Greece.

METHODS

As survival rate was the same in the two arms, a cost-minimisation analysis was carried out, from the perspectives of the National Health Service (NHS), Social Insurance Funds (SIF) and patients in Greece. Patient data were combined with 2008 unit prices to estimate the total cost of patient care, the patients' travelling expenditure and their productivity losses. Raw data were bootstrapped 5000 times in order to allow statistical testing.

RESULTS

From an NHS perspective, the mean chemotherapy cost was 8762 euro with FOLFOX6 and 9713 euro with XELOX; costs of administration and hospitalisations were 5154 euro and 1050 euro, respectively. Total treatment cost with FOLFOX6 reached 17,480 euro and with XELOX 12 525 euro, a difference of 4955 euro (p < 0.001) in favour of the latter therapy. From an SIF perspective, the total cost of treatment was 16,240 euro with FOLFOX6 and 12,617 euro with XELOX, a reduction of 3623 euro (p < 0.001) with the latter therapy. Mean patient travelling cost was 184 euro with FOLFOX6 and 80 euro with XELOX, a difference of 104 euro (p < 0.001). Mean productivity loss was 100 euro with FOLFOX6 and 31 euro with XELOX, a difference of 69 euro (p < 0.001).

CONCLUSIONS

Chemotherapy combining oral capecitabine and oxaliplatin reduces total treatment cost for the Greek National Health Service and Social Insurance Funds, mainly through a reduction in the cost of administration. From patients' perspective, it reduces travelling expenditure and productivity losses. Therefore, this combination may be a cost-effective approach for the management of colorectal cancer patients who have had surgery in Greece. This is an analysis alongside a clinical trial, and should be interpreted in this specific context in which it was undertaken.