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Xu Y, Xu B, Guan H, Zhao Z. Cost-effectiveness analysis of 11 pharmacotherapies for recurrent glioblastoma in the USA and China. Ther Adv Med Oncol 2024; 16:17588359241264727. [PMID: 39091601 PMCID: PMC11292717 DOI: 10.1177/17588359241264727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 06/11/2024] [Indexed: 08/04/2024] Open
Abstract
Background Several studies have systematically assessed the efficacy and safety of progressive or recurrent glioblastoma multiforme (GBM). However, the discernible limitations of efficacy and the elevated costs of interventions instigate an investigation into the cost-effectiveness of these treatments. Objectives This study aimed to evaluate cost-effectivenesses of 11 pharmacotherapeutic interventions for recurrent GBM from the perspective of healthcare payers in the United States (US) and China. Design A model-based pharmacoeconomic evaluation. Methods A partitioned survival model was employed to evaluate the cost-effectiveness of 11 distinct drug-based treatments. The clinical efficacy and safety data were obtained from a network meta-analysis, while the medical expenditure and health utility were primarily derived from published literature. One-way sensitivity analyses, scenario analyses, and probabilistic sensitivity analyses (PSA) were performed to scrutinize the impact of potential uncertainties to ensure the robustness of the model. The primary endpoint was the incremental cost-effectiveness ratio. Results Among the therapeutic interventions evaluated, lomustine emerged as the cheapest option, with costs amounting to $78,998 in the United States and $30,231 in China, respectively. Regorafenib displayed the highest quality-adjusted life years at 0.475 in the United States and 0.465 in China. The one-way sensitivity analyses underscored that drug price was a key factor influencing cost-effectiveness. Both scenario and PSA consistently demonstrated that, considering the willingness-to-pay thresholds, lomustine was a cost-effective treatment with probability of more than 94%. Conclusion In comparison to the alternative antitumor agents, lomustine was likely to be a cost-effective option for relapsed GBM patients from the perspective of healthcare payers in both the United States and China.
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Affiliation(s)
- Yanan Xu
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- School of Pharmacy, Capital Medical University, Beijing, China
| | - Boya Xu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haijing Guan
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- School of Pharmacy, Capital Medical University, Beijing 100069, China
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2
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Xiang Y, Chen Y, Xu Z, Zhou S, Qin Z, Chen L, Xiao D, Liu S. Real-world cost- effectiveness analysis: Tumor Treating Fields for newly diagnosed glioblastoma in China. J Neurooncol 2024; 168:259-267. [PMID: 38563851 DOI: 10.1007/s11060-024-04662-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Glioblastoma (GBM) stands as the most aggressive and prevalent primary brain malignancy. Tumor Treating Fields (TTFields), an innovative therapy complementing chemotherapy for GBM treatment, which can significantly enhance overall survival, disease progression-free survival, and patient's quality of life. However, there is a dearth of health economics evaluation on TTFields therapy both domestically and internationally. OBJECTIVE The study aims to assess the cost-effectiveness of TTFields + temozolomide (TMZ) in comparison to TMZ alone for newly diagnosed GBM patients. The intent is to provide robust economic evidence to serve as a foundation for policymaking and decision-making processes in GBM treatment. METHODS We estimated outcomes for newly diagnosed GBM patients over a lifetime horizon using a partitioned survival model with three states: Progression-Free Survival, Progression Disease, and Death. The survival model was derived from a real-world study in China, with long-term survival data drawn from GBM epidemiology literature. Adverse event rates were sourced from the EF-14 trial data. Cost data, validated by expert consultation, was obtained from public literature and databases. Utility values were extracted from published literature. Using Microsoft Excel, we calculated expected costs and quality-adjusted life years (QALYs) over 15 years from a health system perspective. The willingness-to-pay threshold was set at three times the Chinese per capita Gross Domestic Product (GDP) in 2022, amounting to CN¥242,928 (US$37,655) /QALY. A 5% discount rate was applied to costs and utilities. Results underwent analysis through single factor and probability sensitivity analyses. RESULTS TTFields + TMZ demonstrated a mean increase in cost by CN¥389,326 (US$57,859) and an increase of 2.46 QALYs compared to TMZ alone. The incremental cost-effectiveness ratio (ICER) was CN¥157,979 (US$23,474) per QALY gained. The model exhibited heightened sensitivity to changes in the discount rate. Probability sensitivity analysis indicates that, under the existing threshold, the probability of TTFields + TMZ being economical is 95.60%. CONCLUSIONS This cost-effectiveness analysis affirms that incorporating TTFields into TMZ treatment proves to be cost-effective, given a threshold three times the Chinese per capita GDP.
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Affiliation(s)
- Yuliang Xiang
- School of Public Health, Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, 130 Dongan Rd, Xuhui, Shanghai, 200032, China
| | - Yingyao Chen
- School of Public Health, Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, 130 Dongan Rd, Xuhui, Shanghai, 200032, China
| | - Zian Xu
- School of Public Health, Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, 130 Dongan Rd, Xuhui, Shanghai, 200032, China
| | - Shanyan Zhou
- School of Public Health, Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, 130 Dongan Rd, Xuhui, Shanghai, 200032, China
| | - Zhiyong Qin
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
| | - Lingchao Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
| | - Dunming Xiao
- School of Public Health, Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, 130 Dongan Rd, Xuhui, Shanghai, 200032, China
| | - Shimeng Liu
- School of Public Health, Fudan University, Shanghai, China.
- National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, 130 Dongan Rd, Xuhui, Shanghai, 200032, China.
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Zahirian Moghadam T, Powell J, Sharghi A, Zandian H. Economic evaluation of dialysis and comprehensive conservative care for chronic kidney disease using the ICECAP-O and EQ-5D-5L; a comparison of evaluation instruments. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:81. [PMID: 37924060 PMCID: PMC10625205 DOI: 10.1186/s12962-023-00491-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Chronic Kidney Disease (CKD) patients often require long-term care, and while Hemodialysis (HD) is the standard treatment, Comprehensive Conservative Care (CCC) is gaining popularity as an alternative. Economic evaluations comparing their cost-effectiveness are crucial. This study aims to perform a cost-utility analysis comparing HD and CCC using the EQ-5D-5L and ICECAP-O instruments to assessing healthcare interventions in CKD patients. METHODS This short-term economic evaluation involved 183 participants (105 HD, 76 CCC) and collected data on demographics, comorbidities, laboratory results, treatment costs, and HRQoL measured by ICECAP-O and EQ-5D-5L. Incremental Cost-Effectiveness Ratios (ICERs) and Net Monetary Benefit (NMB) were calculated separately for each instrument, and Probabilistic Sensitivity Analysis (PSA) assessed uncertainty. RESULTS CCC demonstrated significantly lower costs (mean difference $8,544.52) compared to HD. Both EQ-5D-5L and ICECAP-O indicated higher Quality-Adjusted Life Years (QALYs) for both groups, but the difference was not statistically significant (p > 0.05). CCC dominated HD in terms of HRQoL measures, with ICERs of -$141,742.67 (EQ-5D-5L) and -$4,272.26 (ICECAP-O). NMB was positive for CCC and negative for HD, highlighting its economic feasibility. CONCLUSION CCC proves a preferable and more cost-effective treatment option than HD for CKD patients aged 65 and above, regardless of the quality-of-life measure used for QALY calculations. Both EQ-5D-5L and ICECAP-O showed similar results in cost-utility analysis.
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Affiliation(s)
- Telma Zahirian Moghadam
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Jane Powell
- Centre for Public Health and Wellbeing, School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Afshan Sharghi
- Department of Community Medicine, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Hamed Zandian
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran.
- Centre for Public Health and Wellbeing, School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK.
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Neutel CLG, Viozzi I, Overduin CG, Rijpma A, Grutters JPC, Hannink G, van Eijsden P, Robe PA, Rovers MM, Ter Laan M. Study protocol for a multicenter randomised controlled trial on the (cost)effectiveness of biopsy combined with same-session MR-guided LITT versus biopsy alone in patients with primary irresectable glioblastoma (EMITT trial). BMC Cancer 2023; 23:788. [PMID: 37612610 PMCID: PMC10463911 DOI: 10.1186/s12885-023-11282-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Glioblastoma (GBM) is the most common primary, malignant brain tumour with a 5-year survival of 5%. If possible, a glioblastoma is resected and further treated with chemoradiation therapy (CRT), but resection is not feasible in about 30% of cases. Current standard of care in these cases is a biopsy followed by CRT. Magnetic resonance (MR) imaging-guided laser interstitial thermal therapy (LITT) has been suggested as a minimally invasive alternative when surgery is not feasible. However, high-quality evidence directly comparing LITT with standard of care is lacking, precluding any conclusions on (cost-)effectiveness. We therefore propose a multicenter randomized controlled study to assess the (cost-)effectiveness of MR-guided LITT as compared to current standard of care (EMITT trial). METHODS AND ANALYSIS The EMITT trial will be a multicenter pragmatic randomized controlled trial in the Netherlands. Seven Dutch hospitals will participate in this study. In total 238 patients will be randomized with 1:1 allocation to receive either biopsy combined with same-session MR-guided LITT therapy followed by CRT or the current standard of care being biopsy followed by CRT. The primary outcomes will be health-related quality of life (HR-QoL) (non-inferiority) using EORTC QLQ-C30 + BN20 scores at 5 months after randomization and overall survival (superiority). Secondary outcomes comprise cost-effectiveness (healthcare and societal perspective) and HR-QoL of life over an 18-month time horizon, progression free survival, tumour response, disease specific survival, longitudinal effects, effects on adjuvant treatment, ablation percentage and complication rates. DISCUSSION The EMITT trial will be the first RCT on the effectiveness of LITT in patients with glioblastoma as compared with current standard of care. Together with the Dutch Brain Tumour Patient association, we hypothesize that LITT may improve overall survival without substantially affecting patients' quality of life. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (NCT05318612).
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Affiliation(s)
- Céline L G Neutel
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ilaria Viozzi
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiaan G Overduin
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne Rijpma
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pieter van Eijsden
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pierre A Robe
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maroeska M Rovers
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark Ter Laan
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.
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5
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Olubajo F, Thorpe A, Davis C, Sinha R, Crofton A, Mills SJ, Williams M, Jenkinson MD, Price SJ, Watts C, Brodbelt AR. Tumour treating fields in glioblastoma: is the treatment tolerable, effective, and practical in UK patients? Br J Neurosurg 2022; 36:770-776. [PMID: 35200077 DOI: 10.1080/02688697.2022.2028722] [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: 01/05/2023]
Abstract
BACKGROUND Tumour Treating Fields (TTF) in combination with standard therapy, prolongs survival in patients with glioblastoma (GBM). The aim of the current study was to assess the feasibility of integrating TTF into a standard UK neuro-oncology service with a focus on patient tolerability, compliance, and treatment delivery. METHODS A prospective study was performed of UK patients with IDH 1 Wild Type, MGMT Unmethylated GBM treated with TTF, in conjunction with conventional therapy. Patient compliance data, device-specific tolerability questions, and an evaluation of disease progression and survival were collected. Monthly quality of life (QoL) questionnaires (EORTC QLQ-C30 with BN-20) examined the trend of global health, psychosocial function, and symptom progression. RESULTS Nine patients were enrolled with a median age of 47 (seven males; two females). Overall, compliance with TTF was 89% (range 16-97%). Only one patient failed to comply with treatment. Patients tolerated the device with minimal side effects. Eight patients described mild to moderate skin irritation, whilst all patients were keen to recommend the device to other patients (100%). Most patients found the weight and size of the device to be its biggest drawback (72%). Progression-free survival was 5.5 months and median overall survival was 14.9 months. CONCLUSIONS TTF was well-tolerated amongst a small cohort of UK patients, who were able to comply with treatment without any significant complication. QoL questionnaires showed no sustained deterioration in global health, physical and emotional function until the final months of life when the disease burden was greatest.
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Affiliation(s)
- Farouk Olubajo
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Antonia Thorpe
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Charles Davis
- Department of Neurosurgery, Royal Preston Hospital, Preston, UK
| | - Rohitashwa Sinha
- Academic Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Anna Crofton
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | | | | | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre, Liverpool, UK.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Stephen J Price
- Academic Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Colin Watts
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
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6
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Chen Z, Tian F, Chen X. Cost-Effectiveness Analysis of a Three-Drug Regimen Containing Bevacizumab for the Treatment of Recurrent Pediatric Medulloblastoma in China: Based on a COG Randomized Phase II Screening Trial. Front Public Health 2022; 10:914536. [PMID: 35719637 PMCID: PMC9201059 DOI: 10.3389/fpubh.2022.914536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023] Open
Abstract
Background Medulloblastoma is the most common malignant brain tumor of childhood, accounting for 6 to 7 percent of all childhood CNS tumors. The purpose of this study was to evaluate the economic efficacy of a bevacizumab combined with temozolomide + irinotecan regimen for the treatment of recurrent pediatric medulloblastoma in China. Methods The data analyzed were from a randomized phase II screening trial that showed an improved survival benefit in child patients with recurrent medulloblastoma treated with a T+I+B combination regimen. A Markov model is constructed to estimate the incremental cost–effectiveness ratio (ICER) from the perspective of Chinese society. The uncertainty in the model is solved by one-way certainty and probabilistic sensitivity analysis. Results Our base case analysis showed that the total costs of treatment increased from $8,786.403 to $27,603.420 with the combination bevacizumab vs. the two-agent chemotherapy regimen. Treatment with T+I+B combination therapy was associated with an increase in effectiveness of 0.280 QALYs from 0.867 to 1.147 QALYs T+I regimen. The incremental cost-effectiveness ratio was $67,203.632/QALY, which exceeded our pre-specified willingness-to-pay threshold ($38,136.26/QALY). Cost changes associated with grade 3–4 AE management, tests used, or hospitalization costs had little effect on the ICER values predicted by sensitivity analysis. Conclusions Taken together, the results of this study suggest that the combination of bevacizumab with temozolomide and irinotecan is not a cost-effective option from the perspective of Chinese payers as a first-line treatment option for children with recurrent medulloblastoma in China.
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Affiliation(s)
- Zhaoyan Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Chen
- Department of Integrated Care Management Center, West China Hospital, Sichuan University, Chengdu, China
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7
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Chen J, Tong X, Han M, Zhao S, Ji L, Qin Y, He Z, Pan Y, Wang C, Liu A. Cost-Effectiveness of Short-Course Radiation Plus Temozolomide for the Treatment of Newly Diagnosed Glioblastoma Among Elderly Patients in China and the United States. Front Pharmacol 2021; 12:743979. [PMID: 34646141 PMCID: PMC8502816 DOI: 10.3389/fphar.2021.743979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Glioblastoma multiforme (GBM) is a fatal type of brain tumor with a high incidence among elderly people. Temozolomide (TMZ) has proven to be an effective chemotherapeutic agent with significant survival benefits. This study aimed to evaluate the economic outcomes of radiotherapy (RT) and TMZ for the treatment of newly diagnosed GBM in elderly people in the United States (US) and China. Methods: A partitioned survival model was constructed for RT plus TMZ and RT alone among patients with methylated and unmethylated tumor status. Base case calculations and one-way and probabilistic sensitivity analyses were performed. Life-years, quality-adjusted life-years (QALYs), costs (in 2021 US dollars [$] and Chinese Yuan Renminbi [¥]), and incremental cost-effectiveness ratios (ICERs) were calculated. Results: RT plus TMZ was found to be associated with significantly higher costs and QALYs in all groups. Only US patients with methylated status receiving RT plus TMZ had an ICER ($89358.51) less than the willingness-to-pay (WTP) threshold of $100000 per QALY gained when compared with receiving RT alone. When the WTP threshold ranged from $100000 to $150000 from the US perspective, the probability of RT plus TMZ being cost-effective increased from 80.5 to 99.8%. The cost of TMZ must be lower than ¥120 per 20 mg for RT plus TMZ to be cost-effective among patients with methylated tumor status in China. Conclusion: RT plus TMZ was not cost-effective in China, and a reduction in the TMZ price was justified. However, it is highly likely to be cost-effective for patients with methylated tumor status in the US.
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Affiliation(s)
- Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Songfeng Zhao
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Linjin Ji
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yongkai Qin
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zilong He
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Chunhui Wang
- Department of Neurosurgery, The 905th Hospital, Naval Medical University, Shanghai, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
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Gupta N, Prinja S, Patil V, Bahuguna P. Cost-Effectiveness of Temozolamide for Treatment of Glioblastoma Multiforme in India. JCO Glob Oncol 2021; 7:108-117. [PMID: 33449801 PMCID: PMC8081547 DOI: 10.1200/go.20.00288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Glioblastoma multiforme (GBM) has poor outcomes following surgery and radiation. Adjuvant temozolamide along with radiation therapy has been shown to improve survival. In this paper, we evaluate the cost-effectiveness of concomitant temozolamide with radiation and maintenance temozolamide for 6 months of treatment for GBM in India. MATERIALS AND METHODS We used a Markov model to evaluate the lifetime costs and consequences of treating GBM with radiation alone versus radiation with adjuvant temozolamide. The model was calibrated using the published evidence from European Organisation for Research and Treatment of Cancer-NCIC trial on progression-free survival and overall survival to estimate the life years (LYs) and quality-adjusted LYs (QALYs). Cost of treatment and management of complications were estimated using the data from the National Health System Cost Database and Indian studies. Future cost and consequences were discounted at 3%. Incremental cost per QALY gained with temozolamide was estimated to assess cost effectiveness. RESULTS Temozolamide resulted in an increase of 0.59 (0.53-0.66) LY and 0.33 (0.29-0.40) QALY per person at an incremental cost of ₹75,120 in Indian national rupee (INR) (59,337-93,960). Overall, the use of temozolamide incurs an incremental cost of ₹212,020 INR (138,127-401,466) per QALY gained, which has a 4.7% probability to be cost-effective at 1-time per capita Gross Domestic Product (GDP) threshold. In case the current price of temozolamide could be decreased by 90%, the probability of its use for GBM being cost-effective increases to 80%. CONCLUSION Temozolamide is not cost-effective for treatment of patients with GBM in India. This evidence should be used while framing guidelines for treatment and price regulation.
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Affiliation(s)
- Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Pankaj Bahuguna
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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9
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Tuohy K, Fernandez A, Hamidi N, Padmanaban V, Mansouri A. Current State of Health Economic Analyses for Low-Grade Glioma Management: A Systematic Review. World Neurosurg 2021; 152:189-197.e1. [PMID: 34087462 DOI: 10.1016/j.wneu.2021.05.112] [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: 03/01/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Health economic analyses help determine the value of a medical intervention by assessing the costs and outcomes associated with it. The objective of this study was to assess the level of evidence in economic evaluations for low-grade glioma (LGG) management. METHODS Following the PRISMA guidelines, we conducted a systematic review of English articles in Medline, Embase, The Central Registration Depository, EconPapers, and EconLit. The results were screened, and data were extracted by 2 independent reviewers for studies reporting economic evaluations for LGG. The quality of each study was evaluated using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) checklist, the hierarchy scale developed by Cooper et al. (2005), and the Quality of Health Economic Studies instrument. RESULTS Three studies met our inclusion criteria. The adjusted incremental cost-effectiveness ratio (ICER) values for the included studies ranged from $3934 to $9936, but each evaluated a different aspect of LGG management. All had a good quality of reporting per the CHEERS checklist. Based on the Cooper et al. hierarchy scale, the quality of data use was lacking most for utilities. The quality of study design was scored as 82, 92, and 100 for each study using the Quality of Health Economic Studies instrument. CONCLUSIONS Although a limited number of economic evaluations were identified, the studies evaluated here were well designed. The interventions assessed were all considered cost-effective, but pooled analysis was not possible because of heterogeneity in the interventions assessed. Given the importance of value and cost-effectiveness in medical care, more evidence is needed in this area.
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Affiliation(s)
- Kyle Tuohy
- Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA.
| | - Ajay Fernandez
- Doctor of Osteopathic Medicine Program, Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | - Nima Hamidi
- Doctor of Osteopathic Medicine Program, Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | - Varun Padmanaban
- Penn State Department of Neurosurgery, Hershey, Pennsylvania, USA
| | - Alireza Mansouri
- Penn State Department of Neurosurgery, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
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10
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Connock M, Auguste P, Armoiry X. A comparison of published time invariant Markov models with Partitioned Survival models for cost effectiveness estimation; three case studies of treatments for glioblastoma multiforme. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:89-100. [PMID: 33130929 DOI: 10.1007/s10198-020-01239-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 10/12/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Cost-effectiveness analyses of treatments for glioblastoma multiforme (GBM) have mostly used state transition Markov models with time invariant transition probabilities (TIMMs). In three case studies of GBM treatments, we compared Partitioned Survival model (PSM) results with published outputs from TIMMs. METHODS PSMs used the same RCT data sources, utility values, time horizons, cycle times and annual discounting used in published TIMMs. Reported overall survival and progression-free survival plots were digitised and fitted with a range of parametric models. Economic model outputs were generated in the same form as reported for the TIMMs. PSM output uncertainty was explored in univariate and in multivariate sensitivity analyses. RESULTS PSMs generated incremental cost-effectiveness ratios that were different to the published TIMMs. The magnitude of difference was substantial in two cases. The PSMs were reasonably robust and in sensitivity analyses were sensitive to variations in the same model inputs as were the TIMMs. When compared to the RCT data, the TIMMs tended to generate underestimates of the likely overall survival gain. TIMM estimates for depletion of individuals from the stable disease state and for accumulation in the dead state had relatively poor resemblance to the source RCT data. CONCLUSION TIMMs delivered different cost-effectiveness estimates to PSMs; in two cases, TIMMs produced substantially lower ICER values than PSMs. Model output differences appear attributable to less realistic cost-and-benefit estimates generated in TIMMs due to rapid depletion from the stable disease state and/or accumulation in the dead state.
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Affiliation(s)
- Martin Connock
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV47AL, UK
| | - Peter Auguste
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV47AL, UK
| | - Xavier Armoiry
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV47AL, UK.
- Pharmacy Department, School of Pharmacy (ISPB)/UMR CNRS 5510 MATEIS/Edouard Herriot Hospital, University of Lyon, Lyon, France.
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11
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Goel NJ, Bird CE, Hicks WH, Abdullah KG. Economic implications of the modern treatment paradigm of glioblastoma: an analysis of global cost estimates and their utility for cost assessment. J Med Econ 2021; 24:1018-1024. [PMID: 34353213 DOI: 10.1080/13696998.2021.1964775] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Glioblastoma is the most common primary brain tumor in adults. Standard of care includes maximal surgical resection of the tumor followed by concurrent chemotherapy and radiation. The treatment of glioblastoma must account for an increased disease severity and treatment intensity compared to other cancers which place a significant cost burden on the patient and health system. Cost assessments of glioblastoma treatment have been sparse in comparison to other solid cancer subtypes. This study evaluates all currently available cost literature with an emphasis on the modern treatment paradigm to properly assess the economic implications of this disease. METHODS A critical review of 21 studies from 13 different countries measuring direct costs related to glioblastoma management was performed. Evaluated data included itemized costs, total costs of treatment regimens from diagnosis until death, the cost of second-line care after recurrence, and the incremental costs and cost-effectiveness of emerging therapies. RESULTS The average cost of a craniotomy was $10,042 across studies. Imaging for the duration of glioblastoma care had a mean cost of $2,788 ± 3,719. Studies examined different combinations of treatment modalities. Utilization of the modern treatment paradigm led to survival of 16.3 months across studies and had a mean cost of $62,602. Surgery for the recurrent disease had an average cost of $27,442 ± 18,992. LIMITATIONS AND CONCLUSIONS Direct cost estimates for glioblastoma varied substantially between institutions and countries and often failed to uniformly describe direct cost estimates associated with care for glioblastoma. The limitations of these studies make a true economic assessment of standards of care, costs of recurrence, and incremental costs associated with adjunctive therapy uncertain.
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Affiliation(s)
- Nicholas J Goel
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cylaina E Bird
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William H Hicks
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kalil G Abdullah
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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12
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Keeney E, Mohiuddin S, Zienius K, Ben-Shlomo Y, Ozawa M, Grant R, Hamilton W, Weller D, Brennan PM, Hollingworth W. Economic evaluation of GPs' direct access to computed tomography for identification of brain tumours. Eur J Cancer Care (Engl) 2020; 30:e13345. [PMID: 33184924 DOI: 10.1111/ecc.13345] [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: 02/11/2020] [Revised: 07/18/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND When GPs suspect a brain tumour, a referral for specialist assessment and subsequent brain imaging is generally the first option. NICE has recommended that GPs have rapid direct access to brain imaging for adults with progressive sub-acute loss of central nervous function; however, no studies have evaluated the cost-effectiveness. METHODS We developed a cost-effectiveness model based on data from one region of the UK with direct access computed tomography (DACT), routine data from GP records and the literature, to explore whether unrestricted DACT for patients with suspected brain tumour might be more cost-effective than criteria-based DACT or no DACT. RESULTS Although criteria-based DACT allows some patients without brain tumour to avoid imaging, our model suggests this may increase costs of diagnosis due to non-specific risk criteria and high costs of diagnosing or 'ruling out' brain tumours by other pathways. For patients diagnosed with tumours, differences in outcomes between the three diagnostic strategies are small. CONCLUSIONS Unrestricted DACT may reduce diagnostic costs; however, the evidence is not strong and further controlled studies are required. Criteria-based access to CT for GPs might reduce demand for DACT, but imperfect sensitivity and specificity of current risk stratification mean that it will not necessarily be cost-effective.
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Affiliation(s)
- Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Syed Mohiuddin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Karolis Zienius
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mio Ozawa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robin Grant
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - William Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, College House, St Luke's Campus, University of Exeter, Exeter, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul M Brennan
- Translational Neurosurgery Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Brain Tumour Research Group, Institute of Clinical Neuroscience, Learning and Research Building, Southmead Hospital, University of Bristol, Bristol, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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13
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Xiao ZZ, Wang ZF, Lan T, Huang WH, Zhao YH, Ma C, Li ZQ. Carmustine as a Supplementary Therapeutic Option for Glioblastoma: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:1036. [PMID: 33041980 PMCID: PMC7527463 DOI: 10.3389/fneur.2020.01036] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Glioblastoma (GBM) is the most aggressive type of primary malignant brain tumor. Carmustine is used by intravenous injection or local implantation in the resection cavity for gliomas, including GBMs. However, the therapeutic potential of carmustine is not well-recognized. This analysis aimed to evaluate the survival benefits of carmustine in glioma patients, especially those with GBM. Methods: Randomized controlled trials (RCTs) and cohort studies regarding carmustine for glioma treatment were searched in PubMed, the Cochrane Library, and Embase from January 1979 to March 2020. Quality assessment was conducted with Jadad and Newcastle-Ottawa scales (NOS). Statistical analysis was conducted by the Revman 5.3 software. Results: Twenty-two eligible RCTs and cohort studies involving 5,821 glioma patients were included. Overall, glioma patients receiving carmustine as an adjuvant therapy had better progression-free survival [PFS; hazard ratio (HR) = 0.85, 95% CI = 0.77-0.94, P = 0.002] and overall survival (OS; HR = 0.85, 95% CI = 0.79-0.92, P < 0.0001) than those without carmustine treatment. Subgroup analysis showed that the OS benefit was observed in GBM (HR = 0.84, 95% CI = 0.78-0.91, P < 0.00001) but not in anaplastic glioma patients (HR = 1.20, 95% CI = 0.70-2.07, P = 0.50). Additionally, both newly diagnosed and recurrent GBM patients who received carmustine treatment showed better OS (HR = 0.86, 95% CI = 0.79-0.95, P = 0.002; HR = 0.77, 95% CI = 0.67-0.89, P = 0.0002, respectively). Both carmustine implantation in resection cavity and intravenous administration significantly prolonged OS (HR = 0.84, 95% CI = 0.78-0.92, P < 0.0001; HR = 0.86, 95% CI = 0.75-0.99, P = 0.04, respectively). Moreover, GBM patients receiving a combined carmustine and temozolomide (TMZ) therapy had longer OS than those receiving TMZ alone (HR = 0.78, 95% CI = 0.63-0.97, P = 0.03). Conclusion: Carmustine implantation in resection cavity provides survival benefit for GBM patients, and it may be a promising supplement to standard therapeutic protocol by offering a bridge between surgical resection and onset of TMZ therapy.
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Affiliation(s)
- Zhi-Ze Xiao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ze-Fen Wang
- Department of Physiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Tian Lan
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen-Hong Huang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yu-Hang Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhi-Qiang Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Laboratory of Neuro-Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
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14
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Kim J, Lee WW, Hwang ES. Human Cytomegalovirus (HCMV)-infected Astrocytoma Cells Impair the Function of HCMV-specific Cytotoxic T Cells. J Korean Med Sci 2020; 35:e218. [PMID: 32657085 PMCID: PMC7358065 DOI: 10.3346/jkms.2020.35.e218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Human cytomegalovirus (HCMV) infection in glioblastoma multiforme (GBM) is associated with a poor prognosis and may affect the pathogenesis of GBM. In this study, we investigated the role of HCMV-infected astrocytoma cells in impairing the activity of cytotoxic T lymphocytes (CTLs) specific to the HCMV protein. METHODS CTLs specific to HCMV immediate early (IE)-1 were expanded from peripheral blood mononuclear cells of healthy donors by stimulating CD8+ T lymphocytes with U373MG cells (ATCC HTB-17: male) expressing HCMV IE-1. The death rate of the target and the effector cells was determined by the total count of the remaining respective cells after the interaction of them. RESULTS The death rate of the target cells by CTLs increased depending on HLA restriction and the effector:target (E:T) ratio. The death rate of effector cells in the HCMV-infected U373MG cell culture was 37.1% on day 4 post-infection. The removal of the culture supernatant from HCMV-infected U373MG cells prior to adding the effector cells increased target cell death from 8.4% to 40.8% at E:T = 1:1, but not at E:T = 3:1. The transfer of cells from a 24-hour co-culture of the HCMV-infected U373MG cells and CTLs to HCMV IE-1-expressing target cells resulted in decreasing the cell death rate of the target cells from 31.1% to 13.0% at E:T = 1:1, but not at E:T = 3:1. HCMV infection of U373MG cells decreases the activity of CTLs specific to HCMV when the number of CTLs is low. CONCLUSION These results suggest that HCMV could impair CTL activity and facilitate glioblastoma growth unchecked by CTLs.
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Affiliation(s)
- Jiyeon Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- BK21 Plus Biomedical Science Project, Seoul National University College of Medicine, Seoul, Korea
- Institute of Endemic Diseases, Seoul National University Medical Research Center, Seoul, Korea
| | - Won Woo Lee
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- BK21 Plus Biomedical Science Project, Seoul National University College of Medicine, Seoul, Korea
- Institute of Endemic Diseases, Seoul National University Medical Research Center, Seoul, Korea
| | - Eung Soo Hwang
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Endemic Diseases, Seoul National University Medical Research Center, Seoul, Korea.
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15
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A systematic review of tumor treating fields therapy for high-grade gliomas. J Neurooncol 2020; 148:433-443. [DOI: 10.1007/s11060-020-03563-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/15/2020] [Indexed: 01/18/2023]
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16
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Chen Z, Zhan M, Tian F, Xu T. Cost-effectiveness analysis of the addition of bevacizumab to temozolomide therapy for the treatment of unresected glioblastoma. Oncol Lett 2019; 19:424-430. [PMID: 31897155 PMCID: PMC6924092 DOI: 10.3892/ol.2019.11099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/30/2019] [Indexed: 02/05/2023] Open
Abstract
Glioblastoma, a cancer that originates from astrocytes, is the most prevalent malignant glioma in the adult population. The aim of the present study was to evaluate the cost-effectiveness of bevacizumab (BEV) as a supplement to standard temozolomide (TMZ) treatment for unresected glioblastoma. The analyzed data were from a phase II trial that showed a survival benefit following combination therapy, when compared with TMZ monotherapy. According to the clinical symptoms and disease progression, a Markov model was constructed to estimate the incremental cost-effectiveness ratio (ICER) from a Chinese societal perspective. Health outcomes were retrieved from the GENOM 009 trial, and utility parameters were obtained from published literature. Uncertainties within the model were addressed through one-way deterministic and probabilistic sensitivity analyses. The addition of BEV to TMZ therapy increased overall costs by $30,894.99, with a gain of 0.18 quality-adjusted life-years (QALYs), resulting in an ICER of $171,638.83/QALY. Both one-way sensitivity and probabilistic sensitivity analyses confirmed that BEV/TMZ co-treatment was not cost-effective in the context of a $26,508.00/QALY willingness-to-pay (WTP) threshold. The utility of the progression-free survival state had the most noticeable impact on the ICER. In summary, the combination of BEV and TMZ should not be considered a cost-effective neoadjuvant treatment option for patients with unresected glioblastoma in China, from a societal perspective. However, in view of the survival benefits conferred, an appropriate price discount or the use of medical insurance could make BEV affordable for this patient population.
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Affiliation(s)
- Zhaoyan Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Mei Zhan
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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17
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Guzauskas GF, Pollom EL, Stieber VW, Wang BCM, Garrison LP. Tumor treating fields and maintenance temozolomide for newly-diagnosed glioblastoma: a cost-effectiveness study. J Med Econ 2019; 22:1006-1013. [PMID: 31050315 DOI: 10.1080/13696998.2019.1614933] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Purpose: The EF-14 trial demonstrated that adding tumor treating fields (TTFields) to maintenance temozolomide (TMZ) significantly extends progression-free survival (PFS) and overall survival (OS) for newly-diagnosed glioblastoma (GBM) patients. This study assessed the cost-effectiveness of TTFields and TMZ for newly-diagnosed GBM from the US healthcare system perspective. Methods and materials: Outcomes for newly-diagnosed GBM patients were estimated over a lifetime horizon using an area under the curve model with three states: stable disease, progressive disease, or death. The survival model integrated the 5-year EF-14 trial results with long-term GBM epidemiology data and US background mortality rates. Adverse event rates were derived from the EF-14 trial data. Utility values to determine quality-adjusted life-years, adverse event costs, and supportive care costs were obtained from published literature. A 3% discount rate was applied to future costs and outcomes. One-way and probabilistic sensitivity analyses were performed to assess result uncertainty due to parameter variability. Results: Treatment with TTFields and TMZ was estimated to result in a mean increase in survival of 1.25 life years (95% credible range [CR] = 0.89-1.67) and 0.96 quality-adjusted life years (QALYs) (95% CR = 0.67-1.30) compared to treatment with TMZ alone. The incremental total cost was $188,637 (95% CR = $145,324-$225,330). The incremental cost-effectiveness ratio (ICER) was $150,452 per life year gained and $197,336 per QALY gained. The model was most sensitive to changes in the cost of TTFields treatment. Conclusions: Adding TTFields to maintenance TMZ resulted in a substantial increase in the estimated mean lifetime survival and quality-adjusted survival for newly-diagnosed GBM patients. Treatment with TTFields can be considered cost-effective within the reported range of willingness-to-pay thresholds in the US.
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Affiliation(s)
- Gregory F Guzauskas
- Department of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington , Seattle , WA , USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University , Stanford , CA , USA
| | - Volker W Stieber
- Department of Radiation Oncology, Novant Health Forsyth Medical Center , Winston-Salem , NC , USA
| | | | - Louis P Garrison
- Department of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington , Seattle , WA , USA
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18
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Butenschoen VM, Kelm A, Meyer B, Krieg SM. Quality-adjusted life years in glioma patients: a systematic review on currently available data and the lack of evidence-based utilities. J Neurooncol 2019; 144:1-9. [PMID: 31187319 DOI: 10.1007/s11060-019-03210-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cost-effectiveness studies gain importance in the context of rising health care expenses and treatment options. Especially in the neuro-oncological context, surgical therapy may increase overall survival, but restrain the patient by postoperative disability. Quality-adjusted life years, express treatment effects and are based on health utilities. In our study, we analyze the current evidence on health economic evaluations in glioma patients. MATERIAL AND METHODS We performed a systematic database search including Medline and Cochrane Library. Studies were critically appraised for statistical analyzes including glioma patients, health economic modeling and detailed health outcome. Study evidence was classified according to levels of evidence for therapeutic studies from the Centre for Evidence-Based Medicine (Oxford). RESULTS 37 studies (1995-2018) were identified, 29 matched our inclusion criteria. Studies addressed surgical cost-efficiency and/or the standard treatment, postoperative chemotherapy (n = 6) and 5-ALA (n = 3). Only 16 studies used QALY as the outcome measure, most used overall survival or life years gained (LYG). Utilities were either based on one single study (Garside et al. in Health Technol Assess 11:iii-iv, ix-221) or derived from visual analogue scale (VAS). None assessed quality of life values for specific health statuses or utilities. Incremental cost-effectiveness ratios varied from 8325€ per QALY (5-ALA) to 518,342€ per LYG (tumor treating fields). CONCLUSIONS Only one study generated utility values to conduct cost-effectiveness analysis (CEA); most studies used indirect outcomes such as LYG or based their model on previously published data. Health economic evaluations lack specific utilities, further investigations are necessary to conduct reliable CEA in the neurosurgical context.
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Affiliation(s)
- Vicki Marie Butenschoen
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Anna Kelm
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany.
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19
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Abraham P, Sarkar R, Brandel MG, Wali AR, Rennert RC, Lopez Ramos C, Padwal J, Steinberg JA, Santiago-Dieppa DR, Cheung V, Pannell JS, Murphy JD, Khalessi AA. Cost-effectiveness of Intraoperative MRI for Treatment of High-Grade Gliomas. Radiology 2019; 291:689-697. [PMID: 30912721 PMCID: PMC6543900 DOI: 10.1148/radiol.2019182095] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 01/04/2019] [Accepted: 02/04/2019] [Indexed: 01/19/2023]
Abstract
Background Intraoperative MRI has been shown to improve gross-total resection of high-grade glioma. However, to the knowledge of the authors, the cost-effectiveness of intraoperative MRI has not been established. Purpose To construct a clinical decision analysis model for assessing intraoperative MRI in the treatment of high-grade glioma. Materials and Methods An integrated five-state microsimulation model was constructed to follow patients with high-grade glioma. One-hundred-thousand patients treated with intraoperative MRI were compared with 100 000 patients who were treated without intraoperative MRI from initial resection and debulking until death (median age at initial resection, 55 years). After the operation and treatment of complications, patients existed in one of three health states: progression-free survival (PFS), progressive disease, or dead. Patients with recurrence were offered up to two repeated resections. PFS, valuation of health states (utility values), probabilities, and costs were obtained from randomized controlled trials whenever possible. Otherwise, national databases, registries, and nonrandomized trials were used. Uncertainty in model inputs was assessed by using deterministic and probabilistic sensitivity analyses. A health care perspective was used for this analysis. A willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained was used to determine cost efficacy. Results Intraoperative MRI yielded an incremental benefit of 0.18 QALYs (1.34 QALYs with intraoperative MRI vs 1.16 QALYs without) at an incremental cost of $13 447 ($176 460 with intraoperative MRI vs $163 013 without) in microsimulation modeling, resulting in an incremental cost-effectiveness ratio of $76 442 per QALY. Because of parameter distributions, probabilistic sensitivity analysis demonstrated that intraoperative MRI had a 99.5% chance of cost-effectiveness at a willingness-to-pay threshold of $100 000 per QALY. Conclusion Intraoperative MRI is likely to be a cost-effective modality in the treatment of high-grade glioma. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Bettmann in this issue.
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Affiliation(s)
- Peter Abraham
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Reith Sarkar
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Michael G. Brandel
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Arvin R. Wali
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Robert C. Rennert
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Christian Lopez Ramos
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Jennifer Padwal
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Jeffrey A. Steinberg
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - David R. Santiago-Dieppa
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Vincent Cheung
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - J. Scott Pannell
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - James D. Murphy
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
| | - Alexander A. Khalessi
- From the School of Medicine (P.A., R.S., M.G.B., C.L.R., J.P.),
Department of Neurosurgery (A.R.W., R.C.R., J.A.S., D.R.S.D., V.C., J.S.P.,
A.A.K.), and Department of Radiation Oncology (J.D.M.), University of
California–San Diego, 9300 Campus Point Dr, Mail Code 7893, La Jolla, CA
92037
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Connock M, Auguste P, Dussart C, Guyotat J, Armoiry X. Cost-effectiveness of tumor-treating fields added to maintenance temozolomide in patients with glioblastoma: an updated evaluation using a partitioned survival model. J Neurooncol 2019; 143:605-611. [PMID: 31127507 DOI: 10.1007/s11060-019-03197-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 01/13/2023]
Abstract
PURPOSE A first cost-effectiveness analysis has raised a strong concern regarding the cost of tumor treatment fields (TTF) added to maintenance temozolomide for patients with glioblastoma. This evaluation was based on effectiveness outcomes from an interim analysis of the pivotal trial, moreover it used a "standard" Markov model. Our objective was to update the cost-effectiveness evaluation using the more flexible potential of the "partitioned survival" model design and using the latest effectiveness data. METHODS We developed the model with three mutually exclusive health states: stable disease, progressive disease, and dead. Good fit parametric models were developed for overall survival and progression free survival and these generated clinically plausible extrapolations beyond the observed data. We adopted the perspective of the French national health insurance and used a 20-year time horizon. Results were expressed as cost/life-years (LY) gained (LYG). RESULTS The base case model generated incremental benefit of 0.604 LY at a cost of €453,848 which, after 4% annual discounting of benefits and costs, yielded an incremental cost effectiveness ratio (ICER) of €510,273/LYG. Using sensitivity analyses and bootstrapping methods results were found to be relatively robust and were only sensitive to TTF device costs and the modelling of overall survival. To achieve an ICER below €100,000/LYG would require a reduction in TTF device cost of approximately 85%. CONCLUSIONS Using a different type of model and updated survival outcomes, our results show TTF remains an intervention that is not cost-effective, which greatly restrains its diffusion to potentially eligible patients.
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Affiliation(s)
- Martin Connock
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV47AL, UK
| | - Peter Auguste
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV47AL, UK
| | - Claude Dussart
- University of Lyon, EA 4129 P2S (Parcours, Santé, Systémique), Lyon, France
| | - Jacques Guyotat
- Pierre Wertheimer Hospital, Neurosurgery Department, Lyon, France
| | - Xavier Armoiry
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV47AL, UK.
- Pharmacy Department, Edouard Herriot Hospital, Lyon, France.
- Public Health Department, School of Pharmacy (ISPB)/ UMR CNRS MATEIS, Claude Bernard University Lyon 1, University of Lyon, 8 Avenue Rockefeller, 69008, Lyon, France.
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Qian Y, Maruyama S, Kim H, Pollom EL, Kumar KA, Chin AL, Harris JP, Chang DT, Pitt A, Bendavid E, Owens DK, Durkee BY, Soltys SG. Cost-effectiveness of radiation and chemotherapy for high-risk low-grade glioma. Neuro Oncol 2018; 19:1651-1660. [PMID: 28666368 DOI: 10.1093/neuonc/nox121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The addition of procarbazine, lomustine, vincristine (PCV) chemotherapy to radiotherapy (RT) for patients with high-risk (≥40 y old or subtotally resected) low-grade glioma (LGG) results in an absolute median survival benefit of over 5 years. We evaluated the cost-effectiveness of this treatment strategy. Methods A decision tree with an integrated 3-state Markov model was created to follow patients with high-risk LGG after surgery treated with RT versus RT+PCV. Patients existed in one of 3 health states: stable, progressive, or dead. Survival and freedom from progression were modeled to reflect the results of RTOG 9802 using time-dependent transition probabilities. Health utility values and costs of care were derived from the literature and national registry databases. Analysis was conducted from the health care perspective. Deterministic and probabilistic sensitivity analysis explored uncertainty in model parameters. Results Modeled outcomes demonstrated agreement with clinical data in expected benefit of addition of PCV to RT. The addition of PCV to RT yielded an incremental benefit of 4.77 quality-adjusted life-years (QALYs) (9.94 for RT+PCV vs 5.17 for RT alone) at an incremental cost of $48635 ($188234 for RT+PCV vs $139598 for RT alone), resulting in an incremental cost-effectiveness ratio of $10186 per QALY gained. Probabilistic sensitivity analysis demonstrates that within modeled distributions of parameters, RT+PCV has 99.96% probability of being cost-effectiveness at a willingness-to-pay threshold of $100000 per QALY. Conclusion The addition of PCV to RT is a cost-effective treatment strategy for patients with high-risk LGG.
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Affiliation(s)
- Yushen Qian
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Satoshi Maruyama
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Haju Kim
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Kiran A Kumar
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Jeremy P Harris
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Allison Pitt
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Eran Bendavid
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Douglas K Owens
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Ben Y Durkee
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California; Division of Management Science and Engineering, Department of Engineering, Stanford University, Stanford, California; VA Palo Alto Health Care System, and Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, California; Swedish American Hospital, a division of the University of Wisconsin, Rockford, Illinois
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Mima A, Tansho K, Nagahara D, Watase K. Treatment of secondary hyperparathyroidism in patients on hemodialysis using a novel synthetic peptide calcimimetic, etelcalcetide: a short-term clinical study. J Int Med Res 2018; 46:4578-4585. [PMID: 30027791 PMCID: PMC6259360 DOI: 10.1177/0300060518786913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Secondary hyperparathyroidism (SHPT) is a major complication in patients with chronic kidney disease (CKD). SHPT is related to chronic kidney disease-mineral bone disorder, leading to increased morbidity and mortality. Etelcalcetide is intravenously administered at the end of hemodialysis (HD). Etelcalcetide differs from the oral calcimimetic cinacalcet because it reduces gastrointestinal adverse events, thereby improving therapeutic effects. Etelcalcetide has only been approved by the U.S. Food and Drug Administration for several months. Therefore, there have only been a few reports regarding treatment of SHPT using etelcalcetide. This study aimed to evaluate the efficacy of etelcalcetide in patients on HD with SHPT. Methods Nine patients on HD (four men and five women, aged 58 ± 10 years) were enrolled in this study. All of the patients received etelcalcetide (5–10 mg, three times a week after HD). The observation period was 4.4 ± 1.0 months. Results All of the patients showed a significant reduction in serum parathyroid hormone levels during the observation period (−59% ± 20%). No significant adverse effects were observed. Conclusions Although this study had an uncontrolled small group and a short observation period, our results suggest that etelcalcetide could be a promising agent for SHPT treatment.
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Affiliation(s)
- Akira Mima
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Kosuke Tansho
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Dai Nagahara
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Kenji Watase
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
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Gray E, Butler HJ, Board R, Brennan PM, Chalmers AJ, Dawson T, Goodden J, Hamilton W, Hegarty MG, James A, Jenkinson MD, Kernick D, Lekka E, Livermore LJ, Mills SJ, O'Neill K, Palmer DS, Vaqas B, Baker MJ. Health economic evaluation of a serum-based blood test for brain tumour diagnosis: exploration of two clinical scenarios. BMJ Open 2018; 8:e017593. [PMID: 29794088 PMCID: PMC5988134 DOI: 10.1136/bmjopen-2017-017593] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To determine the potential costs and health benefits of a serum-based spectroscopic triage tool for brain tumours, which could be developed to reduce diagnostic delays in the current clinical pathway. DESIGN A model-based health pre-trial economic assessment. Decision tree models were constructed based on simplified diagnostic pathways. Models were populated with parameters identified from rapid reviews of the literature and clinical expert opinion. SETTING Explored as a test in both primary and secondary care (neuroimaging) in the UK health service, as well as application to the USA. PARTICIPANTS Calculations based on an initial cohort of 10 000 patients. In primary care, it is estimated that the volume of tests would approach 75 000 per annum. The volume of tests in secondary care is estimated at 53 000 per annum. MAIN OUTCOME MEASURES The primary outcome measure was quality-adjusted life-years (QALY), which were employed to derive incremental cost-effectiveness ratios (ICER) in a cost-effectiveness analysis. RESULTS Results indicate that using a blood-based spectroscopic test in both scenarios has the potential to be highly cost-effective in a health technology assessment agency decision-making process, as ICERs were well below standard threshold values of £20 000-£30 000 per QALY. This test may be cost-effective in both scenarios with test sensitivities and specificities as low as 80%; however, the price of the test would need to be lower (less than approximately £40). CONCLUSION Use of this test as triage tool in primary care has the potential to be both more effective and cost saving for the health service. In secondary care, this test would also be deemed more effective than the current diagnostic pathway.
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Affiliation(s)
- Ewan Gray
- Health Improvement Scotland, Glasgow, UK
| | - Holly J Butler
- Department of Pure and Applied Chemistry, University of Strathclyde Technology and Innovation Centre, Glasgow, UK
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
| | - Ruth Board
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Preston, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Anthony J Chalmers
- Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, UK
| | - Timothy Dawson
- Neurosurgery Department, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Preston, UK
| | - John Goodden
- Neurosurgery Department, Leeds General Infirmary, Leeds, UK
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, College House, University of Exeter, Exeter, UK
| | - Mark G Hegarty
- Department of Pure and Applied Chemistry, University of Strathclyde Technology and Innovation Centre, Glasgow, UK
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
| | - Allan James
- Institute of Molecular Cell and Systems Biology, Glasgow, UK
| | - Michael D Jenkinson
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Translational Medicine, Clinical Science Centre, University of Liverpool, Liverpool, UK
| | | | - Elvira Lekka
- Neurosurgery Department, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Preston, UK
| | - Laurent J Livermore
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Samantha J Mills
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kevin O'Neill
- John Fulcher Neuro-Oncology Laboratory, Imperial College, London, UK
| | - David S Palmer
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
- WestCHEM, Department of Pure and Applied Chemistry, University of Strathclyde, Glasgow, UK
| | - Babar Vaqas
- John Fulcher Neuro-Oncology Laboratory, Imperial College, London, UK
| | - Matthew J Baker
- Department of Pure and Applied Chemistry, University of Strathclyde Technology and Innovation Centre, Glasgow, UK
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
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24
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Wang Y, Huang N, Li H, Liu S, Chen X, Yu S, Wu N, Bian XW, Shen HY, Li C, Xiao L. Promoting oligodendroglial-oriented differentiation of glioma stem cell: a repurposing of quetiapine for the treatment of malignant glioma. Oncotarget 2018; 8:37511-37524. [PMID: 28415586 PMCID: PMC5514926 DOI: 10.18632/oncotarget.16400] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/01/2017] [Indexed: 12/15/2022] Open
Abstract
As a major contributor of chemotherapy resistance and malignant recurrence, glioma stem cells (GSCs) have been proposed as a target for the treatment of gliomas. To evaluate the therapeutic potential of quetiapine (QUE), an atypical antipsychotic, for the treatment of malignant glioma, we established mouse models with GSCs-initiated orthotopic xenograft gliomas and subcutaneous xenograft tumors, using GSCs purified from glioblastoma cell line GL261. We investigated antitumor effects of QUE on xenograft gliomas and its underlying mechanisms on GSCs. Our data demonstrated that (i) QUE monotherapy can effectively suppress GSCs-initiated tumor growth; (ii) QUE has synergistic effects with temozolomide (TMZ) on glioma suppression, and importantly, QUE can effectively suppress TMZ-resistant (or -escaped) tumors generated from GSCs; (iii) mechanistically, the anti-glioma effect of QUE was due to its actions of promoting the differentiation of GSCs into oligodendrocyte (OL)-like cells and its inhibitory effect on the Wnt/β-catenin signaling pathway. Together, our findings suggest an effective approach for anti-gliomagenic treatment via targeting OL-oriented differentiation of GSCs. This also opens a door for repurposing QUE, an FDA approved drug, for the treatment of malignant glioma.
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Affiliation(s)
- Yun Wang
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
| | - Nanxin Huang
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
| | - Hongli Li
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
| | - Shubao Liu
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
| | - Xianjun Chen
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
| | - Shichang Yu
- Department of Pathology, Southwest Hospital, Chongqing 400038, China
| | - Nan Wu
- Department of Neurosurgery, Southwest Hospital, Chongqing 400038, China
| | - Xiu-Wu Bian
- Department of Pathology, Southwest Hospital, Chongqing 400038, China
| | - Hai-Ying Shen
- Robert Stone Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR 97232, USA
| | - Chengren Li
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
| | - Lan Xiao
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Third Military Medical University, Chongqing 400038, China
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Genetic polymorphisms and response to 5-fluorouracil, doxorubicin and cyclophosphamide chemotherapy in breast cancer patients. Oncotarget 2018; 7:66790-66808. [PMID: 27527855 PMCID: PMC5341838 DOI: 10.18632/oncotarget.11053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/18/2016] [Indexed: 11/25/2022] Open
Abstract
Clinical resistance to chemotherapy is one of the major problems in breast cancer treatment. In this study we analyzed possible impact of 22 polymorphic variants on the treatment response in 324 breast cancer patients. Selected genes were involved in FAC chemotherapy drugs transport (ABCB1, ABCC2, ABCG2, SLC22A16), metabolism (CYP1B1, CYP2C19, GSTT1, GSTM1, GSTP1, TYMS, MTHFR, DPYD), drug-induced damage repair (ERCC1, ERCC2, XRCC1) and involved in regulation of DNA damage response and cell cycle control (ATM, TP53). Apart from preexisting metastases three polymorphic variants were independent prognostic high risk factors of lack of response to FAC chemotherapy. Our results showed that the response to treatment depended of the variability in genes engaged in drugs’ transport (ABCC2 c.-24C>T, ABCB1 p.Ser893Ala/Thr) and in DNA repair machinery (ERCC2 p.Lys751Gln). Furthermore, the growing number of high-risk genotypes was reflected in gradual increase in risk of the non-responsiveness to treatment- from OR 2.68 for presence of two genotypes to OR 9.93 for carriers of all three negative genotypes in the group of all patients. Similar gene-dosage effect was observed in the subgroup of TNBCs. Also, TFFS significantly shortened with the increasing number of high-risk genotypes, with median of 54.4 months for carriers of one variant, to 51.5 and 34.9 months for the carriers of two and three genotypes, respectively. Our results demonstrate that results of cancer treatment are the effect of many clinical and genetic factors. It seems that multifactorial polymorphic models could be a potentially useful tool in personalization of cancer therapies. The novelty in our model is the over representation of triple negative breast cancer (TNBC) patients among the carriers of all unfavorable polymorphic variants. This finding contributes to the elucidation of the mechanisms of drug resistance in this subgroup of breast cancer patients.
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Schiff D, Schrag D. Living in a material world: tumor-treating fields at the top of the charts. Neuro Oncol 2018; 18:1033-4. [PMID: 27382117 DOI: 10.1093/neuonc/now138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Schiff
- University of Virginia Neuro-Oncology Center, Charlottesville, Virginia (D. Schiff); Dana-Farber Cancer Institute, Boston, Massachusetts (D. Schrag)
| | - Deborah Schrag
- University of Virginia Neuro-Oncology Center, Charlottesville, Virginia (D. Schiff); Dana-Farber Cancer Institute, Boston, Massachusetts (D. Schrag)
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Wu B, Liu M, Li T, Lin H, Zhong H. An economic analysis of high-dose imatinib, dasatinib, and nilotinib for imatinib-resistant chronic phase chronic myeloid leukemia in China: A CHEERS-compliant article. Medicine (Baltimore) 2017; 96:e7445. [PMID: 28723754 PMCID: PMC5521894 DOI: 10.1097/md.0000000000007445] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of the study was to test the cost-effectiveness of dasatinib compared to high-dose imatinib and nilotinib in Chinese patients who were diagnosed with imatinib-resistant chronic myeloid leukemia in the chronic phase (CML-CP). METHODS A Markov model combined with clinical effectiveness, utility, and cost data was used. The sensitivity analyses were conducted to determine the robustness of the model outcomes. The impact of patient assistance programs (PAPs) was assessed. RESULTS Treatment with dasatinib is expected to produce 3.65, 0.59, and 0.15 more quality-adjusted life years (QALYs) in comparison with high-dose imatinib (600 and 800 mg) and nilotinib, respectively. When a PAP was available, dasatinib yielded an incremental cost of $16,417 per QALY compared to imatinib (600 mg) and was cost-saving compared to imatinib (800 mg) and nilotinib. CONCLUSION When PAP is available in the Chinese setting, dasatinib is likely to be a cost-effective strategy for patients with CML-CP standard-dose imatinib resistance. The results should be carefully explained due to the assumptions and limitations used in the study.
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Affiliation(s)
- Bin Wu
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai
| | - Maobai Liu
- Department of Pharmacy, Fujian Union Hospital, Affiliated with Fujian Medical University, Fujian
| | - Te Li
- Department of Pharmacy, Yuxi People's Hospital, Affiliated with the Kunming Medical College, Yuxi
| | - Houwen Lin
- Department of Pharmacy, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University
| | - Hua Zhong
- Department of Hematology, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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28
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Bernard-Arnoux F, Lamure M, Ducray F, Aulagner G, Honnorat J, Armoiry X. The cost-effectiveness of tumor-treating fields therapy in patients with newly diagnosed glioblastoma. Neuro Oncol 2016; 18:1129-36. [PMID: 27177573 PMCID: PMC4933490 DOI: 10.1093/neuonc/now102] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND There is strong concern about the costs associated with adding tumor-treating fields (TTF) therapy to standard first-line treatment for glioblastoma (GBM). Hence, we aimed to determine the cost-effectiveness of TTF therapy for the treatment of newly diagnosed patients with GBM. METHODS We developed a 3-health-state Markov model. The perspective was that of the French Health Insurance, and the horizon was lifetime. We calculated the transition probabilities from the survival parameters reported in the EF-14 trial. The main outcome measure was incremental effectiveness expressed as life-years gained (LYG). Input costs were derived from the literature. We calculated the incremental cost-effectiveness ratio (ICER) expressed as cost/LYG. We used 1-way deterministic and probabilistic sensitivity analysis to evaluate the model uncertainty. RESULTS In the base-case analysis, adding TTF therapy to standard of care resulted in increases of life expectancy of 4.08 months (0.34 LYG) and €185 476 per patient. The ICER was €549 909/LYG. The discounted ICER was €596 411/LYG. Parameters with the most influence on ICER were the cost of TTF therapy, followed equally by overall survival and progression-free survival in both arms. The probabilistic sensitivity analysis showed a 95% confidence interval of the ICER of €447 017/LYG to €745 805/LYG with 0% chance to be cost-effective at a threshold of €100 000/LYG. CONCLUSION The ICER of TTF therapy at first-line treatment is far beyond conventional thresholds due to the prohibitive announced cost of the device. Strong price regulation by health authorities could make this technology more affordable and consequently accessible to patients.
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Affiliation(s)
- F Bernard-Arnoux
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - M Lamure
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - F Ducray
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - G Aulagner
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - J Honnorat
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
| | - X Armoiry
- Université de Lyon, Claude Bernard Lyon 1, Lyon, France (F.B.-A., M.L.); Neuro-oncology Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University of Lyon, University Claude Bernard Lyon 1, Lyon, France (F.D., J.H.); Hospices Civils de Lyon, Groupement Hospitalier Est, Pharmacy Department/UMR CNRS 5510 MATEIS, University of Lyon, University Claude Bernard Lyon 1, Bron, France (G.A.); Hospices Civils de Lyon, Délégation à la Recherche Clinique et à l'Innovation, Cellule Innovation/UMR CNRS 5510 MATEIS, Bron, France (X.A.)
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Zhao J, Chen ZQ, Li GW, Yang M, Shao J, Li M. The associations of vascular endothelial growth factor gene polymorphisms with susceptibility to osteosarcoma: evidence from a meta-analysis. Eur J Cancer Care (Engl) 2016; 26. [PMID: 27144378 DOI: 10.1111/ecc.12513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2016] [Indexed: 12/20/2022]
Abstract
Several studies have investigated the associations of the vascular endothelial growth factor (VEGF) gene polymorphisms with the susceptibility to osteosarcoma, while their conclusions are conflicting. This meta-analysis was performed to provide a comprehensive assessment on those associations. Electronic bibliographic databases were searched for potential studies focused on the relationship between VEGF polymorphisms and the susceptibility to osteosarcoma on 10 December 2015. Pooled odds ratios with 95% confidence intervals were conducted to assess the associations. After strict screening process, six articles consisted of 1220 osteosarcoma patients and 1576 controls were selected. The pooled results suggested that VEGF-2578C/A polymorphism was significantly associated with osteosarcoma risk in all genetic models as well as VEGF-634G/C polymorphism. When it came to VEGF+936C/T polymorphism, we detected significant associations under allele contrast, heterozygote, dominant and recessive models. As to VEFG-460T/C polymorphism, significant associations were demonstrated in allele contrast and heterozygote models. With regard to VEGF-1156G/A polymorphism, significant association was observed only in alleles contrast model. However, there was no significant association between VEGF-1612G/A polymorphism and risk of osteosarcoma. This meta-analysis suggests that these polymorphisms comprised of VEGF-2578C/A, VEGF-1156G/A, VEGF+936C/T, VEGF-634G/C and VEGF-460T/C are associated with osteosarcoma risk in Chinese Han population.
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Affiliation(s)
- J Zhao
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Z Q Chen
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - G W Li
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - M Yang
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - J Shao
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - M Li
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai, China
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Abstract
Radiotherapy (RT) has proven to be an effective therapeutic tool in treatment of a wide variety of brain tumors; however, it has a negative impact on quality of life and neurocognitive function. Cognitive dysfunction associated with both the disease and adverse effects of RT is one of the most concerning complication among long-term survivors. The effects of RT to brain can be divided into acute, early delayed, and late delayed. It is, however, the late delayed effects of RT that lead to severe neurological consequences such as minor-to-severe cognitive deficits due to irreversible focal or diffuse necrosis of brain parenchyma. In this review, we discuss current and emerging data regarding the relationship between RT and neurocognitive outcomes, and therapeutic strategies to prevent/treat postradiation neurocognitive deficits.
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31
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Lien LM, Wang MJ, Chen RJ, Chiu HC, Wu JL, Shen MY, Chou DS, Sheu JR, Lin KH, Lu WJ. Nobiletin, a Polymethoxylated Flavone, Inhibits Glioma Cell Growth and Migration via Arresting Cell Cycle and Suppressing MAPK and Akt Pathways. Phytother Res 2015; 30:214-21. [PMID: 26560814 DOI: 10.1002/ptr.5517] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/15/2015] [Accepted: 10/19/2015] [Indexed: 12/18/2022]
Abstract
Nobiletin, a bioactive polymethoxylated flavone (5,6,7,8,3(') ,4(') -hexamethoxyflavone), is abundant in citrus fruit peel. Although nobiletin exhibits antitumor activity against various cancer cells, the effect of nobiletin on glioma cells remains unclear. The aim of this study was to determine the effects of nobiletin on the human U87 and Hs683 glioma cell lines. Treating glioma cells with nobiletin (20-100 µm) reduced cell viability and arrested the cell cycle in the G0/G1 phase, as detected using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and propidium iodide (PI) staining, respectively; however, nobiletin did not induce cell apoptosis according to PI-annexin V double staining. Data from western blotting showed that nobiletin significantly attenuated the expression of cyclin D1, cyclin-dependent kinase 2, cyclin-dependent kinase 4, and E2 promoter-binding factor 1 (E2F1) and the phosphorylation of Akt/protein kinase B and mitogen-activated protein kinases, including p38, extracellular signal-regulated kinase, and c-Jun N-terminal kinase. Our data also showed that nobiletin inhibited glioma cell migration, as detected by both functional wound healing and transwell migration assays. Altogether, the present results suggest that nobiletin inhibits mitogen-activated protein kinase and Akt/protein kinase B pathways and downregulates positive regulators of the cell cycle, leading to subsequent suppression of glioma cell proliferation and migration. Our findings evidence that nobiletin may have potential for treating glioblastoma multiforme.
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Affiliation(s)
- Li-Ming Lien
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Meng-Jiy Wang
- Department of Chemical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan.,Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Ray-Jade Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hou-Chang Chiu
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Jia-Lun Wu
- Central Laboratory, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ming-Yi Shen
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Duen-Suey Chou
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Joen-Rong Sheu
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Hung Lin
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan.,Central Laboratory, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wan-Jung Lu
- Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan.,Department of Medical Research, Taipei Medical University Hospital, Taipei, Taiwan
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Hutóczki G, Bognár L, Tóth J, Scholtz B, Zahuczky G, Hanzély Z, Csősz É, Reményi-Puskár J, Kalló G, Hortobágyi T, Klekner A. Effect of Concomitant Radiochemotherapy on Invasion Potential of Glioblastoma. Pathol Oncol Res 2015; 22:155-60. [PMID: 26450124 DOI: 10.1007/s12253-015-9989-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/29/2015] [Indexed: 01/22/2023]
Abstract
Glioblastoma (GBM) is the most common primary brain tumor in adults with inevitable recurrence after oncotherapy. The insufficient effect of "gold standard" temozolomide-based concomitant radiochemotherapy may be due to the inability to prevent tumor cell invasion. Peritumoral infiltration depends mainly on the interaction between extracellular matrix (ECM) components and cell membrane receptors. Changes in invasive behaviour after oncotherapy can be evaluated at the molecular level by determining the RNA expression and protein levels of the invasion-related ECM components. The expression of nineteen ECM molecules was determined at both RNA and protein levels in thirty-one GBM samples. Fifteen GBM samples originated from the first surgical procedure on patients before oncotherapy, and sixteen GBM samples were collected at the second surgery due to local recurrence after concomitant chemoirradiation. RNA expressions were measured with qRT-PCR, and protein levels were determined by quantitative analysis of Western blots. Only MMP-9 RNA transcript level was reduced (p < 0.05) whereas at protein level, eight molecules showed changes concordant with RNA expression with significant decrease in brevican only. The results suggest that concomitant radiochemotherapy does not have sufficient impact on the expression of invasion-related ECM components of glioblastoma, oncotherapy does not significantly affect its invasive behavior. To avoid the spread of tumors into the brain parenchyma, supplementation of antiproliferative treatment with anti-invasive agents may be worth consideration in oncotherapy for glioblastoma.
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Affiliation(s)
- Gábor Hutóczki
- Department of Neurosurgery, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - László Bognár
- Department of Neurosurgery, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary.
| | - Judit Tóth
- Department of Oncology, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Beáta Scholtz
- Department of Biochemistry and Molecular Biology, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Gábor Zahuczky
- Department of Biochemistry and Molecular Biology, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary.,UD-Genomed Medical Genomic Technologies Ltd., Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Zoltán Hanzély
- National Institute of Clinical Neurosciences, Amerikai út 57, Budapest, 1145, Hungary
| | - Éva Csősz
- Department of Biochemistry and Molecular Biology, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Judit Reményi-Puskár
- Department of Neurosurgery, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Gergő Kalló
- Department of Biochemistry and Molecular Biology, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Tibor Hortobágyi
- Division of Neuropathology, Institute of Pathology, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, 4032, Hungary
| | - Almos Klekner
- Department of Neurosurgery, University of Debrecen, Clinical Center, Nagyerdei krt. 98, Debrecen, 4032, Hungary
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Xanthohumol from Humulus lupulus L. induces glioma cell autophagy via inhibiting Akt/mTOR/S6K pathway. J Funct Foods 2015. [DOI: 10.1016/j.jff.2015.08.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Esteves S, Alves M, Castel-Branco M, Stummer W. A pilot cost-effectiveness analysis of treatments in newly diagnosed high-grade gliomas: the example of 5-aminolevulinic Acid compared with white-light surgery. Neurosurgery 2015; 76:552-62; discussion 562. [PMID: 25714513 PMCID: PMC4410964 DOI: 10.1227/neu.0000000000000673] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High-grade gliomas are aggressive, incurable tumors characterized by extensive diffuse invasion of the normal brain parenchyma. Novel therapies at best prolong survival; their costs are formidable and benefit is marginal. Economic restrictions thus require knowledge of the cost-effectiveness of treatments. Here, we show the cost-effectiveness of enhanced resections in malignant glioma surgery using a well-characterized tool for intraoperative tumor visualization, 5-aminolevulinic acid (5-ALA). OBJECTIVE To evaluate the cost-effectiveness of 5-ALA fluorescence-guided neurosurgery compared with white-light surgery in adult patients with newly diagnosed high-grade glioma, adopting the perspective of the Portuguese National Health Service. METHODS We used a Markov model (cohort simulation). Transition probabilities were estimated with the use of data from 1 randomized clinical trial and 1 noninterventional prospective study. Utility values and resource use were obtained from published literature and expert opinion. Unit costs were taken from official Portuguese reimbursement lists (2012 values). The health outcomes considered were quality-adjusted life-years, life-years, and progression-free life-years. Extensive 1-way and probabilistic sensitivity analyses were performed. RESULTS The incremental cost-effectiveness ratios are below &OV0556;10 000 in all evaluated outcomes, being around &OV0556;9100 per quality-adjusted life-year gained, &OV0556;6700 per life-year gained, and &OV0556;8800 per progression-free life-year gained. The probability of 5-ALA fluorescence-guided surgery cost-effectiveness at a threshold of &OV0556;20000 is 96.0% for quality-adjusted life-year, 99.6% for life-year, and 98.8% for progression-free life-year. CONCLUSION 5-ALA fluorescence-guided surgery appears to be cost-effective in newly diagnosed high-grade gliomas compared with white-light surgery. This example demonstrates cost-effectiveness analyses for malignant glioma surgery to be feasible on the basis of existing data.
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Affiliation(s)
- Susana Esteves
- *Clinical Research Unit, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal; ‡Epidemiology and Statistics Unit, Research Center of Centro Hospitalar de Lisboa Central, Hospital Dona Estefânia, Lisboa, Portugal; §Microbiology Department, Escola Superior de Hotelaria e Turismo do Estoril, Estoril, Portugal; ¶Department of Neurosurgery, University of Münster, Münster, Germany
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35
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Savitz ST, Chen RC, Sher DJ. Cost-effectiveness analysis of neurocognitive-sparing treatments for brain metastases. Cancer 2015; 121:4231-9. [DOI: 10.1002/cncr.29642] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/27/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Samuel T. Savitz
- Department of Health Policy and Management; University of North Carolina Gillings School of Global Public Health; Chapel Hill North Carolina
| | - Ronald C. Chen
- Department of Radiation Oncology; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Lineberger Comprehensive Cancer Center; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - David J. Sher
- Department of Radiation Oncology; University of Texas Southwestern Medical Center; Dallas Texas
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Kovic B, Xie F. Economic Evaluation of Bevacizumab for the First-Line Treatment of Newly Diagnosed Glioblastoma Multiforme. J Clin Oncol 2015; 33:2296-302. [DOI: 10.1200/jco.2014.59.7245] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Purpose The Avastin in Glioblastoma trial has shown that patients newly diagnosed with glioblastoma multiforme (GBM) treated with bevacizumab plus radiotherapy and temozolomide versus radiotherapy and temozolomide alone showed improvement in progression-free survival, possibly leading to a new indication for first-line use of bevacizumab in GBM. The cost-utility of this new intervention remains unknown; therefore, we developed a Markov model estimating the incremental cost-utility ratio (ICUR) from a Canadian public payer perspective. Methods We incorporated trial data for state transitions and treatment effects from the Avastin in Glioblastoma trial, costs and resource use data from Canadian published studies and databases, and utility parameters from published literature. We addressed uncertainty through one-way deterministic and probabilistic sensitivity analyses, extended the model to lifetime horizon and by another arm to compare first-line versus second-line use of bevacizumab on progression, performed value of information analysis, and performed US costing sensitivity analysis. Results Adding bevacizumab to radiotherapy and temozolomide resulted in increases of 0.13 quality-adjusted life-years (QALYs) and $80,000 per patient over 2-year time horizon at the base case analysis. The ICUR was $607,966/QALY (95% CI, $305,000/QALY to $2,550,000/QALY), with 0% chance of being cost effective at the $100,000/QALY willingness-to-pay threshold and never going below $450,000/QALY in the one-way sensitivity analysis. The ICUR using the US costing data was $787,519/QALY. The lifetime ICUR was $439,764/QALY (95% CI, $235,000/QALY to $1,520,000/QALY), never going below $350,000/QALY in the sensitivity analysis. Second-line use of bevacizumab on progression is more effective and less expensive than its first-line use. Value of information analysis revealed that future research is unwarranted. Conclusion Bevacizumab has only limited effectiveness and is therefore not likely to be cost effective in treating adult patients with newly diagnosed GBM.
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Affiliation(s)
- Bruno Kovic
- All authors: McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- All authors: McMaster University, Hamilton, Ontario, Canada
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37
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Xing WK, Shao C, Qi ZY, Yang C, Wang Z. The role of Gliadel wafers in the treatment of newly diagnosed GBM: a meta-analysis. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:3341-8. [PMID: 26170620 PMCID: PMC4492653 DOI: 10.2147/dddt.s85943] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Standard treatment for high-grade glioma (HGG) includes surgery followed by radiotherapy and/or chemotherapy. Insertion of carmustine wafers into the resection cavity as a treatment for malignant glioma is currently a controversial topic among neurosurgeons. Our meta-analysis focused on whether carmustine wafer treatment could significantly benefit the survival of patients with newly diagnosed glioblastoma multiforme (GBM). Method We searched the PubMed and Web of Science databases without any restrictions on language using the keywords “Gliadel wafers”, “carmustine wafers”, “BCNU wafers”, or “interstitial chemotherapy” in newly diagnosed GBM for the period from January 1990 to March 2015. Randomized controlled trials (RCTs) and cohort studies/clinical trials that compared treatments designed with and without carmustine wafers and which reported overall survival or hazard ratio (HR) or survival curves were included in this study. Moreover, the statistical analysis was conducted by the STATA 12.0 software. Results Six studies including two RCTs and four cohort studies, enrolling a total of 513 patients (223 with and 290 without carmustine wafers), matched the selection criteria. Carmustine wafers showed a strong advantage when pooling all the included studies (HR =0.63, 95% confidence interval (CI) =0.49–0.81; P=0.019). However, the two RCTs did not show a statistical increase in survival in the group with carmustine wafer compared to the group without it (HR =0.51, 95% CI =0.18–1.41; P=0.426), while the cohort studies demonstrated a significant survival increase (HR =0.59, 95% CI =0.44–0.79; P<0.0001). Conclusion Carmustine-impregnated wafers play a significant role in improving survival when used for patients with newly diagnosed GBM. More studies should be designed for newly diagnosed GBM in the future.
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Affiliation(s)
- Wei-kang Xing
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Chuan Shao
- Department of Neurosurgery, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, Sichuan, People's Republic of China
| | - Zhen-yu Qi
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Chao Yang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
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38
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Chowdhary SA, Ryken T, Newton HB. Survival outcomes and safety of carmustine wafers in the treatment of high-grade gliomas: a meta-analysis. J Neurooncol 2015; 122:367-82. [PMID: 25630625 PMCID: PMC4368843 DOI: 10.1007/s11060-015-1724-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 01/19/2015] [Indexed: 11/24/2022]
Abstract
Carmustine wafers (CW; Gliadel(®) wafers) are approved to treat newly-diagnosed high-grade glioma (HGG) and recurrent glioblastoma. Widespread use has been limited for several reasons, including concern that their use may preclude enrollment in subsequent clinical trials due to uncertainty about confounding of results and potential toxicities. This meta-analysis estimated survival following treatment with CW for HGG. A literature search identified relevant studies. Overall survival (OS), median survival, and adverse events (AEs) were summarized. Analysis of variance evaluated effects of treatment (CW vs non-CW) and diagnosis (new vs recurrent) on median survival. The analysis included 62 publications, which reported data for 60 studies (CW: n = 3,162; non-CW: n = 1,736). For newly-diagnosed HGG, 1-year OS was 67 % with CW and 48 % without; 2-year OS was 26 and 15 %, respectively; median survival was 16.4 ± 21.6 months and 13.1 ± 29.9 months, respectively. For recurrent HGG, 1-year OS was 37 % with CW and 34 % without; 2-year OS was 15 and 12 %, respectively; median survival was 9.7 ± 20.9 months and 8.6 ± 22.6 months, respectively. Effects of treatment (longer median survival with CW than without; P = 0.043) and diagnosis (longer median survival for newly-diagnosed HGG than recurrent; P < 0.001) on median survival were significant, with no significant treatment-by-diagnosis interaction (P = 0.620). The most common AE associated with wafer removal was surgical site infection (SSI); the most common AEs for repeat surgery were mass effect, SSI, hydrocephalus, cysts in resection cavity, acute hematoma, wound healing complications, and brain necrosis. These data may be useful in the context of utilizing CW in HGG management, and in designing future clinical trials to allow CW-treated patients to participate in experimental protocols.
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Affiliation(s)
- Sajeel A. Chowdhary
- Department of Neuro-Oncology, Florida Hospital Cancer Institute, 2501 N. Orange Avenue, Suite 286, Orlando, FL 32804 USA
| | - Timothy Ryken
- Department of Neurosurgery, Iowa Spine and Brain Institute, 2710 St. Francis Drive, Waterloo, IA 50702 USA
| | - Herbert B. Newton
- Departments of Neurology, Neurosurgery, and Oncology, Wexner Medical Center at the Ohio State University and James Cancer Hospital, M410-B Starling-Loving Hall, 320 West 10th Avenue, Columbus, OH 43210 USA
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Müller D, Pullenayegum E, Gandjour A. Impact of small study bias on cost-effectiveness acceptability curves and value of information analyses. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2015; 16:219-223. [PMID: 24840608 DOI: 10.1007/s10198-014-0607-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 04/23/2014] [Indexed: 06/03/2023]
Abstract
It is well known that small, randomized, controlled trials (RCTs) have limited validity. When comparing the results of meta-analyses with those of later large trials or with those of large trials removed from the meta-analyses, discrepancies were reported. This paper addresses two issues: (1) how measures of the uncertainty in cost-effectiveness, i.e., cost-effectiveness acceptability curves (CEACs), and the expected value of perfect information (EVPI) are affected by the limited validity of small trials and (2) how to deal with this bias. To this end, the paper adopts a Bayesian approach. Using empirical estimates for the validity of small RCTs compared to larger RCTs, the probability of cost-effectiveness drops by almost 10 %, while the EVPI is three times higher. In conclusion, traditional CEACs and EVPI analyses based on (small) RCTs may need careful appraisal. Ignoring prior evidence on the validity of small-size trials leads to an underestimation of uncertainty in cost-effectiveness. For future economic analyses, it is important to incorporate aspects of uncertainty which are caused by flawed data on effectiveness .
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Affiliation(s)
- Dirk Müller
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany,
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Koh J, Cho H, Kim H, Kim SI, Yun S, Park CK, Lee SH, Choi SH, Park SH. IDH2 mutation in gliomas including novel mutation. Neuropathology 2014; 35:236-44. [PMID: 25495392 DOI: 10.1111/neup.12187] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/25/2014] [Accepted: 10/28/2014] [Indexed: 11/28/2022]
Abstract
Glioblastomas (GBMs) are the most aggressive type of primary brain tumors and provide a dismal prognosis. Thus far, several key genes have been identified in GBMs as prognostic and therapeutic targets. Mutations in two isocitrate dehydrogenase (IDH) genes, IDH1 and IDH2, commonly occur in low-grade gliomas and secondary high-grade gliomas, but are rare in primary GBMs. These mutations alter the catalytic activity of IDH proteins, promoting gliomagenesis. Gliomas with IDH1 or IDH2 mutation have better outcomes than do gliomas with wild-type IDH. The hot spots of IDH1 mutations (R132) and IDH2 mutations (R140 and R172) are well known and are considered as a possible biochemical explanation for the differing clinical characteristics of primary and secondary GBMs. We sought to find the incidence of IDH2 mutation and the characteristics of the gliomas with IDH2 mutation. Among 134 gliomas, which were operated in our hospital consecutively, we studied IDH1 and IDH2 mutations by Sanger sequencing and IDH2 mutation was identified in seven cases (5.2%, four oligodendrogliomas and three GBMs). IDH2 mutation was found in 3.3% of GBMs (3/90 cases) and 9.0% (4/44) of grades II to III gliomas. Here, we report the clinicopathological characteristics of the gliomas with IDH2 mutations including two cases of primary GBM carrying a novel missense IDH2 mutation (c. 484C>T, p. P162S).
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Affiliation(s)
- Jaemoon Koh
- Department of Pathology, Seoul National University Hospital, Seoul, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Hwajin Cho
- Department of Pathology, Seoul National University Hospital, Seoul, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Hannah Kim
- Department of Pathology, Seoul National University Hospital, Seoul, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Ik Kim
- Department of Pathology, Seoul National University Hospital, Seoul, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Sumi Yun
- Department of Pathology, Seoul National University Hospital, Seoul, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Se-Hoon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung Hong Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Seoul, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea.,Neuroscience Institute, Seoul National University College of Medicine, Seoul, Korea
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Raizer JJ, Fitzner KA, Jacobs DI, Bennett CL, Liebling DB, Luu TH, Trifilio SM, Grimm SA, Fisher MJ, Haleem MS, Ray PS, McKoy JM, DeBoer R, Tulas KME, Deeb M, McKoy JM. Economics of Malignant Gliomas: A Critical Review. J Oncol Pract 2014; 11:e59-65. [PMID: 25466707 DOI: 10.1200/jop.2012.000560] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Approximately 18,500 persons are diagnosed with malignant glioma in the United States annually. Few studies have investigated the comprehensive economic costs. We reviewed the literature to examine costs to patients with malignant glioma and their families, payers, and society. METHODS A total of 18 fully extracted studies were included. Data were collected on direct and indirect costs, and cost estimates were converted to US dollars using the conversion rate calculated from the study's publication date, and updated to 2011 values after adjustment for inflation. A standardized data abstraction form was used. Data were extracted by one reviewer and checked by another. RESULTS Before approval of effective chemotherapeutic agents for malignant gliomas, estimated total direct medical costs in the United States for surgery and radiation therapy per patient ranged from $50,600 to $92,700. The addition of temozolomide (TMZ) and bevacizumab to glioblastoma treatment regimens has resulted in increased overall costs for glioma care. Although health care costs are now less front-loaded, they have increased over the course of illness. Analysis using a willingness-to-pay threshold of $50,000 per quality-adjusted life-year suggests that the benefits of TMZ fall on the edge of acceptable therapies. Furthermore, indirect medical costs, such as productivity losses, are not trivial. CONCLUSION With increased chemotherapy use for malignant glioma, the paradigm for treatment and associated out-of-pocket and total medical costs continue to evolve. Larger out-of-pocket costs may influence the choice of chemotherapeutic agents, the economic implications of which should be evaluated prospectively.
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Affiliation(s)
- Jeffrey J Raizer
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Karen A Fitzner
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Daniel I Jacobs
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Charles L Bennett
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Dustin B Liebling
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Thanh Ha Luu
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Steven M Trifilio
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Sean A Grimm
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Matthew J Fisher
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Meraaj S Haleem
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Paul S Ray
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Judith M McKoy
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Rebecca DeBoer
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Katrina-Marie E Tulas
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - Mohammed Deeb
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
| | - June M McKoy
- Northwestern University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University; DePaul University; Rush Medical College; Northwestern Memorial Hospital; University of Chicago, Chicago; Midwestern University, Downers Grove; Northshore University Health Systems, Skokie Hospital, Skokie, IL; Yale School of Public Health, New Haven, CT; and South Carolina Center of Economic Excellence for Medication Safety and Efficacy and the Southern Network on Adverse Reactions, South Carolina College of Pharmacy, the University of South Carolina, Columbia, SC
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Messali A, Villacorta R, Hay JW. A review of the economic burden of glioblastoma and the cost effectiveness of pharmacologic treatments. PHARMACOECONOMICS 2014; 32:1201-1212. [PMID: 25085219 DOI: 10.1007/s40273-014-0198-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Grade IV glioma (glioblastoma) is one of the most common brain/central nervous system cancers. In 2005, the standard of care for adjuvant treatment was significantly changed with the approval of temozolomide. Carmustine wafers have also gained some popularity. Phase III trials are currently evaluating bevacizumab in conjunction with the standard temozolomide regimen. Despite these recent advances in pharmacotherapy, roughly two-thirds of patients do not survive longer than 2 years after diagnosis. Meanwhile, the costs of treatment are substantial. The goal of this study is to review the clinical, cost-of-illness, and cost-effectiveness literature relevant to treating glioblastoma. Estimates of the economic burden of glioblastoma within different healthcare systems were converted to 2013 US dollars. Temozolomide has demonstrated a 2.5-month increase in overall survival and a 1.9-month increase in progression-free survival, relative to radiotherapy alone. Carmustine wafers have also been shown to increase overall survival by 2.3 months, compared with placebo wafers. Cost-effectiveness studies of temozolomide have produced incremental cost-effectiveness ratios, adjusted to 2013 US dollars, with a range from US$73,586 per quality-adjusted life-year (QALY) (UK National Health Service perspective) to US$105,234 per QALY (US societal perspective). More research is needed to quantify the full societal burden of illness.
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Affiliation(s)
- Andrew Messali
- Department of Clinical Pharmacy and Pharmaceutical Economics and Policy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, 3335 S. Figueroa St., Unit A, University Park Campus, UGW-Unit A, Los Angeles, CA, 90089-7273, USA,
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43
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Rankeillor KL, Cairns DA, Loughrey C, Short SC, Chumas P, Ismail A, Chakrabarty A, Lawler SE, Roberts P. Methylation-specific multiplex ligation-dependent probe amplification identifies promoter methylation events associated with survival in glioblastoma. J Neurooncol 2014; 117:243-51. [PMID: 24554053 DOI: 10.1007/s11060-014-1372-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/18/2014] [Indexed: 12/22/2022]
Abstract
DNA methylation plays an important role in cancer biology and methylation events are important prognostic and predictive markers in many tumor types. We have used methylation-specific multiplex ligation-dependent probe amplification to survey the methylation status of MGMT and 25 tumor suppressor genes in 73 glioblastoma cases. The data obtained was correlated with overall survival and response to treatment. The study revealed that methylation of promoter regions in TP73 (seven patients), THBS1 (eight patients) and PYCARD (nine patients) was associated with improved outcome, whereas GATA5 (21 patients) and WT1 (24 patients) promoter methylation were associated with poor outcome. In patients treated with temozolomide and radiation MGMT and PYCARD promoter methylation events remained associated with improved survival whereas GATA5 was associated with a poor outcome. The identification of GATA5 promoter methylation in glioblastoma has not previously been reported. Furthermore, a cumulative methylation score separated patients into survival groups better than any single methylation event. In conclusion, we have identified specific methylation events associated with patient outcome and treatment response in glioblastoma, and these may be of functional and predictive/prognostic significance. This study therefore provides novel candidates and approaches for future prospective validation.
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Affiliation(s)
- K L Rankeillor
- Yorkshire Regional Cytogenetics Unit, St James's University Hospital, Leeds, LS9 7TF, UK,
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44
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Xu GF, Xie WF. Effect of ERBB2 expression on invasiveness of glioma TJ905 cells. ASIAN PAC J TROP MED 2013; 6:964-7. [DOI: 10.1016/s1995-7645(13)60172-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/15/2013] [Accepted: 11/15/2013] [Indexed: 11/16/2022] Open
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Holmes MW, Goodacre S, Stevenson MD, Pandor A, Pickering A. The cost-effectiveness of diagnostic management strategies for children with minor head injury. Arch Dis Child 2013; 98:939-44. [PMID: 23968775 DOI: 10.1136/archdischild-2012-302820] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To estimate the cost-effectiveness of diagnostic management strategies for children with minor head injury and identify an optimal strategy. METHODS A probabilistic decision analysis model was developed to estimate the costs and quality-adjusted life years (QALYs) accrued by each of six potential management strategies for minor head injury, including a theoretical 'zero option' strategy of discharging all patients home without investigation. The model took a lifetime horizon and the perspective of the National Health Service. RESULTS The optimal strategy was based on the Children's Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) rule, although the costs and outcomes associated with each strategy were broadly similar. CONCLUSIONS Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost saving, with the CHALICE rule being the optimal strategy, although there is some uncertainty in the results. Incremental changes in the costs and QALYs are very small when all selective CT strategies are compared. The estimated cost of caring for patients with brain injury worsened by delayed treatment is very high compared with the cost of CT scanning. This analysis suggests that all hospitals receiving children with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence-based guidelines.
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Affiliation(s)
- M W Holmes
- School of Health and Related Research, The University of Sheffield, , Sheffield, England
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The Methanol Extract of Angelica sinensis Induces Cell Apoptosis and Suppresses Tumor Growth in Human Malignant Brain Tumors. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:394636. [PMID: 24319475 PMCID: PMC3844186 DOI: 10.1155/2013/394636] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/29/2013] [Accepted: 08/12/2013] [Indexed: 01/20/2023]
Abstract
Glioblastoma multiforme (GBM) is a highly vascularized and invasive neoplasm. The methanol extract of Angelica sinensis (AS-M) is commonly used in traditional Chinese medicine to treat several diseases, such as gastric mucosal damage, hepatic injury, menopausal symptoms, and chronic glomerulonephritis. AS-M also displays potency in suppressing the growth of malignant brain tumor cells. The growth suppression of malignant brain tumor cells by AS-M results from cell cycle arrest and apoptosis. AS-M upregulates expression of cyclin kinase inhibitors, including p16, to decrease the phosphorylation of Rb proteins, resulting in arrest at the G0-G1 phase. The expression of the p53 protein is increased by AS-M and correlates with activation of apoptosis-associated proteins. Therefore, the apoptosis of cancer cells induced by AS-M may be triggered through the p53 pathway. In in vivo studies, AS-M not only suppresses the growth of human malignant brain tumors but also significantly prolongs patient survival. In addition, AS-M has potent anticancer effects involving cell cycle arrest, apoptosis, and antiangiogenesis. The in vitro and in vivo anticancer effects of AS-M indicate that this extract warrants further investigation and potential development as a new antibrain tumor agent, providing new hope for the chemotherapy of malignant brain cancer.
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Messali A, Hay JW, Villacorta R. The cost-effectiveness of temozolomide in the adjuvant treatment of newly diagnosed glioblastoma in the United States. Neuro Oncol 2013; 15:1532-42. [PMID: 23935155 DOI: 10.1093/neuonc/not096] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The objective of this work was to determine the cost-effectiveness of temozolomide compared with that of radiotherapy alone in the adjuvant treatment of newly diagnosed glioblastoma. Temozolomide is the only chemotherapeutic agent to have demonstrated a significant survival benefit in a randomized clinical trial. Our analysis builds on earlier work by incorporating caregiver time costs and generic temozolomide availability. It is also the first analysis applicable to the US context. METHODS A systematic literature review was conducted to collect relevant data. Transition probabilities were calculated from randomized controlled trial data comparing temozolomide plus radiotherapy with radiotherapy alone. Direct costs were calculated from charges reported by the Mayo Clinic. Utilities were obtained from a previous cost-utility analysis. Using these data, a Markov model with a 1-month cycle length and 5-year time horizon was constructed. RESULTS The addition of brand Temodar and generic temozolomide to the standard radiotherapy regimen was associated with base-case incremental cost-effectiveness ratios of $102 364 and $8875, respectively, per quality-adjusted life-year. The model was most sensitive to the progression-free survival associated with the use of only radiotherapy. CONCLUSIONS Both the brand and generic base-case estimates are cost-effective under a willingness-to-pay threshold of $150 000 per quality-adjusted life-year. All 1-way sensitivity analyses produced incremental cost-effectiveness ratios below this threshold. We conclude that both the brand Temodar and generic temozolomide are cost-effective treatments for newly diagnosed glioblastoma within the US context. However, assuming that the generic product produces equivalent quality of life and survival benefits, it would be significantly more cost-effective than the brand option.
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Affiliation(s)
- Andrew Messali
- Corresponding Author: Andrew Messali, PharmD, Leonard D. Schaeffer Center for Health Policy and Economics 3335 South Figueroa Street, Unit A Los Angeles, CA 90089-7273.
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Understanding high grade glioma: molecular mechanism, therapy and comprehensive management. Cancer Lett 2013; 331:139-46. [PMID: 23340179 DOI: 10.1016/j.canlet.2012.12.024] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 12/25/2012] [Indexed: 11/21/2022]
Abstract
High-grade gliomas (HGGs) account for the vast majority of all gliomas, including glioblastoma (World Health Organization (WHO) grade IV) and anaplasticgliomas (WHO grade III). Despite tremendous efforts in developing multimodal treatments, the overall prognosis remains poor; however, survival time varies considerably between patients. The nature of diffuse permeation into surrounding brain parenchyma poses dilemma for neurosurgeons between extensive surgical resection to eliminate as much as tumor cells as possible and adverse effects associated with brain function. Heterogeneity in both cytology and gene expression makes it difficult to coordinate an effective therapy which works for every patient. This article reviews recent advancements in the molecular mechanism, multimodal treatment and clinical management, and the updated view on the biomarkers in patients with HGG, both in primary and recurrent setting, with an emphasis on targeted therapies tailored to the patient.
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Kleinberg L. Polifeprosan 20, 3.85% carmustine slow-release wafer in malignant glioma: evidence for role in era of standard adjuvant temozolomide. CORE EVIDENCE 2012; 7:115-30. [PMID: 23118709 PMCID: PMC3484478 DOI: 10.2147/ce.s23244] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Indexed: 11/23/2022]
Abstract
The Polifeprosan 20 with carmustine (BCNU, bis-chloroethylnitrosourea, Gliadel®) polymer implant wafer is a biodegradable compound containing 3.85% carmustine which slowly degrades to release carmustine and protects it from exposure to water with resultant hydrolysis until the time of release. The carmustine implant wafer was demonstrated to improve survival in blinded placebo-controlled trials in selected patients with newly diagnosed or recurrent malignant glioma, with little increased risk of adverse events. Based on these trials and other supporting data, US and European regulatory authorities granted approval for its use in recurrent and newly diagnosed malignant glioma, and it remains the only approved local treatment. The preclinical and clinical data suggest that it is optimally utilized primarily in the proportion of patients who may have total or near total removal of gross tumor. The aim of this work was to review the evidence for the use of carmustine implants in the management of malignant astrocytoma (World Health Organization grades III and IV), including newly diagnosed and recurrent disease, especially in the setting of a standard of care that has changed since the randomized trials were completed. Therapy has evolved such that patients now generally receive temozolomide chemotherapy during and after radiotherapy treatment. For patients undergoing repeat resection for malignant glioma, a randomized, blinded, placebo-controlled trial demonstrated a median survival for 110 patients who received carmustine polymers of 31 weeks compared with 23 weeks for 122 patients who only received placebo polymers. The benefit achieved statistical significance only on analysis adjusting for prognostic factors rather than for the randomized groups as a whole (hazard ratio = 0.67, P = 0.006). A blinded, placebo-controlled trial has also been performed for carmustine implant placement in newly diagnosed patients prior to standard radiotherapy. Median survival was improved from 11.6 to 13.9 months (P = 0.03), with a 29% reduction in the risk of death. When patients with glioblastoma multiforme alone were analyzed, the median survival improved from 11.4 to 13.5 months, but this improvement was not statistically significant. When a Cox’s proportional hazard model was utilized to account for other potential prognostic factors, there was a significant 31% reduction in the risk of death (P = 0.04) in this subgroup. Data from other small reports support these results and confirm that the incidence of adverse events does not appear to be increased meaningfully. Given the poor prognosis without possibility of cure, these benefits from a treatment with a favorable safety profile were considered meaningful. There is randomized evidence to support the use of carmustine wafers placed during resection of recurrent disease. Therefore, although there is limited specific evidence, this treatment is likely to be efficacious in an environment when nearly all patients receive temozolomide as part of initial management. Given that half of the patients in the randomized trial assessing the value of carmustine implants in recurrent disease had received prior chemotherapy, it is likely that this remains a valuable treatment at the time of repeat resection, even after temozolomide. There are data from multiple reports to support safety. Although there is randomized evidence to support the use of this therapy in newly diagnosed patients who will receive radiotherapy alone, it is now standard to administer both adjuvant temozolomide and radiotherapy. There are survival outcome reports for small cohorts of patients receiving temozolomide with radiotherapy, but this information is not sufficient to support firm recommendations. Based on the rationale and evidence of safety, this approach appears to be a reasonable option as more information is acquired. Available data support the safety of using carmustine wafers in this circumstance, although special attention to surgical guidelines for implanting the wafers is warranted.
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Affiliation(s)
- Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Oncology Center Johns Hopkins University, Baltimore, MD, USA
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Holmes MW, Goodacre S, Stevenson MD, Pandor A, Pickering A. The cost-effectiveness of diagnostic management strategies for adults with minor head injury. Injury 2012; 43:1423-31. [PMID: 21835403 DOI: 10.1016/j.injury.2011.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 07/18/2011] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVE To estimate the cost-effectiveness of diagnostic management strategies for adults with minor head injury. METHODS A mathematical model was constructed to evaluate the incremental costs and effectiveness (Quality Adjusted Life years Gained, QALYs) of ten diagnostic management strategies for adults with minor head injuries. Secondary analyses were undertaken to determine the cost-effectiveness of hospital admission compared to discharge home and to explore the cost-effectiveness of strategies when no responsible adult was available to observe the patient after discharge. RESULTS The apparent optimal strategy was based on the high and medium risk Canadian CT Head Rule (CCHRhm), although the costs and outcomes associated with each strategy were broadly similar. Hospital admission for patients with non-neurosurgical injury on CT dominated discharge home, whilst hospital admission for clinically normal patients with a normal CT was not cost-effective compared to discharge home with or without a responsible adult at £39 and £2.5 million per QALY, respectively. A selective CT strategy with discharge home if the CT scan was normal remained optimal compared to not investigating or CT scanning all patients when there was no responsible adult available to observe them after discharge. CONCLUSION Our economic analysis confirms that the recent extension of access to CT scanning for minor head injury is appropriate. Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost-saving. The cost of CT scanning is very small compared to the estimated cost of caring for patients with brain injury worsened by delayed treatment. It is recommended therefore that all hospitals receiving patients with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence based guidelines. Provisionally the CCHRhm decision rule appears to be the best strategy although there is considerable uncertainty around the optimal decision rule. However, the CCHRhm rule appears to be the most widely validated and it therefore seems appropriate to conclude that the CCHRhm rule has the best evidence to support its use.
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Affiliation(s)
- M W Holmes
- School of Health and Related Research, The University of Sheffield, United Kingdom.
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