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Meertens A, Van Coile L, Van Iseghem T, Brochez L, Verhaeghe N, Hoorens I. Cost-of-Illness of Skin Cancer: A Systematic Review. PHARMACOECONOMICS 2024; 42:751-765. [PMID: 38755518 DOI: 10.1007/s40273-024-01389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Skin cancer's rising incidence demands understanding of its economic impact. The current understanding is fragmented because of the various methodological approaches applied in skin cancer cost-of-illness studies. OBJECTIVE This study systematically reviews melanoma and keratinocyte carcinoma cost-of-illness studies to provide an overview of the applied methodological approaches and to identify the main cost drivers. METHODS This systematic review was conducted adhering to the 2020 PRISMA guidelines. PubMed, Embase, and Web of Science were searched from December 2022 until December 2023 using a search strategy with entry terms related to the concepts of skin cancer and cost of illness. The records were screened on the basis of the title and abstract and subsequently on full text against predetermined eligibility criteria. Articles published before 2012 were excluded. A nine-item checklist adapted for cost-of-illness studies was used to assess the methodological quality of the articles. RESULTS This review included a total of 45 studies, together evaluating more than half a million patients. The majority of the studies (n = 36) focused on melanoma skin cancer, a few (n = 3) focused on keratinocyte carcinomas, and 6 studies examined both. Direct costs were estimated in all studies, while indirect costs were only estimated in nine studies. Considerable heterogeneity was observed across studies, mainly owing to disparities in study population, methodological approaches, included cost categories, and differences in healthcare systems. In melanoma skin cancer, both direct and indirect costs increased with progressing tumor stage. In advanced stage melanoma, systemic therapy emerged as the main cost driver. In contrast, for keratinocyte carcinoma no obvious cost drivers were identified. CONCLUSIONS A homogeneous skin cancer cost-of-illness study design would be beneficial to enhance between-studies comparability, identification of cost drivers, and support evidence-based decision-making for skin cancer.
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Affiliation(s)
- Annick Meertens
- Department of Dermatology, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
- Department of Public Health and Primary Care, Interuniversity Centre for Health Economics Research (I-CHER), Ghent University, Ghent, Belgium
| | - Laura Van Coile
- Department of Dermatology, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Tijs Van Iseghem
- Department of Public Health and Primary Care, Interuniversity Centre for Health Economics Research (I-CHER), Ghent University, Ghent, Belgium
| | - Lieve Brochez
- Department of Dermatology, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Nick Verhaeghe
- Department of Public Health and Primary Care, Interuniversity Centre for Health Economics Research (I-CHER), Ghent University, Ghent, Belgium
- Department of Public Health, Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium
| | - Isabelle Hoorens
- Department of Dermatology, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium.
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Laeijendecker AE, El Sharouni MA, Stathonikos N, Spoto CPE, van de Wiel BA, Eijken EJE, Mulder M, Mooyaart AL, Szumera-Cieckiewicz A, Mihic-Probst D, Massi D, Cook M, Koljenovic S, Alos L, van Diest PJ, van Akkooi ACJ, Blokx W. The difficulty with measuring the largest melanoma tumour diameter in sentinel lymph nodes. J Clin Pathol 2024; 77:372-377. [PMID: 38378246 DOI: 10.1136/jcp-2023-209354] [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: 12/12/2023] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
Identification of sentinel node (SN) metastases can set the adjuvant systemic therapy indication for stage III melanoma patients. For stage IIIA patients, a 1.0 mm threshold for the largest SN tumour diameter is used. Therefore, uniform reproducible measurement of its size is crucial. At present, the number of deposits or their microanatomical sites are not part of the inclusion criteria for adjuvant treatment. The goal of the current study was to show examples of the difficulty of measuring SN melanoma tumour diameter and teach how it should be measured. Histopathological slides of SN-positive melanoma patients were retrieved using the Dutch Pathology Registry (PALGA). Fourteen samples with the largest SN metastasis around 1.0 mm were uploaded via tele-pathology and digitally measured by 12 pathologists to reflect current practice of measurements in challenging cases. Recommendations as educational examples were provided. Microanatomical location of melanoma metastases was 1 subcapsular, 2 parenchymal and 11 combined. The smallest and largest difference in measurements were 0.24 mm and 4.81 mm, respectively. 11/14 cases (78.6%) showed no agreement regarding the 1.0 mm cut-off. The median discrepancy for cases ≤5 deposits was 0.5 mm (range 0.24-0.60, n=3) and 2.51 mm (range 0.71-4.81, n=11) for cases with ≥6 deposits. Disconcordance in measuring SN tumour burden is correlated with the number of deposits. Awareness of this discordance in challenging cases, for example, cases with multiple small deposits, is important for clinical management. Illustrating cases to reduce differences in size measurement are provided.
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Affiliation(s)
- Annelien E Laeijendecker
- Department of Dermatology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Mary-Ann El Sharouni
- Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Camperdown, Victoria, Australia
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nikolaos Stathonikos
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Bart A van de Wiel
- Department of Pathology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Erik J E Eijken
- Laboratory for Pathology East Netherlands (LabPON), Hengelo, Netherlands
| | - Marijne Mulder
- Symbiant Pathology Expert Center, Hoorn/Zaandam, Netherlands
| | - Antien L Mooyaart
- Department of Pathology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anna Szumera-Cieckiewicz
- Department of Pathology and Laboratory Diagnostics and Department of Diagnostic Hematology, Institute of Hematology and Transfusion Medicine, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Daniela Mihic-Probst
- Department of Surgical Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Daniela Massi
- Section of Anatomic Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Martin Cook
- Department of Histopathology, Royal Surrey County Hospital, Guildford, UK
| | - Senada Koljenovic
- Department of Pathology, Antwerp University Hospital, University of Antwerp, Antwerpen, Belgium
| | - Llucia Alos
- Department of Pathology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Alexander C J van Akkooi
- Melanoma Institute Australia, The University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Willeke Blokx
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
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van Lith PEA, Schreuder K, Jalving M, Reyners AKL, Been LB, Rácz E, Fransen HP, Louwman MWJ. Systemic therapy timing and use in patients with advanced melanoma at the end of life: A retrospective cohort study. J Dermatol 2024; 51:584-591. [PMID: 38078557 DOI: 10.1111/1346-8138.17061] [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: 04/20/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 04/04/2024]
Abstract
Novel systemic therapies for advanced melanoma improve survival, but carry potential serious side effects and high costs. This study aimed to assess the timing and use of systemic therapies in the months before death. Patients diagnosed with advanced melanoma (July 2017-June 2020) who died before July 2020 were selected from the Netherlands Cancer Registry. We evaluated the timing of systemic therapies within 30 days and 3 months before death, and studied patient and tumor characteristics associated with systemic therapy use between diagnosis and death. Out of 1097 patients 68% received systemic therapy. Almost 25% and 10% started a new therapy within 90 days and within 30 days before death, respectively. Female sex, elevated LDH, BRAF mutation, poor ECOG performance status (≥3), and high comorbidity index reduced the odds of receiving immune therapy. Poor performance status and high comorbidity decreased the odds for both therapies. A considerable number of patients started systemic therapy shortly before death, emphasizing the importance of considering potential benefits and drawbacks through shared decision-making.
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Affiliation(s)
- P E A van Lith
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - K Schreuder
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - M Jalving
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A K L Reyners
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - L B Been
- Department of Surgical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - E Rácz
- Department of Dermatology, University of Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H P Fransen
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - M W J Louwman
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
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Bateni SB, Nguyen P, Eskander A, Seung SJ, Mittmann N, Jalink M, Gupta A, Chan KKW, Look Hong NJ, Hanna TP. Changes in Health Care Costs, Survival, and Time Toxicity in the Era of Immunotherapy and Targeted Systemic Therapy for Melanoma. JAMA Dermatol 2023; 159:1195-1204. [PMID: 37672282 PMCID: PMC10483386 DOI: 10.1001/jamadermatol.2023.3179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/27/2023] [Indexed: 09/07/2023]
Abstract
Importance Melanoma treatment has evolved during the past decade with the adoption of adjuvant and palliative immunotherapy and targeted therapies, with an unclear impact on health care costs and outcomes in routine practice. Objective To examine changes in health care costs, overall survival (OS), and time toxicity associated with primary treatment of melanoma. Design, Setting, and Participants This cohort study assessed a longitudinal, propensity score (PS)-matched, retrospective cohort of residents of Ontario, Canada, aged 20 years or older with stages II to IV cutaneous melanoma identified from the Ontario Cancer Registry from January 1, 2018, to March 31, 2019. A historical comparison cohort was identified from a population-based sample of invasive melanoma cases diagnosed from the Ontario Cancer Registry from January 1, 2007, to December 31, 2012. Data analysis was performed from October 17, 2022, to March 13, 2023. Exposures Era of melanoma diagnosis (2007-2012 vs 2018-2019). Main Outcomes and Measures The primary outcomes were mean per-capita health care and systemic therapy costs (Canadian dollars) during the first year after melanoma diagnosis, time toxicity (days with physical health care contact) within 1 year of initial treatment, and OS. Standardized differences were used to compare costs and time toxicity. Kaplan-Meier methods and Cox proportional hazards regression were used to compare OS among PS-matched cohorts. Results A PS-matched cohort of 731 patients (mean [SD] age, 67.9 [14.8] years; 437 [59.8%] male) with melanoma from 2018 to 2019 and 731 patients (mean [SD] age, 67.9 [14.4] years; 440 [60.2%] male) from 2007 to 2012 were evaluated. The 2018 to 2019 patients had greater mean (SD) health care (including systemic therapy) costs compared with the 2007 to 2012 patients ($47 886 [$55 176] vs $33 347 [$31 576]), specifically for stage III ($67 108 [$57 226] vs $46 511 [$30 622]) and stage IV disease ($117 450 [$79 272] vs $47 739 [$37 652]). Mean (SD) systemic therapy costs were greater among 2018 to 2019 patients: stage II ($40 823 [$40 621] vs $10 309 [$12 176]), III ($55 699 [$41 181] vs $9764 [$12 771]), and IV disease ($79 358 [$50 442] vs $9318 [$14 986]). Overall survival was greater for the 2018 to 2019 cohort compared with the 2007 to 2012 cohort (3-year OS: 74.2% [95% CI, 70.8%-77.2%] vs 65.8% [95% CI, 62.2%-69.1%], hazard ratio, 0.72 [95% CI, 0.61-0.85]; P < .001). Time toxicity was similar between eras. Patients with stage IV disease spent more than 1 day per week (>52 days) with physical contact with the health care system by 2018 to 2019 (mean [SD], 58.7 [43.8] vs 44.2 [26.5] days; standardized difference, 0.40; P = .20). Conclusions and Relevance This cohort study found greater health care costs in the treatment of stages II to IV melanoma and substantial time toxicity for patients with stage IV disease, with improvements in OS associated with the adoption of immunotherapy and targeted therapies. These health system-wide data highlight the trade-off with adoption of new therapies, for which there is a greater economic burden to the health care system and time burden to patients but an associated improvement in survival.
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Affiliation(s)
- Sarah B. Bateni
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham
| | - Paul Nguyen
- ICES at Queen’s University, Kingston, Ontario, Canada
| | - Antoine Eskander
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Soo Jin Seung
- Health Outcomes and PharmacoEconomics (HOPE) Research Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Nicole Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew Jalink
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Arjun Gupta
- Division of Hematology, Oncology, & Transplantation, University of Minnesota, Minneapolis
| | - Kelvin K. W. Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nicole J. Look Hong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Timothy P. Hanna
- ICES at Queen’s University, Kingston, Ontario, Canada
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
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5
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Crealey GE, Hackett C, Harkin K, Heckmann P, Kelleher F, Lyng Á, McCarthy T, McEnery M, Meaney C, Roche D, Tobin AM. Melanoma-related costs by disease stage and phase of management in Ireland. J Public Health (Oxf) 2023; 45:714-722. [PMID: 37169550 PMCID: PMC10470331 DOI: 10.1093/pubmed/fdac154] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/08/2022] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Management options for the treatment of melanoma have expanded in recent years. In an era of promising, but expensive novel pharmacological treatments, robust stage-specific melanoma-related cost estimates are necessary to support budgetary planning, evaluation of cost-effectiveness and to contribute to the investment case for prevention. METHODS A detailed decision model, describing the melanoma care pathway (by disease stage) from diagnosis, through treatment and follow-up was developed over a 5-year time frame from the perspective of the Irish healthcare system. The model was populated with real-world data from the National Cancer Registry Ireland. Uncertainty was explored using one-way and probabilistic sensitivity analysis. RESULTS The cost of managing a case of melanoma diagnosed at Stage IV (€122 985) was more than 25 times more expensive than managing a case diagnosed at Stage IA (€4269). Total costs were sensitive to the choice of immunotherapeutic and targeted drug, duration of treatment and proportion of patients receiving immunotherapy agents. CONCLUSIONS The rising incidence of melanoma and high cost of new novel therapies presents an immediate challenge to cancer control and public health globally. This study highlights the cost differential between early and late detection and the potential return on investment for prevention versus high-cost treatment.
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Affiliation(s)
| | | | - Katharine Harkin
- HSE National Cancer Control Programme (NCCP), King’s Inns House, 200 Parnell Street, Dublin 1 DO1 A3Y8, Ireland
| | - Patricia Heckmann
- HSE National Cancer Control Programme (NCCP), King’s Inns House, 200 Parnell Street, Dublin 1 DO1 A3Y8, Ireland
| | - Fergal Kelleher
- St. James and Tallaght University Hospitals, Department of Medicine, Trinity College Dublin, Dublin 2 D02 R590, Ireland
| | - Áine Lyng
- HSE National Cancer Control Programme (NCCP), King’s Inns House, 200 Parnell Street, Dublin 1 DO1 A3Y8, Ireland
| | - Triona McCarthy
- HSE National Cancer Control Programme (NCCP), King’s Inns House, 200 Parnell Street, Dublin 1 DO1 A3Y8, Ireland
| | - Maria McEnery
- HSE National Cancer Control Programme (NCCP), King’s Inns House, 200 Parnell Street, Dublin 1 DO1 A3Y8, Ireland
| | - Clare Meaney
- National Cancer Control Programme (NCCP), King’s Inn House, 200 Parnell Street, Dublin, D01 A3Y8, Ireland
| | | | - Anne-Marie Tobin
- Tallaght University Hospital, Tallaght, Dublin 24 D24 NR0A, Ireland
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Avila FR, Spaulding AC, Rinker BD, Huayllani MT, Boczar D, Torres-Guzman RA, Maita KC, Ho OA, Forte AJ. Demographic Characteristics Influence Treatment Costs of Invasive Melanoma in Florida. Ann Plast Surg 2023; 90:248-254. [PMID: 36796047 DOI: 10.1097/sap.0000000000003422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Demographic characteristics are known to influence the treatment and outcomes of patients with invasive melanoma. Whether these characteristics influence treatment costs is unknown. We aimed to analyze whether patient demographics and tumor characteristics influence treatment costs for patients with invasive cutaneous melanoma in Florida. METHODS This was a cross-sectional study in which the Florida Inpatient and Outpatient Dataset of the Agency for Health Care Administration was analyzed for patients with a diagnosis of invasive melanoma between January 1, 2013 and December 31, 2018. Categorical variables were assessed using Pearson χ2 tests, and continuous variables were evaluated using Kruskal-Wallis tests. Logistic regression analysis was conducted to identify the association between patient demographics and total costs. All analyses were done using SAS 9.4 statistical software (SAS Institute, Inc). RESULTS Multivariate analysis showed that sex (P < 0.001), hospital setting (P < 0.001), race/ethnicity (P < 0.01), patient region (P < 0.01), Elixhauser Comorbidity Index score (P < 0.001), presence of metastasis (P < 0.01), total number of procedures (P < 0.001), and length of stay (P < 0.001) were correlated with the cost of treatment of invasive cutaneous melanoma. After stratification, the association between cost and race/ethnicity disappeared for inpatients but remained for Black patients in the outpatient setting (P < 0.001). The association between cost and patient residence regions also differed when the cohort was stratified. CONCLUSIONS Strategies addressing disparities in treatment cost of invasive melanoma should differ, depending on the hospital setting where the patient is being treated.
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Affiliation(s)
| | - Aaron C Spaulding
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | | | - Maria T Huayllani
- Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, OH
| | - Daniel Boczar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | | | | | - Olivia A Ho
- From the Division of Plastic Surgery, Mayo Clinic
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ter Maat L, van Duin IA, Elias SG, Leiner T, Verhoeff JJ, Arntz ER, Troenokarso MF, Blokx WA, Isgum I, de Wit GA, van den Berkmortel FW, Boers-Sonderen MJ, Boomsma MF, van den Eertwegh FJ, de Groot JWB, Piersma D, Vreugdenhil A, Westgeest HM, Kapiteijn E, van Diest PJ, Pluim J, de Jong PA, Suijkerbuijk KP, Veta M. CT radiomics compared to a clinical model for predicting checkpoint inhibitor treatment outcomes in patients with advanced melanoma. Eur J Cancer 2023; 185:167-177. [PMID: 36996627 DOI: 10.1016/j.ejca.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Predicting checkpoint inhibitors treatment outcomes in melanoma is a relevant task, due to the unpredictable and potentially fatal toxicity and high costs for society. However, accurate biomarkers for treatment outcomes are lacking. Radiomics are a technique to quantitatively capture tumour characteristics on readily available computed tomography (CT) imaging. The purpose of this study was to investigate the added value of radiomics for predicting clinical benefit from checkpoint inhibitors in melanoma in a large, multicenter cohort. METHODS Patients who received first-line anti-PD1±anti-CTLA4 treatment for advanced cutaneous melanoma were retrospectively identified from nine participating hospitals. For every patient, up to five representative lesions were segmented on baseline CT, and radiomics features were extracted. A machine learning pipeline was trained on the radiomics features to predict clinical benefit, defined as stable disease for more than 6 months or response per RECIST 1.1 criteria. This approach was evaluated using a leave-one-centre-out cross validation and compared to a model based on previously discovered clinical predictors. Lastly, a combination model was built on the radiomics and clinical model. RESULTS A total of 620 patients were included, of which 59.2% experienced clinical benefit. The radiomics model achieved an area under the receiver operator characteristic curve (AUROC) of 0.607 [95% CI, 0.562-0.652], lower than that of the clinical model (AUROC=0.646 [95% CI, 0.600-0.692]). The combination model yielded no improvement over the clinical model in terms of discrimination (AUROC=0.636 [95% CI, 0.592-0.680]) or calibration. The output of the radiomics model was significantly correlated with three out of five input variables of the clinical model (p < 0.001). DISCUSSION The radiomics model achieved a moderate predictive value of clinical benefit, which was statistically significant. However, a radiomics approach was unable to add value to a simpler clinical model, most likely due to the overlap in predictive information learned by both models. Future research should focus on the application of deep learning, spectral CT-derived radiomics, and a multimodal approach for accurately predicting benefit to checkpoint inhibitor treatment in advanced melanoma.
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Gautron Moura B, Gerard CL, Testart N, Caikovski M, Wicky A, Aedo-Lopez V, Berthod G, Homicsko K, Prior JO, Dromain C, Kandalaft LE, Cuendet MA, Michielin O. Estimated Costs of the Ipilimumab-Nivolumab Therapy and Related Adverse Events in Metastatic Melanoma. Cancers (Basel) 2022; 15:cancers15010031. [PMID: 36612030 PMCID: PMC9817856 DOI: 10.3390/cancers15010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Combined ipilimumab and nivolumab significantly improve outcomes in metastatic melanoma patients but bear an important financial impact on the healthcare system. Here, we analyze the treatment costs, focusing on irAE. We conducted a retrospective analysis of 62 melanoma patients treated with ipilimumab-nivolumab at the Lausanne University Hospital between 1 June 2016 and 31 August 2019. The frequency of irAEs and outcomes were evaluated. All melanoma-specific costs were analyzed from the first ipilimumab-nivolumab dose until the therapy given subsequently or death. A total of 54/62 (87%) patients presented at least one irAE, and 31/62 (50%) presented a grade 3-4 irAE. The majority of patients who had a complete response 12/14 (86%) and 21/28 (75%) of overall responders presented a grade 3-4 toxicity, and there were no responses in patients without toxicity. Toxicity costs represented only 3% of the total expenses per patient. The most significant contributions were medication costs (44%) and disease costs (39%), mainly disease-related hospitalization costs, not toxicity-related. Patients with a complete response had the lowest global median cost per week of follow up (EUR 2425) and patients who had progressive disease (PD), the highest one (EUR 8325). Except for one patient who had a Grade 5 toxicity (EUR 6043/week), we observe that less severe toxicity grades (EUR 9383/week for Grade 1), or even the absence of toxicity (EUR 9922/week), are associated with higher median costs per week (vs. EUR 3266/week for Grade 4 and EUR 2850/week for Grade 3). The cost of toxicities was unexpectedly low compared to the total costs, especially medication costs. Patients with higher toxicity grades had better outcomes and lower total costs due to treatment discontinuation.
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Affiliation(s)
- Bianca Gautron Moura
- Service of Oncology, Cantonal Hospital Fribourg (HFR), Chemin des Pensionnats 1-6, 1700 Fribourg, Switzerland
- Correspondence: (B.G.M.); (O.M.)
| | - Camille L. Gerard
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
| | - Nathalie Testart
- Department of Radiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Marian Caikovski
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
| | - Alexandre Wicky
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
| | - Veronica Aedo-Lopez
- Department of Oncology, Monash Medical Centre, 823-865 Centre Road, East Bentleigh, Melbourne, VIC 3165, Australia
| | - Grégoire Berthod
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
- Service of Oncology, Valais Hospital (CHVR), Avenue Grand Champsec 80, 1951 Sion, Switzerland
| | - Krisztian Homicsko
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
| | - John O. Prior
- Department of Radiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Clarisse Dromain
- Department of Radiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Lana E. Kandalaft
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
| | - Michel A. Cuendet
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
- Department of Physiology and Biophysics, Weill Cornell Medicine, 1300 York Av., New York, NY 10065, USA
- Swiss Institute of Bioinformatics, UNIL Sorge, 1015 Lausanne, Switzerland
| | - Olivier Michielin
- Department of Oncology, Lausanne University Hospital and Agora Translational Cancer Research Center, Rue du Bugnon, 1011 Lausanne, Switzerland
- Swiss Institute of Bioinformatics, UNIL Sorge, 1015 Lausanne, Switzerland
- Correspondence: (B.G.M.); (O.M.)
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van Breeschoten J, Ismail RK, Wouters MW, Hilarius DL, de Wreede LC, Haanen JB, Blank CU, Aarts MJ, van den Berkmortel FW, de Groot JWB, Hospers GA, Kapiteijn E, Piersma D, van Rijn RS, Stevense-den Boer MA, van der Veldt AA, Vreugdenhil G, Boers-Sonderen MJ, Suijkerbuijk KP, van den Eertwegh AJ. End-of-Life Use of Systemic Therapy in Patients With Advanced Melanoma: A Nationwide Cohort Study. JCO Oncol Pract 2022; 18:e1611-e1620. [DOI: 10.1200/op.22.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: The introduction of immune checkpoint inhibitors and targeted therapies improved the overall survival of patients with advanced melanoma. It is not known how often these costly treatments with potential serious side effects are ineffectively applied in the last phase of life. This study aimed to investigate the start of a new systemic therapy within 45 and 90 days of death in Dutch patients with advanced melanoma. METHODS: We selected patients who were diagnosed with unresectable IIIC or stage IV melanoma, registered in the Dutch Melanoma Treatment Registry, and died between 2013 and 2019. Primary outcome was the probability of starting a new systemic therapy 45 and 90 days before death. Secondary outcomes were type of systemic therapy started, grade 3/4 adverse events (AEs), and the total costs of systemic therapies. RESULTS: Between 2013 and 2019, 3,797 patients with unresectable IIIC or stage IV melanoma were entered in the registry and died. The percentage of patients receiving a new systemic therapy within 45 and 90 days before death was significantly different between Dutch melanoma centers (varying from 6% to 23% and 20% to 46%, respectively). Thirteen percent of patients (n = 146) developed grade 3/4 AEs in the last period before death. The majority of patients with an AE required hospital admission (n = 102, 69.6%). Mean total costs of systemic therapy per cohort year of the patients who received a new systemic therapy within 90 days before death were 2.3%-2.8% of the total costs spent on melanoma therapies. CONCLUSION: The minority of Dutch patients with metastatic melanoma started a new systemic therapy in the last phase of life. However, the percentages varied between Dutch melanoma centers. Financial impact of these therapies in the last phase of life is relatively small.
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Affiliation(s)
- Jesper van Breeschoten
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Rawa K. Ismail
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands
| | - Michel W.J.M. Wouters
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Liesbeth C. de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - John B. Haanen
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Christian U. Blank
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Maureen J.B. Aarts
- Department of Medical Oncology, GROW School for Oncology and Developmental Biology. Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Geke A.P. Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | | | | | - Gerard Vreugdenhil
- Department of Internal Medicine, Maxima Medical Center, Eindhoven, the Netherlands
| | - Marye J. Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Alfons J.M. van den Eertwegh
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
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10
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Franken MG, Leeneman B, Aarts MJB, van Akkooi ACJ, van den Berkmortel FWPJ, Boers-Sonderen MJ, van den Eertwegh AJM, de Groot JWB, Hospers GAP, Kapiteijn E, Piersma D, van Rijn RS, Suijkerbuijk KPM, van der Veldt AAM, Westgeest HM, Wouters MWJM, Haanen JBAG, Uyl-de Groot CA. Trends in survival and costs in metastatic melanoma in the era of novel targeted and immunotherapeutic drugs. ESMO Open 2021; 6:100320. [PMID: 34856511 PMCID: PMC8639434 DOI: 10.1016/j.esmoop.2021.100320] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/08/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background The objective of this study was to evaluate trends in survival and health care costs in metastatic melanoma in the era of targeted and immunotherapeutic drugs. Materials and methods Data on survival and health care resource use were retrieved from the Dutch Melanoma Treatment Registry. The Kaplan–Meier method was used to estimate overall survival. Health care costs and budget impact were computed by applying unit costs to individual patient resource use. All outcomes were stratified by year of diagnosis. Results Baseline characteristics were balanced across cohort years. The percentage of patients receiving systemic treatment increased from 73% in 2013 to 90% in 2018. Patients received on average 1.85 [standard deviation (SD): 1.14] lines of treatment and 41% of patients received at least two lines of treatment. Median survival increased from 11.8 months in 2013 [95% confidence interval (CI): 10.7-13.7 months] to 21.1 months in 2018 (95% CI: 18.2 months-not reached). Total mean costs were €100 330 (SD: €103 699); systemic treatments accounted for 84% of the total costs. Costs for patients who received systemic treatment [€118 905 (SD: €104 166)] remained reasonably stable over the years even after the introduction of additional (combination of) novel drugs. From mid-2013 to 2018, the total budget impact for all patients was €452.79 million. Conclusion Our study shows a gain in survival in the era of novel targeted and immunotherapeutic drugs. These novel drugs came, however, along with substantial health care costs. Further insights into the cost-effectiveness of the novel drugs are crucial for ensuring value for money in the treatment of patients with metastatic melanoma. The median survival of patients with metastatic melanoma increased from 11.8 months in 2013 to 21.1 months in 2018. The gain in survival came along with substantial health care costs; health care costs were on average €100 300 per patient. Costs were much higher for patients with systemic treatment (€118 905) than for patients without systemic treatment (€8316). Costs for patients who received systemic treatment remained stable even after the introduction of additional novel drugs. Insights into the cost-effectiveness of the novel drugs are crucial for ensuring value for money in metastatic melanoma.
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Affiliation(s)
- M G Franken
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - B Leeneman
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - M J B Aarts
- Department of Medical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - M J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A J M van den Eertwegh
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - G A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - E Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R S van Rijn
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - K P M Suijkerbuijk
- Department of Medical Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - A A M van der Veldt
- Department of Medical Oncology and Radiology & Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - H M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | - M W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - J B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - C A Uyl-de Groot
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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11
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Mulder EEAP, Smit L, Grünhagen DJ, Verhoef C, Sleijfer S, van der Veldt AAM, Uyl-de Groot CA. Cost-effectiveness of adjuvant systemic therapies for patients with high-risk melanoma in Europe: a model-based economic evaluation. ESMO Open 2021; 6:100303. [PMID: 34781194 PMCID: PMC8599106 DOI: 10.1016/j.esmoop.2021.100303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The introduction of adjuvant systemic treatment has significantly improved recurrence-free survival in patients with resectable high-risk melanoma. Adjuvant treatment with immune checkpoint inhibitors and targeted therapy, however, substantially impacts health care budgets, while the number of patients with melanoma who are treated in the adjuvant setting is still increasing. To evaluate the socioeconomic impact of the three adjuvant treatments, a cost-effectiveness analysis (CEA) was carried out. MATERIALS AND METHODS Data were obtained from the three pivotal registration phase III clinical trials on the adjuvant treatment of patients with resected high-risk stage III in melanoma (KEYNOTE-054, CheckMate 238, and COMBI-AD). For this CEA, a Markov model with three health states (no evidence of disease, recurrent/progressive disease, and death) was applied. From a societal perspective, different adjuvant strategies were compared according to total costs, life years (LYs), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. To evaluate model uncertainty, sensitivity analyses (deterministic and probabilistic) were carried out. RESULTS In the adjuvant setting, total costs (per patient) were €168 826 for nivolumab, €194 529 for pembrolizumab, and €211 110 for dabrafenib-trametinib. These costs were mainly determined by drug acquisition costs, whereas routine surveillance costs varied from €126 096 to €134 945. Compared with routine surveillance, LYs improved by approximately 1.41 for all therapies and QALYs improved by 2.02 for immune checkpoint inhibitors and 2.03 for targeted therapy. This resulted in incremental cost-effectiveness ratios of €21 153 (nivolumab), €33 878 (pembrolizumab), and €37 520 (dabrafenib-trametinib) per QALY gained. CONCLUSIONS This CEA compared the three EMA-approved adjuvant systemic therapies for resected stage III melanoma. Adjuvant treatment with nivolumab was the most cost-effective, followed by pembrolizumab. Combination therapy with dabrafenib-trametinib was the least cost-effective. With the increasing number of patients with high-risk melanoma who will be treated with adjuvant treatment, there is an urgent need to reduce drug costs while developing better prognostic and predictive tools to identify patients who will benefit from adjuvant treatment.
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Affiliation(s)
- E E A P Mulder
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - L Smit
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - A A M van der Veldt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C A Uyl-de Groot
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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12
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El Sharouni MA, Laeijendecker AE, Suijkerbuijk KP, Witkamp AJ, Sigurdsson V, van Diest PJ, van Gils CH, Blokx WA. High discordance rate in assessing sentinel node positivity in cutaneous melanoma: Expert review may reduce unjustified adjuvant treatment. Eur J Cancer 2021; 149:105-113. [PMID: 33848712 DOI: 10.1016/j.ejca.2021.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/01/2021] [Accepted: 03/05/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Identification of sentinel node (SN) metastases can set the adjuvant systemic therapy indication for patients with stage III melanoma. Studies re-evaluating the diagnosis of initially positive SN biopsies are scarce. MATERIALS AND METHODS Dutch patients with melanoma who underwent SN biopsy between 2003 and 2014 were selected from PALGA, the Dutch Pathology Registry. Histopathological slides of SN-positive patients were retrieved for review. A random sample was reassessed by an expert melanoma pathologist. Recurrence-free survival (RFS) of patients who were misclassified (false-positive) was compared with those with a true positive SN status. For comparison, a group of SN-negative patients was included. Multivariable logistic analysis was performed to assess clinicopathological characteristics associated with misclassification of SN status. RESULTS Diagnosis was downgraded from melanoma metastasis to nodal nevus in 38 of the 322 reviewed patients (11.8%). Considering the inclusion criteria of phase III adjuvant trials, at least 4.3% of patients would have falsely qualified for adjuvant therapy. In multivariable analysis, patients with a low SN tumour burden and subcapsular SN tumour location had a significantly higher chance of being misclassified. The five-year RFS of the 38 downgraded patients was 86.7% (95% confidence interval [CI] = 72.6-96.6), similar to the 85.9% (95% CI = 84.9-86.8, p = 0.18) for 6413 SN-negative patients and better than the 53.2% (95% CI = 47.2-59.9, p = 0.009) of 284 patients who were truly SN positive upon review. CONCLUSION More than 10% of originally positive SN biopsies of patients with melanoma concern misclassified nodal nevi. We advocate that when adjuvant treatment is considered in patients with stage III melanoma, SN biopsies should be reassessed by an expert melanoma pathologist.
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Affiliation(s)
- Mary-Ann El Sharouni
- Department of Dermatology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands.
| | - Annelien E Laeijendecker
- Department of Dermatology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Karijn Pm Suijkerbuijk
- Department of Medical Oncology, University Medical Center Cancer Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Vigfús Sigurdsson
- Department of Dermatology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Carla H van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Willeke Am Blokx
- Department of Pathology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
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13
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Mulder EEAP, de Joode K, Litière S, Ten Tije AJ, Suijkerbuijk KPM, Boers-Sonderen MJ, Hospers GAP, de Groot JWB, van den Eertwegh AJM, Aarts MJB, Piersma D, van Rijn RS, Kapiteijn E, Vreugdenhil G, van den Berkmortel FWPJ, Hoop EOD, Franken MG, Ryll B, Rutkowski P, Sleijfer S, Haanen JBAG, van der Veldt AAM. Early discontinuation of PD-1 blockade upon achieving a complete or partial response in patients with advanced melanoma: the multicentre prospective Safe Stop trial. BMC Cancer 2021; 21:323. [PMID: 33765967 PMCID: PMC7993897 DOI: 10.1186/s12885-021-08018-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/09/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The introduction of programmed cell death protein 1 (PD-1) blockers (i.e. nivolumab and pembrolizumab) has significantly improved the prognosis of patients with advanced melanoma. However, the long treatment duration (i.e. two years or longer) has a high impact on patients and healthcare systems in terms of (severe) toxicity, health-related quality of life (HRQoL), resource use, and healthcare costs. While durable tumour responses have been observed and PD-1 blockade is discontinued on an individual basis, no consensus has been reached on the optimal treatment duration. The objective of the Safe Stop trial is to evaluate whether early discontinuation of first-line PD-1 blockade is safe in patients with advanced and metastatic melanoma who achieve a radiological response. METHODS The Safe Stop trial is a nationwide, multicentre, prospective, single-arm, interventional study in the Netherlands. A total of 200 patients with advanced and metastatic cutaneous melanoma and a confirmed complete response (CR) or partial response (PR) according to response evaluation criteria in solid tumours (RECIST) v1.1 will be included to early discontinue first-line monotherapy with nivolumab or pembrolizumab. The primary objective is the rate of ongoing responses at 24 months after discontinuation of PD-1 blockade. Secondary objectives include best overall and duration of response, need and outcome of rechallenge with PD-1 blockade, and changes in (serious) adverse events and HRQoL. The impact of treatment discontinuation on healthcare resource use, productivity losses, and hours of informal care will also be assessed. Results will be compared to those from patients with CR or PR who completed 24 months of treatment with PD-1 blockade and had an ongoing response at treatment discontinuation. It is hypothesised that it is safe to early stop first-line nivolumab or pembrolizumab at confirmed tumour response while improving HRQoL and reducing costs. DISCUSSION From a patient, healthcare, and economic perspective, shorter treatment duration is preferred and overtreatment should be prevented. If early discontinuation of first-line PD-1 blockade appears to be safe, early discontinuation of PD-1 blockade may be implemented as the standard of care in a selected group of patients. TRIAL REGISTRATION The Safe Stop trial has been registered in the Netherlands Trial Register (NTR), Trial NL7293 (old NTR ID: 7502), https://www.trialregister.nl/trial/7293 . Date of registration September 30, 2018.
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Affiliation(s)
- E E A P Mulder
- Department of Medical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
- Department of Surgical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - K de Joode
- Department of Medical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - S Litière
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - A J Ten Tije
- Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | - K P M Suijkerbuijk
- Department of Medical Oncology, University Medical Centre Utrecht Cancer Centre, Utrecht, The Netherlands
| | - M J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - G A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - J W B de Groot
- Department of Medical Oncology, Isala Oncological Centre, Zwolle, The Netherlands
| | - A J M van den Eertwegh
- Department of Medical Oncology, Amsterdam University Medical Centre - location VU, Amsterdam, The Netherlands
| | - M J B Aarts
- Department of Medical Oncology, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - D Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R S van Rijn
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - E Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - G Vreugdenhil
- Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands
| | | | - E Oomen-de Hoop
- Department of Medical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - M G Franken
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - B Ryll
- Melanoma Patient Network Europe, Uppsala, Sweden
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - S Sleijfer
- Department of Medical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - J B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A A M van der Veldt
- Department of Medical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands.
- Department of Radiology & Nuclear Medicine, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands.
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