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Lemmon CA, Zhou J, Hobbs B, Pennell NA. Modeling Costs and Life-Years Gained by Population-Wide Next-Generation Sequencing or Single-Gene Testing in Nonsquamous Non-Small-Cell Lung Cancer in the United States. JCO Precis Oncol 2023; 7:e2200294. [PMID: 36634300 PMCID: PMC9928881 DOI: 10.1200/po.22.00294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Many patients with actionable driver oncogenes (ADOs) are never identified and thus never receive targeted treatment. This study evaluated the economic impact and the potential life-years gained (LYG) that can be attributed to the extent of next-generation sequencing (NGS) testing in the United States compared with single-gene testing (SGT) in patients with metastatic nonsquamous non-small-cell lung cancer in the United States. METHODS A model was developed to evaluate incremental rates of SGT or NSG testing on the basis of LYG and cost per LYG. ADOs included for NGS included EGFR, ALK, ROS1, BRAF, RET, MET, and NTRK. SGT included EGFR and ALK. Assumptions were made for expected incidence of ADOs. Survival distributions were fit to published trial averages of median and 5-year overall survival. Treatment costs were estimated from drug cost averages. Reimbursement costs were based on data from the Center for Medicare and Medicaid Services. RESULTS Each incremental 10% increase in NGS testing produces an average of 2,627.4 additional LYG, with an average cost savings per LYG of $75 US dollars (USD). Replacing SGT at the current rate of 80% with NGS testing would result in an average additional 21,09.6 LYG and reduce cost per LYG by an average of $599 USD. If 100% of eligible patients were tested with NGS and each identified patient had matched treatment, the total average cost per LYG would be $16,641.57 USD. CONCLUSION On the basis of current evidence, population-level simulations demonstrate that clinically relevant gains in survival with non-negligible reduction in costs are obtainable from widespread adoption of NGS testing and appropriate treatment matching for patients with advanced nonsquamous non-small-cell lung cancer.
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Affiliation(s)
- Christopher A. Lemmon
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH,Present address: University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Hematology and Oncology, Cincinnati, OH,Christopher A. Lemmon, MD, University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Hematology and Oncology, Vontz Center, 3109 Eden Ave, Room 1330, Cincinnati, OH 45219; e-mail:
| | - Jie Zhou
- Cleveland Clinic Lerner Research Institute, Department of Quantitative Health Sciences, Cleveland, OH,Present address: Department of Neuroscience, Novartis, Cambridge, MA
| | - Brian Hobbs
- Cleveland Clinic Lerner Research Institute, Department of Quantitative Health Sciences, Cleveland, OH,Present address: Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Nathan A. Pennell
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Bosserman LD, Mambetsariev I, Ladbury C, Barzi A, Johnson D, Morse D, Deaville D, Smith W, Rajurkar S, Merla A, Hajjar G, Kim D, Fricke J, Trisal V, Salgia R. Pyramidal Decision Support Framework Leverages Subspecialty Expertise across Enterprise to Achieve Superior Cancer Outcomes and Personalized, Precision Care Plans. J Clin Med 2022; 11:jcm11226738. [PMID: 36431215 PMCID: PMC9697355 DOI: 10.3390/jcm11226738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
The complexity of cancer care requires integrated and continuous support to deliver appropriate care. An expert network with complementary expertise and the capability of multidisciplinary care is an integral part of contemporary oncology care. Appropriate infrastructure is necessary to empower this network to deliver personalized precision care to their patients. Providing decision support as cancer care becomes exponentially more complex with new diagnostic and therapeutic choices remains challenging. City of Hope has developed a Pyramidal Decision Support Framework to address these challenges, which were exacerbated by the COVID pandemic, health plan restrictions, and growing geographic site diversity. Optimizing efficient and targeted decision support backed by multidisciplinary cancer expertise can improve individual patient treatment plans to achieve improved care and survival wherever patients are treated.
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Affiliation(s)
- Linda D. Bosserman
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
| | - Afsaneh Barzi
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Deron Johnson
- Department of Clinical Informatics, City of Hope, Duarte, CA 91010, USA
| | - Denise Morse
- Department of Quality, Risk and Regulatory Management, City of Hope, Duarte, CA 91010, USA
| | - Debbie Deaville
- Department of Enterprise Business Intelligence, City of Hope, Irwindale, CA 91706, USA
| | - Wade Smith
- Department of Medical Oncology and Therapeutics Research, City of Hope, Newport Beach, CA 92660, USA
| | - Swapnil Rajurkar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Upland, CA 91784, USA
| | - Amartej Merla
- Department of Medical Oncology and Therapeutics Research, City of Hope, Antelope Valley, CA 93534, USA
| | - George Hajjar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Mission Hills, CA 91345, USA
| | - Daniel Kim
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Vijay Trisal
- Department of Medicine, City of Hope, Duarte, CA 91010, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
- Correspondence:
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Dickson NR, Beauchamp KD, Perry TS, Roush A, Goldschmidt D, Edwards ML, Blakely LJ. Impact of clinical pathways on treatment patterns and outcomes for patients with non-small-cell lung cancer: real-world evidence from a community oncology practice. J Comp Eff Res 2022; 11:609-619. [PMID: 35546311 DOI: 10.2217/cer-2021-0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The evolving treatment landscape for non-small-cell lung cancer (NSCLC) and complexities of regulations and reimbursement present challenges to community oncologists. Clinical pathways are tools to optimize care, but information on their value in the real world is limited. This retrospective study assessed treatment patterns and clinical outcomes in patients with Stage I-III NSCLC pre- and post-pathways implementation at Tennessee Oncology, a large, community-based oncology practice in the USA. Methods & Materials: Chart data were abstracted for adults diagnosed with Stage I-III NSCLC who received systemic treatment. Patients were divided into pre-pathways (treatment initiation 2014-2015) and post-pathways (treatment initiation 2016-2018) cohorts. Patient characteristics, treatment patterns and outcomes were summarized descriptively. Kaplan-Meier curves were used to assess time-dependent outcomes, and log-rank test was used to compare the cohorts. Results: 291 patients were included (Stage I-II: 38 pre-pathways, 55 post-pathways; Stage III: 105 pre-pathways, 93 post-pathways). Duration on first-line (1L) therapy was similar for Stage I-II patients pre- and post-pathways (median 1.9 months vs 2.1 months; p = 0.75), but increased for Stage III patients post-pathways (2.1 months vs 1.4 months pre-pathways; p < 0.01). Achievement of a complete or partial response with 1L therapy was similar post-pathways among Stage I-Stage -IIII patients (60.0% vs 55.2% pre-pathways), but increased for Stage III patients (56.0% vs 35.2% pre-pathways). Conclusion: Given that improvements in rates of treatment response post-pathways occurred only for patients diagnosed with Stage III NSCLC, among whom immunotherapy uptake increased post-pathways, such improvements may be attributable to evolving practices in cancer care, including advances in treatment and care delivery, rather than clinical pathways implementation. Further research is warranted to assess the impact of clinical pathways in the current treatment era, given that immunotherapy has now become the standard of care in NSCLC.
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Robert NJ, Espirito JL, Chen L, Nwokeji E, Karhade M, Evangelist M, Spira A, Neubauer M, Bullock S, Walberg J, Cheng SK, Coleman RL. Biomarker testing and tissue journey among patients with metastatic non-small cell lung cancer receiving first-line therapy in The US Oncology Network Biomarker testing in metastatic NSCLC with first-line therapy. Lung Cancer 2022; 166:197-204. [DOI: 10.1016/j.lungcan.2022.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022]
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Mileham KF, Schenkel C, Bruinooge SS, Freeman‐Daily J, Basu Roy U, Moore A, Smith RA, Garrett‐Mayer E, Rosenthal L, Garon EB, Johnson BE, Osarogiagbon RU, Jalal S, Virani S, Weber Redman M, Silvestri GA. Defining comprehensive biomarker-related testing and treatment practices for advanced non-small-cell lung cancer: Results of a survey of U.S. oncologists. Cancer Med 2022; 11:530-538. [PMID: 34921524 PMCID: PMC8729042 DOI: 10.1002/cam4.4459] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND An ASCO taskforce comprised of representatives of oncology clinicians, the American Cancer Society National Lung Cancer Roundtable (NLCRT), LUNGevity, the GO2 Foundation for Lung Cancer, and the ROS1ders sought to: characterize U.S. oncologists' biomarker ordering and treatment practices for advanced non-small-cell lung cancer (NSCLC); ascertain barriers to biomarker testing; and understand the impact of delays on treatment decisions. METHODS We deployed a survey to 2374 ASCO members, targeting U.S. thoracic and general oncologists. RESULTS We analyzed 170 eligible responses. For non-squamous NSCLC, 97% of respondents reported ordering tests for EGFR, ALK, ROS1, and BRAF. Testing for MET, RET, and NTRK was reported to be higher among academic versus community providers and higher among thoracic oncologists than generalists. Most respondents considered 1 (46%) or 2 weeks (52%) an acceptable turnaround time, yet 37% usually waited three or more weeks to receive results. Respondents who waited ≥3 weeks were more likely to defer treatment until results were reviewed (63%). Community and generalist respondents who waited ≥3 weeks were more likely to initiate non-targeted treatment while awaiting results. Respondents <5 years out of training were more likely to cite their concerns about waiting for results as a reason for not ordering biomarker testing (42%, vs. 19% with ≥6 years of experience). CONCLUSIONS Respondents reported high biomarker testing rates in patients with NSCLC. Treatment decisions were impacted by test turnaround time and associated with practice setting and physician specialization and experience.
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Affiliation(s)
| | | | | | | | | | - Amy Moore
- LUNGevity FoundationChicagoIllinoisUSA
| | - Robert A. Smith
- American Cancer Society National Lung Cancer RoundtableAtlantaGeorgiaUSA
| | | | - Lauren Rosenthal
- American Cancer Society National Lung Cancer RoundtableAtlantaGeorgiaUSA
| | - Edward B. Garon
- University of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
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Winfree KB, Sheffield KM, Cui ZL, Sugihara T, Feliciano J. Study of patient characteristics, treatment patterns, EGFR testing patterns and outcomes in real-world patients with EGFRm + non-small cell lung cancer. Curr Med Res Opin 2022; 38:91-99. [PMID: 34544302 DOI: 10.1080/03007995.2021.1983530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This retrospective, observational study examined patient characteristics, treatment patterns, testing patterns, and outcomes of US patients receiving first-/second- or third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). METHODS This study used an electronic health record-derived de-identified database. Eligible patients had advanced EGFRm+ non-small cell lung cancer. Descriptive statistics were used to describe demographic, clinical, and treatment characteristics. Logistic regression models were used to identify patient characteristics that were associated with the use of osimertinib vs. a first-/second-generation EGFR TKI. Kaplan-Meier methods were used for survival analysis. RESULTS Of the 782 patients who received first-line (1L) therapy with first-/second-generation EGFR TKIs in cohort A, erlotinib was the most common (58%), and osimertinib was the most widely prescribed second-line (2L) therapy (52%). Of the patients who received 1L therapy with osimertinib, a greater range of treatments were prescribed in 2L. A third of patients treated with first-/second-generation EGFR TKIs underwent EGFR testing near the end of 1L, and 44% of these patients had T790M positive disease. The median time on targeted therapy (TTT) of the cohort was 11.1 months (95% confidence interval [CI] 9.7, 12.3), and the median overall survival from the start of 1L therapy was 23.5 months (95% CI 20.7, 24.8). CONCLUSIONS The majority of patients treated with first-/second-generation EGFR TKIs went on to receive osimertinib in the 2L setting, but overall, only a third of patients had received molecular testing at progression. Improved testing frequency is vital to inform treatment decisions.
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John A, Yang B, Shah R. Clinical Impact of Adherence to NCCN Guidelines for Biomarker Testing and First-Line Treatment in Advanced Non-Small Cell Lung Cancer (aNSCLC) Using Real-World Electronic Health Record Data. Adv Ther 2021; 38:1552-1566. [PMID: 33537872 PMCID: PMC7932942 DOI: 10.1007/s12325-020-01617-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Although clinical guidelines are broadly available, the relationship between adherence and outcomes is not well studied. This study aimed to assess the association between adherence to National Comprehensive Cancer Network (NCCN) guidelines and clinical outcomes for adult patients with advanced non-small-cell lung cancer (aNSCLC). METHODS This was a retrospective cohort study of adult patients with aNSCLC (stages IIIB, IIIC, and IV) from a de-identified real-world database. The objective was accomplished in a two-step analysis process. We first assessed adherence to NCCN recommendations for biomarker testing and overall survival (OS). Next, we assessed adherence to NCCN-recommended first-line therapy and time to treatment discontinuation (TTD). Multivariable Cox regression analyses were conducted to evaluate the association between guideline adherence and patient outcomes. Kaplan-Meier analyses were used to assess median OS and TTD. RESULTS A total of 28,784 patients with a diagnosis for aNSCLC between January 1, 2011 and July 31, 2019 met the inclusion criteria for the analysis of NCCN-recommended biomarker testing adherence. Two-thirds of these patients (n = 19,787) had evidence of biomarker testing (adherent). Multivariable Cox models found that testing-adherent patients had a significantly lower risk of mortality [hazard ratio (HR) = 0.89, 95% confidence interval (CI) 0.86, 0.92; p < 0.01]. Median OS was modestly longer in the testing-adherent group compared to the testing-non-adherent group (15.4 vs. 14.2 months; p < 0.01). For the first-line therapy analysis, 15,898 patients met the inclusion criteria, of which 69.9% had evidence of appropriate first-line therapy (first-line-adherent). The multivariable Cox model found that adherent patients had significantly lower risk of treatment discontinuation versus non-adherent patients (HR = 0.60, 95% CI 0.57, 0.62; p < 0.01). First-line-adherent patients had a modest, yet significantly longer median TTD compared to first-line-non-adherent patients (3.45 vs. 2.40 months; p < 0.01). CONCLUSIONS Improved clinical outcomes were observed in patients who were adherent to NCCN-recommended biomarker testing and first-line therapy. This study demonstrated the value of following NCCN guideline recommendations and the need to prioritize timely access to biomarker testing and individualized treatment.
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Affiliation(s)
- Ani John
- Roche Diagnostics, Santa Clara, CA, USA.
| | | | - Roma Shah
- Roche Diagnostics, Santa Clara, CA, USA
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VanderLaan PA, Roy-Chowdhuri S. Current and future trends in non-small cell lung cancer biomarker testing: The American experience. Cancer Cytopathol 2021; 128:629-636. [PMID: 32885913 DOI: 10.1002/cncy.22313] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/04/2020] [Accepted: 05/29/2020] [Indexed: 12/11/2022]
Abstract
Biomarker testing in patients with advanced stage non-small cell lung cancer provides essential information that can be used to select the most appropriate therapy. The regular updates of guideline recommendations reflect the growing number of biomarkers that must be assessed, and as such signal the shift from single-gene assays to more comprehensive genomic profiling using next-generation sequencing modalities. Cytology and small biopsy specimens have proven to be more than adequate substrates for these types of ancillary molecular testing; however, other alternative testing substrates are beginning to emerge. These include so-called liquid biopsies as well the supernatant fluid from cytology specimens, both of which have demonstrated promise for use in the clinical realm. This review will briefly cover the current state of non-small cell lung cancer biomarker testing in the United States, with a focus on these novel nonconventional substrates that are increasingly being incorporated into testing paradigms.
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Affiliation(s)
- Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sinchita Roy-Chowdhuri
- Division of Pathology and Laboratory Medicine, Department of Anatomic Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Griesinger F, Eberhardt W, Nusch A, Reiser M, Zahn MO, Maintz C, Bernhardt C, Losem C, Stenzinger A, Heukamp LC, Büttner R, Marschner N, Jänicke M, Fleitz A, Spring L, Sahlmann J, Karatas A, Hipper A, Weichert W, Heilmann M, Sadjadian P, Gleiber W, Grah C, Waller CF, Reck M, Rittmeyer A, Christopoulos P, Sebastian M, Thomas M. Biomarker testing in non-small cell lung cancer in routine care: Analysis of the first 3,717 patients in the German prospective, observational, nation-wide CRISP Registry (AIO-TRK-0315). Lung Cancer 2020; 152:174-184. [PMID: 33358484 DOI: 10.1016/j.lungcan.2020.10.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES An increasing number of treatment-determining biomarkers has been identified in non-small cell lung cancer (NSCLC) and molecular testing is recommended to enable optimal individualized treatment. However, data on implementation of these recommendations in the "real-world" setting are scarce. This study presents comprehensive details on the frequency, methodology and results of biomarker testing of advanced NSCLC in Germany. PATIENTS AND METHODS This analysis included 3,717 patients with advanced NSCLC (2,921 non-squamous; 796 squamous), recruited into the CRISP registry at start of systemic therapy by 150 German sites between December 2015 and June 2019. Evaluated were the molecular biomarkers EGFR, ALK, ROS1, BRAF, KRAS, MET, TP53, RET, HER2, as well as expression of PD-L1. RESULTS In total, 90.5 % of the patients were tested for biomarkers. Testing rates were 92.2 % (non-squamous), 70.7 % (squamous) and increased from 83.2 % in 2015/16 to 94.2% in 2019. Overall testing rates for EGFR, ALK, ROS1, and BRAF were 72.5 %, 74.5 %, 66.1 %, and 53.0 %, respectively (non-squamous). Testing rates for PD-L1 expression were 64.5 % (non-squamous), and 58.5 % (squamous). The most common testing methods were immunohistochemistry (68.5 % non-squamous, 58.3 % squamous), and next-generation sequencing (38.7 % non-squamous, 14.4 % squamous). Reasons for not testing were insufficient tumor material or lack of guideline recommendations (squamous). No alteration was found in 37.8 % (non-squamous), and 57.9 % (squamous), respectively. Most common alterations in non-squamous tumors (all patients/all patients tested for the respective biomarker): KRAS (17.3 %/39.2 %), TP53 (14.1 %/51.4 %), and EGFR (11.0 %/15.1 %); in squamous tumors: TP53 (7.0 %/69.1 %), MET (1.5 %/11.1 %), and EGFR (1.1 %/4.4 %). Median PFS (non-squamous) was 8.7 months (95 % CI 7.4-10.4) with druggable EGFR mutation, and 8.0 months (95 % CI 3.9-9.2) with druggable ALK alterations. CONCLUSION Testing rates in Germany are high nationwide and acceptable in international comparison, but still leave out a significant portion of patients, who could potentially benefit. Thus, specific measures are needed to increase implementation.
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Affiliation(s)
- Frank Griesinger
- Pius-Hospital Oldenburg, Universitätsklinik für Innere Medizin, Oldenburg, Germany.
| | - Wilfried Eberhardt
- Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätszentrum Essen, Germany
| | - Arnd Nusch
- Praxis für Hämatologie und internistische Onkologie, Ratingen, Germany
| | - Marcel Reiser
- PIOH - Praxis internistische Onkologie und Hämatologie, Köln, Germany
| | | | | | | | - Christoph Losem
- MVZ für Onkologie und Hämatologie im Rhein-Kreis, Neuss, Germany
| | | | - Lukas C Heukamp
- Hämatopathologie Hamburg, Hamburg, Germany; Lungen Netzwerk NOWEL.org, Oldenburg, Germany
| | - Reinhard Büttner
- Institut für Pathologie des Universitätsklinikums Köln, Köln, Germany
| | - Norbert Marschner
- Praxis für interdisziplinäre Onkologie und Hämatologie, Freiburg, Germany
| | - Martina Jänicke
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Annette Fleitz
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Lisa Spring
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | | | | | | | - Wilko Weichert
- Institut für Pathologie, Technische Universität München und German Cancer Consortium (DKTK), partner site Munich, München, Germany
| | | | - Parvis Sadjadian
- Universitätsklinik für Hämatologie, Onkologie, Hämostaseologie und Palliativmedizin, Johannes Wesling Klinikum, Universitätsklinikum der Ruhr Universität Bochum, Minden, Germany
| | - Wolfgang Gleiber
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Schwerpunkt Pneumologie/Allergologie, Frankfurt, Germany
| | - Christian Grah
- MVZ Havelhöhe am Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Cornelius F Waller
- Medizinische Klinik I, Hämatologie, Onkologie und Stammzelltransplantation; Fakultät für Medizin, Universitätsklinikum Freiburg, Germany
| | - Martin Reck
- LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | | | - Petros Christopoulos
- Onkologie der Thoraxtumore, Thoraxklinik Heidelberg gGmbH, German Center for Lung Research (DZL), Germany
| | - Martin Sebastian
- Medizinische Klinik II, Hämatologie/Onkologie, Universitätsklinikum Frankfurt, Germany
| | - Michael Thomas
- Onkologie der Thoraxtumore, Thoraxklinik Heidelberg gGmbH, German Center for Lung Research (DZL), Germany
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Salgia R, Mambetsariev I, Pharaon R, Fricke J, Baroz AR, Hozo I, Chen C, Koczywas M, Massarelli E, Reckamp K, Djulbegovic B. Evaluation of Omics-Based Strategies for the Management of Advanced Lung Cancer. JCO Oncol Pract 2020; 17:e257-e265. [PMID: 32639928 DOI: 10.1200/op.20.00117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Omic-informed therapy is being used more frequently for patients with non-small-cell lung cancer (NSCLC) being treated on the basis of evidence-based decision-making. However, there is a lack of a standardized framework to evaluate those decisions and understand the association between omics-based management strategies and survival among patients. Therefore, we compared outcomes between patients with lung adenocarcinoma who received omics-driven targeted therapy versus patients who received standard therapeutic options. PATIENTS AND METHODS This was a retrospective study of patients with advanced NSCLC adenocarcinoma (N = 798) at City of Hope who received genomic sequencing at the behest of their treating oncologists. A thoracic oncology registry was used as a clinicogenomic database to track patient outcomes. RESULTS Of 798 individuals with advanced NSCLC (median age, 65 years [range, 22-99 years]; 60% white; 50% with a history of smoking), 662 patients (83%) had molecular testing and 439 (55%) received targeted therapy on the basis of the omic-data. A fast-and-frugal decision tree (FFT) model was developed to evaluate the impact of omics-based strategy on decision-making, progression-free survival (PFS), and overall survival (OS). We calculated that the overall positive predictive value of the entire FFT strategy for predicting decisions regarding the use of tyrosine kinase inhibitor-based targeted therapy was 88% and the negative predictive value was 96%. In an adjusted Cox regression analysis, there was a significant correlation with survival benefit with the FFT omics-driven therapeutic strategy for both PFS (hazard ratio [HR], 0.56; 95% CI, 0.42 to 0.74; P < .001) and OS (HR, 0.51; 95% CI, 0.36 to 0.71; P < .001) as compared with standard therapeutic options. CONCLUSION Among patients with advanced NSCLC who received care in the academic oncology setting, omics-driven therapy decisions directly informed treatment in patients and was correlated with better OS and PFS.
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Affiliation(s)
- Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Rebecca Pharaon
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Angel Ray Baroz
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, IN
| | - Chen Chen
- Applied AI and Data Science, City of Hope, Duarte, CA
| | - Marianna Koczywas
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Karen Reckamp
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA.,Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Benjamin Djulbegovic
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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Rajurkar S, Mambetsariev I, Pharaon R, Leach B, Tan T, Kulkarni P, Salgia R. Non-Small Cell Lung Cancer from Genomics to Therapeutics: A Framework for Community Practice Integration to Arrive at Personalized Therapy Strategies. J Clin Med 2020; 9:E1870. [PMID: 32549358 PMCID: PMC7356243 DOI: 10.3390/jcm9061870] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease, and therapeutic management has advanced with the identification of various key oncogenic mutations that promote lung cancer tumorigenesis. Subsequent studies have developed targeted therapies against these oncogenes in the hope of personalizing therapy based on the molecular genomics of the tumor. This review presents approved treatments against actionable mutations in NSCLC as well as promising targets and therapies. We also discuss the current status of molecular testing practices in community oncology sites that would help to direct oncologists in lung cancer decision-making. We propose a collaborative framework between community practice and academic sites that can help improve the utilization of personalized strategies in the community, through incorporation of increased testing rates, virtual molecular tumor boards, vendor-based oncology clinical pathways, and an academic-type singular electronic health record system.
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Affiliation(s)
| | | | | | | | | | | | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (S.R.); (I.M.); (R.P.); (B.L.); (T.T.); (P.K.)
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Castellanos EH, Orlando A, Ma X, Parikh RB, O'Connell G, Meropol NJ, Hamrick J, Adamson BJS. Evaluating the Impact of Oncology Care Model Reporting Requirements on Biomarker Testing and Treatment. JCO Oncol Pract 2020; 16:e1216-e1221. [PMID: 32496874 PMCID: PMC7564129 DOI: 10.1200/jop.19.00747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is Medicare's first alternative payment model program for patients with cancer. As of October 2017, participating practices were required to report biomarker testing of patients with advanced non-small-cell lung cancer (aNSCLC). Our objective was to evaluate the effect of this OCM reporting requirement on quality of care. METHODS We selected patients with aNSCLC receiving care in practices in a nationwide de-identified electronic health record-derived database. We used an adjusted difference-in-differences (DID) logistic regression model to compare changes in biomarker testing rates (EGFR, ROS1, and ALK) and receipt of biomarker-guided therapy between patients in OCM versus non-OCM practices, before and after OCM implementation. RESULTS The analysis included 14,048 patients from 45 OCM practices (n = 8,151) and 105 non-OCM practices (n = 5,897). The overall unadjusted rates for biomarker testing and receipt of biomarker-guided therapy increased over the study period (2011-2018) in both OCM (55.5% v 71.6%; 89.8% v 94.6%, respectively) and non-OCM (55.2% v 69.7%; 90.1% v 95.2%, respectively) practices. In the adjusted DID model, the rates of biomarker testing (odds ratio [OR], 1.09 [95% CI, 0.88 to 1.34]; P = .45) and receipt of biomarker-guided therapy (OR, 0.87 [95% CI, 0.52 to 1.45]; P = .58) were similar between OCM and non-OCM practices. CONCLUSION OCM biomarker documentation and reporting requirements did not appear to increase the proportions of patients with aNSCLC who underwent testing or who received biomarker-guided therapy in OCM versus non-OCM practices.
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Wempe MM, Stewart MD, Glass D, Lasiter L, Vega DM, Ramamurthy N, Allen J, Sigal EV. A National Assessment of Diagnostic Test Use for Patients with Advanced NSCLC and Factors Influencing Physician Decision-Making. AMERICAN HEALTH & DRUG BENEFITS 2020; 13:110-119. [PMID: 32699571 PMCID: PMC7370822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/22/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Diagnostic tests, including US Food and Drug Administration (FDA)-approved tests and laboratory-developed tests, are frequently used to guide care for patients with cancer, and, recently, have been the subject of several policy discussions and insurance coverage determinations. As the use of diagnostic testing has evolved, stakeholders have raised questions about the lack of standardized test performance metrics and the risk this poses to patients. OBJECTIVES To describe the use of diagnostic testing for patients with advanced non-small-cell lung cancer (NSCLC), to analyze the utilization of FDA-approved versus laboratory-developed diagnostic tests, and to evaluate the impact of existing regulatory and coverage frameworks on diagnostic test ordering and physician treatment decision-making for patients with advanced NSCLC. METHODS We conducted a 2-part study consisting of an online survey and patient chart review from March 1, 2019, to March 25, 2019, of physicians managing patients with advanced NSCLC. Respondents qualified for this study if they managed at least 5 patients with advanced NSCLC per month and had diagnosed at least 1 patient with advanced NSCLC in the 12 months before the survey. A total of 150 physicians completed the survey; before completing the survey, they were instructed to review between 4 and 8 charts of patients with stage IV NSCLC from their list of active patients. RESULTS A total of 150 practicing oncologists who manage patients with advanced NSCLC responded to the survey and reviewed a total of 815 patient charts. Of these 815 patients, 812 (99.6%) were tested for at least 1 biomarker, including 73% of patients who were tested for EGFR, 70% tested for ALK, 58% tested for BRAF V600E, and 38% of patients tested for ROS1, by FDA-approved diagnostic tests. In all, 185 (83%) patients who tested positive for EGFR and 60 (83%) patients who tested positive for ALK received an FDA-approved targeted therapy for their biomarker. A total of 98 (65%) physicians responded that the patient's insurance coverage factored into their decision to order diagnostic tests and 69 (45%) physicians responded that cost or the patient's insurance coverage could influence them not to prescribe an indicated targeted therapy. CONCLUSION The survey results indicate that diagnostic testing has become routine in the treatment of patients with advanced NSCLC, the use of FDA-approved diagnostic tests has increased, and insurance coverage and cost influence patient access to diagnostic testing as well as to targeted treatment options.
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Affiliation(s)
- Madison M Wempe
- Research Associate, Friends of Cancer Research, Washington, DC
| | - Mark D Stewart
- Vice President, Science Policy, Friends of Cancer Research, Washington, DC
| | - Daniel Glass
- Managing Director, Global Market Research, Deerfield Management, New York, NY
| | - Laura Lasiter
- Director, Health Policy, Friends of Cancer Research, Washington, DC
| | - Diana Merino Vega
- Director, Research Partnerships, Friends of Cancer Research, Washington, DC
| | | | - Jeff Allen
- President and CEO, Friends of Cancer Research, Washington, DC
| | - Ellen V Sigal
- Chairperson and Founder, Friends of Cancer Research, Washington, DC
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Shimizu J, Masago K, Saito H, Nishino K, Kurata T, Itoh Y, Yoshimura Y, Yabuki Y, Dosaka-Akita H. Biomarker testing for personalized, first-line therapy in advanced nonsquamous non-small cell lung cancer patients in the real world setting in Japan: a retrospective, multicenter, observational study (the BRAVE study). Ther Adv Med Oncol 2020; 12:1758835920904522. [PMID: 32127924 PMCID: PMC7036489 DOI: 10.1177/1758835920904522] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 01/06/2020] [Indexed: 11/21/2022] Open
Abstract
Background: Molecular diagnostic testing is necessary to guide optimal first-line
treatment. The number of patients who receive first-line treatment based on
biomarker analysis in Japan is unknown. We aimed to determine the proportion
of nonsquamous non-small cell lung cancer (NSCLC) patients for whom
first-line treatment was selected based on biomarker testing. Methods: This retrospective, multicenter, observational study registered patients aged
⩾20 years with locally advanced or metastatic nonsquamous NSCLC who started
first-line treatment between August and December 2017 in Japan. Data were
collected from medical records between January and May 2018. The primary
endpoint was the proportion of patients with confirmed biomarker status for
first-line treatment decision. Results: Among 202 patients enrolled from 11 centers, 161 (79.7%; 95% confidence
interval, 74.2–85.2%) had confirmed biomarker status. The testing rate was
highest for epidermal growth factor receptor (EGFR; 97.5%),
followed by anaplastic lymphoma kinase (ALK; 88.1%),
programmed death ligand-1 (PD-L1; 87.1%), and ROS1 (67.3%).
For first-line treatment, 70/75 patients with EGFR-positive
tumors were administered an EGFR-TKI; 14/15 patients with
ALK-positive tumors received an ALK inhibitor; 2/2
patients with ROS1-positive tumors received a ROS1
inhibitor; and 29/36 driver mutation-negative patients with a PD-L1 tumor
proportion score ⩾50% were administered an anti-PD-1 monoclonal antibody.
Median times from confirmed diagnosis date to first-line treatment
initiation, and from first biomarker test order to last biomarker test
result were 19 and 11 days, respectively. Conclusions: The proportion of nonsquamous NSCLC patients with confirmed biomarker status
for first-line treatment was considered insufficient and in need of
improvement.
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Affiliation(s)
- Junichi Shimizu
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi 464-8681, Japan
| | - Katsuhiro Masago
- Department of Pathology and Molecular Diagnosis, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Haruhiro Saito
- Department of Thoracic Oncology, Kanagawa Cancer Center, Asahi-ku, Yokohama, Japan
| | - Kazumi Nishino
- Department of Thoracic Oncology, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takayasu Kurata
- Department of Thoracic Oncology, Kansai Medical University Hospital, Hirakata, Osaka, Japan
| | - Yohji Itoh
- Statistics Group, AstraZeneca, Kita-ku, Osaka, Japan
| | | | - Yutaka Yabuki
- Medical Department, AstraZeneca, Kita-ku, Osaka, Japan
| | - Hirotoshi Dosaka-Akita
- Department of Medical Oncology, Faculty of Medicine & Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Mambetsariev I, Wang Y, Chen C, Nadaf S, Pharaon R, Fricke J, Amanam I, Amini A, Bild A, Chu P, Erhunmwunsee L, Kim J, Munu J, Pillai R, Raz D, Sampath S, Vora L, Qiu F, Smith L, Batra SK, Massarelli E, Koczywas M, Reckamp K, Salgia R. Precision medicine and actionable alterations in lung cancer: A single institution experience. PLoS One 2020; 15:e0228188. [PMID: 32045431 PMCID: PMC7012442 DOI: 10.1371/journal.pone.0228188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/10/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Oncology has become more reliant on new testing methods and a greater use of electronic medical records, which provide a plethora of information available to physicians and researchers. However, to take advantage of vital clinical and research data for precision medicine, we must initially make an effort to create an infrastructure for the collection, storage, and utilization of this information with uniquely designed disease-specific registries that could support the collection of a large number of patients. MATERIALS AND METHODS In this study, we perform an in-depth analysis of a series of lung adenocarcinoma patients (n = 415) with genomic and clinical data in a recently created thoracic patient registry. RESULTS Of the 415 patients with lung adenocarcinoma, 59% (n = 245) were female; the median age was 64 (range, 22-92) years with a median OS of 33.29 months (95% CI, 29.77-39.48). The most common actionable alterations were identified in EGFR (n = 177/415 [42.7%]), ALK (n = 28/377 [7.4%]), and BRAF V600E (n = 7/288 [2.4%]). There was also a discernible difference in survival for 222 patients, who had an actionable alteration, with a median OS of 39.8 months as compared to 193 wild-type patients with a median OS of 26.0 months (P<0.001). We identified an unprecedented number of actionable alterations [53.5% (222/415)], including distinct individual alteration rates, as compared with 15.0% and 22.3% in TCGA and GENIE respectively. CONCLUSION The use of patient registries, focused genomic panels and the appropriate use of clinical guidelines in community and academic settings may influence cohort selection for clinical trials and improve survival outcomes.
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Affiliation(s)
- Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Yingyu Wang
- Center for Informatics, City of Hope, Duarte, California, United States of America
| | - Chen Chen
- Center for Informatics, City of Hope, Duarte, California, United States of America
| | - Sorena Nadaf
- Center for Informatics, City of Hope, Duarte, California, United States of America
| | - Rebecca Pharaon
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Idoroenyi Amanam
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Arya Amini
- Department of Radiation Oncology, City of Hope, Duarte, California, United States of America
| | - Andrea Bild
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Peiguo Chu
- Department of Pathology, City of Hope, Duarte, California, United States of America
| | - Loretta Erhunmwunsee
- Department of Thoracic Surgery, City of Hope, Duarte, California, United States of America
| | - Jae Kim
- Department of Thoracic Surgery, City of Hope, Duarte, California, United States of America
| | - Janet Munu
- Center for Informatics, City of Hope, Duarte, California, United States of America
| | - Raju Pillai
- Department of Pathology, City of Hope, Duarte, California, United States of America
| | - Dan Raz
- Department of Thoracic Surgery, City of Hope, Duarte, California, United States of America
| | - Sagus Sampath
- Department of Radiation Oncology, City of Hope, Duarte, California, United States of America
| | - Lalit Vora
- Department of Diagnostic Radiology, City of Hope, Duarte, California, United States of America
| | - Fang Qiu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Lynette Smith
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Surinder K. Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Marianna Koczywas
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Karen Reckamp
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, United States of America
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