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Balaban N, Mohyuddin GR, Kashi A, Massarweh A, Markel G, Bomze D, Goldstein DA, Meirson T. Projecting complete redaction of clinical trial protocols (RAPTURE): redacted cross sectional study. BMJ 2023; 383:e077329. [PMID: 38097263 PMCID: PMC10719744 DOI: 10.1136/bmj-2023-077329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVES To characterise redactions in clinical trials and estimate a time when all protocols are fully removed (RAPTURE). DESIGN Redacted cross sectional study. SETTING Published phase 3 randomised controlled trials from 1 January 2010 to ██████████████. PARTICIPANTS New England Journal of Medicine, ██████████, and Journal of the American Medical Association. MAIN OUTCOME MEASURES █████ ████████ ██████████████ ██████ ██████████ ████████ ████████ ██████████ ███████████ ████████████ ████████████ ████████████████████████ ██████████████████ RESULTS: ████████████████████ met the inclusion criteria, with 268 (56.7%) research protocols available and accessible. The rate of redactions in protocols has increased from 0 in 2010 to 60.8% in 2021 (P<0.001). The degree of data redaction has also increased, with the average cumulative redactions among industry funded trials rising from 0 in 2010 to 3.5 pages in 2021 (P<0.001). Modelling predicts that RAPTURE is expected to occur between 2073 and 2136. Redactions featured predominantly in ████████ sponsored trials and mostly occurred in the statistical design. CONCLUSIONS This study highlights the rise in protocol redactions and predicts that, ██████████████████████████████████████████ will be entirely redacted between 2073 and 2136. A legitimate rationale for the redactions could ███ be found. A multipronged strategy against protocol redactions is required to maintain the integrity of science. AVAILABILITY This paper is partially redacted, but for the sake of ███████████, a version without any redactions can be found in the supplementary material.
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Affiliation(s)
- Nir Balaban
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ghulam Rehman Mohyuddin
- Division of Hematology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Adi Kashi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Massarweh
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Gal Markel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
- Samueli Integrative Cancer Pioneering Institute, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - David Bomze
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Tomer Meirson
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
- Samueli Integrative Cancer Pioneering Institute, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
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Tachiki LML, Hippe DS, Silva KW, Hall ET, McCamy W, Fritzsche D, Perdue A, Majovski J, Pulliam T, Goldstein DA, Veatch J, Ho J, Nghiem PT, Thompson JA, Bhatia S. Correction to: Extended duration of treatment using reduced‑frequency dosing of anti‑PD‑1 therapy in patients with advanced melanoma and Merkel cell carcinoma. Cancer Immunol Immunother 2023; 72:4471. [PMID: 37979010 DOI: 10.1007/s00262-023-03575-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Lisa May Ling Tachiki
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Karly Williams Silva
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Evan Thomas Hall
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - William McCamy
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Dane Fritzsche
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Andrea Perdue
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Julia Majovski
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Thomas Pulliam
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Joshua Veatch
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Joel Ho
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paul T Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - John A Thompson
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Shailender Bhatia
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Margalit O, Harmsen WS, Shacham-Shmueli E, Voss MM, Boursi B, Wagner AD, Cohen R, Olswold CL, Saltz LB, Goldstein DA, Hurwitz H, Tebbutt NC, Kabbinavar FF, Adams RA, Chibaudel B, Grothey A, Yoshino T, Zalcberg J, de Gramont A, Shi Q, Lenz HJ. Corrigendum to "Evaluating sex as a predictive marker for response to bevacizumab in metastatic colorectal carcinoma: Pooled analysis of 3369 patients in the ARCAD database" Eur J Cancer. 2023 Jan;178:162-170. Eur J Cancer 2023; 194:113339. [PMID: 37813779 DOI: 10.1016/j.ejca.2023.113339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Ofer Margalit
- Tel-Aviv University, Tel-Aviv, Israel; Sheba Medical Center, Ramat-Gan, Israel.
| | - William S Harmsen
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA
| | | | - Molly M Voss
- Department of Quantitative Science Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Ben Boursi
- Tel-Aviv University, Tel-Aviv, Israel; Sheba Medical Center, Ramat-Gan, Israel
| | - Anna D Wagner
- Department of Oncology, Division of Medical Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Romain Cohen
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA; Sorbonne University, INSERM, Unité Mixte de Recherche Scientifique 938, Centre de Recherche Saint-Antoine, Equipe Instabilité des Microsatellites et Cancer, Equipe labellisée par la Ligue Nationale contre le Cancer, Paris, France; Sorbonne University, Department of Medical Oncology, Saint-Antoine Hospital, AP-HP, Paris, France
| | - Curtis L Olswold
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Niall C Tebbutt
- University of Melbourne, Melbourne, Australia; Austin Health, Heidelberg, Victoria, Australia
| | - Fairooz F Kabbinavar
- David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Benoist Chibaudel
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | | | - Takayuki Yoshino
- Department of Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - John Zalcberg
- Department of Medical Oncology, Alfred Health and School of Public Health, Monash University, Melbourne, Australia
| | - Aimery de Gramont
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - Qian Shi
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA
| | - Heinz-Josef Lenz
- Department of Gastrointestinal Oncology, Keck School of Medicine at USC, Los Angeles, CA, USA
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Tachiki LML, Hippe DS, Williams Silva K, Hall ET, McCamy W, Fritzsche D, Perdue A, Majovski J, Pulliam T, Goldstein DA, Veatch J, Ho J, Nghiem PT, Thompson JA, Bhatia S. Extended duration of treatment using reduced-frequency dosing of anti-PD-1 therapy in patients with advanced melanoma and Merkel cell carcinoma. Cancer Immunol Immunother 2023; 72:3839-3850. [PMID: 37733060 PMCID: PMC10576731 DOI: 10.1007/s00262-023-03539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Optimal duration of treatment (DoT) with immune checkpoint inhibitors (ICI) in metastatic cancers remains unclear. Many patients, especially those without radiologic complete remission, develop progressive disease after ICI discontinuation. Extending DoT with ICI may potentially improve efficacy outcomes but presents major logistical and cost challenges with standard frequency dosing (SFD). Receptor occupancy data supports reduced frequency dosing (RFD) of anti-PD-1 antibodies, which may represent a more practical and economically viable option to extend DoT. METHODS We conducted a retrospective study of patients with metastatic melanoma and Merkel cell carcinoma (MCC), who received ICI at RFD administered every 3 months, after initial disease control at SFD. We evaluated efficacy, safety, and cost-savings of the RFD approach in this cohort. RESULTS Between 2014 and 2021, 23 patients with advanced melanoma (N = 18) or MCC (N = 5) received anti-PD-1 therapy at RFD. Median DoT was 1.1 years at SFD and 1.2 years at RFD. The 3 year PFS after start of RFD was 73% in melanoma and 100% in MCC patients, which compare favorably to historical control rates. In the subset of 15 patients who received at least 2 years of therapy, total savings amounted to $1.1 million in drug costs and 384 h saved despite the extended DoT (median 3.4 years), as compared to the calculated cost of 2 years at SFD. CONCLUSIONS ICI administration at RFD can allow extension of treatment duration, while preserving efficacy and reducing logistical and financial burden. RFD approach deserves further exploration in prospective clinical trials.
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Affiliation(s)
- Lisa May Ling Tachiki
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Karly Williams Silva
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Evan Thomas Hall
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - William McCamy
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Dane Fritzsche
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Andrea Perdue
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Julia Majovski
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Thomas Pulliam
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Joshua Veatch
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Joel Ho
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paul T Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - John A Thompson
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Shailender Bhatia
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Wesevich A, Goldstein DA, Paydary K, Peer CJ, Figg WD, Ratain MJ. Interventional pharmacoeconomics for immune checkpoint inhibitors through alternative dosing strategies. Br J Cancer 2023; 129:1389-1396. [PMID: 37542109 PMCID: PMC10628132 DOI: 10.1038/s41416-023-02367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/05/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are approved for the treatment of a variety of cancer types. The doses of these drugs, though approved by the Food and Drug Administration (FDA), have never been optimised, likely leading to significantly higher doses than required for optimal efficacy. Dose optimisation would hypothetically decrease the risk, severity, and duration of immune-related adverse events, as well as provide an opportunity to reduce costs through interventional pharmacoeconomic strategies such as off-label dose reductions or less frequent dosing. We summarise existing evidence for ICI dose optimisation to advocate for the role of interventional pharmacoeconomics.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv, Israel
- Optimal Cancer Care Alliance, Chicago, IL, USA
| | - Koosha Paydary
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William D Figg
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.
- Optimal Cancer Care Alliance, Chicago, IL, USA.
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Tannock IF, Bouche G, Goldstein DA, Goto Y, Lichter AS, Prabhash K, Ranganathan P, Saltz LB, Sonke GS, Strohbehn GW, von Moos R, Ratain MJ. Patient-centred, self-funding dose optimisation trials as a route to reduce toxicity, lower cost and improve access to cancer therapy. Ann Oncol 2023:S0923-7534(23)00687-7. [PMID: 37230253 DOI: 10.1016/j.annonc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada; Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
| | - Gauthier Bouche
- Anticancer Fund, Meise, Belgium; Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasushi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | | | - Kumar Prabhash
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Leonard B Saltz
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabe S Sonke
- Department of Medical Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, & University of Amsterdam, Amsterdam, The Netherlands
| | - Garth W Strohbehn
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan; Section of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland & SAKK Competence Center, Bern
| | - Mark J Ratain
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Meirson T, Goldstein DA, Gyawali B, Tannock IF. Review of the monarchE trial suggests no evidence to support use of adjuvant abemaciclib in women with breast cancer. Lancet Oncol 2023:S1470-2045(23)00165-1. [PMID: 37146621 DOI: 10.1016/s1470-2045(23)00165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Clalit Health Service, Tel Aviv, Israel; Optimal Cancer Care Alliance, Ann Arbor, MI, USA
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology & Departments of Oncology and Public Health Sciences, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Ian F Tannock
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Division of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada.
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Averbuch I, Tschernichovsky R, Icht O, Goldstein DA, Mutai R, Dudnik E, Rotem O, Peled N, Allen AM, Laufer-Geva S, Goldberg Y, Zer A. Correlations between pathogenic variants in DNA repair genes and anticancer treatment efficacy in stage IV non-small cell lung cancer: A large real-world cohort and review of the literature. Thorac Cancer 2023. [PMID: 37095004 DOI: 10.1111/1759-7714.14902] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Mutations in genes involved in DNA damage repair (DDR), a hallmark of cancer, are associated with increased cancer cell sensitivity to certain therapies. This study sought to evaluate the association of DDR pathogenic variants with treatment efficacy in patients with advanced non-small cell lung cancer (NSCLC). METHODS A retrospective cohort of consecutive patients with advanced NSCLC attending a tertiary medical center who underwent next-generation sequencing in 01/2015-8/2020 were clustered according to DDR gene status and compared for overall response rate (ORR), progression-free survival (PFS) (patients receiving systemic therapy), local PFS (patients receiving definitive radiotherapy), and overall survival (OS) using log-rank and Cox regression analyses. RESULTS Of 225 patients with a clear tumor status, 42 had a pathogenic/likely pathogenic DDR variant (pDDR), and 183 had no DDR variant (wtDDR). Overall survival was similar in the two groups (24.2 vs. 23.1 months, p = 0.63). The pDDR group had a higher median local PFS after radiotherapy (median 45 months vs. 9.9 months, respectively; p = 0.044), a higher ORR (88.9% vs. 36.2%, p = 0.04), and a longer median PFS (not reached vs. 6.0 months, p = 0.01) in patients treated with immune checkpoint blockade. There was no difference in ORR, median PFS, and median OS in patients treated with platinum-based chemotherapy. CONCLUSION Our retrospective data suggest that in patients with stage 4 NSCLC, pathogenic variants in DDR pathway genes may be associated with higher efficacy of radiotherapy and immune checkpoint inhibitors (ICIs). This should be further explored prospectively.
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Affiliation(s)
- Itamar Averbuch
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | | | - Oded Icht
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | | | - Raz Mutai
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | | | - Ofer Rotem
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Nir Peled
- Oncology Division, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Aaron M Allen
- Oncology Division, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Yael Goldberg
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Alona Zer
- Fishman Oncology Institute, Rambam Health Care Campus, Haifa, Israel
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Icht O, Leader A, Batat E, Yosef L, Shochat T, Goldstein DA, Dudnik E, Spectre G, Raanani P, Hammerman A, Zer A. Arterial and Venous Thromboembolism in ALK-Rearrangement-Positive Non-small Cell Lung Cancer: A Population-Based Cohort Study. Oncologist 2023:7103524. [PMID: 37014824 DOI: 10.1093/oncolo/oyad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/08/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION There is scarce data regarding the incidence of venous thromboembolism (VTE) and arterial thromboembolism (ATE) in the molecular subtypes of non-small cell lung cancer (NSCLC). We aimed to investigate the association between Anaplastic Lymphoma Kinase (ALK)-positive NSCLC and thromboembolic events. METHODS A retrospective population-based cohort study of the Clalit Health Services database, included patients with NSCLC diagnosed between 2012 and 2019. Patients exposed to ALK-tyrosine-kinase inhibitors (TKIs) were defined as ALK-positive. The outcome was VTE (at any site) or ATE (stroke or myocardial infarction) 6 months prior to the diagnosis of cancer, until 5 years post-diagnosis. The cumulative incidence of VTE and ATE and hazard-ratios (HR) with 95% CIs were calculated (at 6- 12- 24 and 60-months), using death as a competing risk. Cox proportional hazards multivariate regression was performed, with the Fine and Gray correction for competing risks. RESULTS The study included 4762 patients, of which 155 (3.2%) were ALK-positive. The overall 5-year VTE incidence was 15.7% (95% CI, 14.7-16.6%). ALK-positive patients had a higher VTE risk compared to ALK-negative patients (HR 1.87 [95% CI, 1.31-2.68]) and a 12-month VTE incidence of 17.7% (13.9-22.7%) compared to 9.9% (9.1-10.9%) in ALK-negative patients. The overall 5-year ATE incidence was 7.6% [6.8-8.6%]. ALK positivity was not associated with ATE incidence (HR 1.24 [0.62-2.47]). CONCLUSIONS In this study, we observed a higher VTE risk, but not ATE risk, in patients with ALK-rearranged NSCLC relative to those without ALK rearrangement. Prospective studies are warranted to evaluate thromboprophylaxis in ALK-positive NSCLC.
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Affiliation(s)
- Oded Icht
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Erez Batat
- The Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Lilach Yosef
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Tzippy Shochat
- Statistical consulting unit, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel A Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Elizabeth Dudnik
- Lung Cancer Service, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Galia Spectre
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ariel Hammerman
- The Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Alona Zer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Oncology Division, Rambam Health Care Campus, Haifa, Israel
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Tannock IF, Goldstein DA, Ofer J, Gyawali B, Meirson T. Evaluating Trials of Adjuvant Therapy: Is There Benefit for People With Resected Renal Cancer? J Clin Oncol 2023; 41:2713-2717. [PMID: 36961983 DOI: 10.1200/jco.23.00280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Affiliation(s)
- Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Optimal Cancer Care Alliance, Ann Arbor, MI
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Ofer
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Departments of Oncology and Public Health Sciences, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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11
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Goldstein DA, Ginsberg GM, Hofnung-Gabbay D, De Abreu Lourenco R, Loong HH, Goh BC, Chan KKW, Di Maio M, Perrone F, Hall PS, Zer A, Rosenbaum E. Multinational Analysis of Estimated Health Care Costs Related to Extended-Interval Fixed Dosing of Checkpoint Inhibitors. JAMA Netw Open 2023; 6:e230490. [PMID: 36821111 PMCID: PMC9951041 DOI: 10.1001/jamanetworkopen.2023.0490] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE New dosing options for immune checkpoint inhibitors have recently been approved by the US Food and Drug Administration (FDA), including fixed dosing with extended intervals. Although the dose intensity appears the same, there is expected to be some waste with extended-interval dosing, as some drug remains in the bloodstream once a decision to stop treatment is made. The economic impact of extended-interval fixed dosing is unknown compared with standard-interval fixed dosing. OBJECTIVE To analyze the potential health care costs of using extended-interval fixed dosing instead of standard-interval fixed dosing. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used a pharmacoeconomic model to simulate 2 cohorts of patients with platinum-resistant metastatic urothelial cancer receiving pembrolizumab as second-line therapy at different dosing intervals using 2020 pricing data. Data were analyzed from 2020 to 2022. EXPOSURES The simulated patients received FDA-approved regimens of either 200 mg every 3 weeks or 400 mg every 6 weeks. MAIN OUTCOMES AND MEASURES The progression-free survival curve from the KEYNOTE-045 trial was used to estimate treatment duration. Drug, imaging, and administration costs were included in analyses. Sensitivity analyses were performed to assess how different imaging frequencies would affect the model results. The potential overall costs of using the 2 different dosing strategies were assessed. The base case was set in the US, while sensitivity analyses were set in several other countries. RESULTS In the base case analysis, dosing every 6 weeks instead of every 3 weeks resulted in an estimated 8.9% increase in pembrolizumab costs for the health care payer. Accounting for a decrease in infusion costs would result in an estimated net additional cost of $7483 per patient in the US (7.9% cost increase). In the US, this would amount to an increase of approximately $28 million annually for health care payers. Similar percentages in cost estimate increases were found for health care payers around the world, such as in Israel, where the net additional cost would be $5491 per patient. CONCLUSIONS AND RELEVANCE This economic evaluation assessed and quantified the potential increased costs related to extended-interval fixed dosing of pembrolizumab. The model method could be applied to other diseases and other drugs for which there has been a movement toward extended-interval dosing. Results may differ in other diseases owing to differing disease courses and patient profiles.
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Affiliation(s)
- Daniel A. Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina, Chapel Hill
- Clalit Health Service, Tel Aviv, Israel
| | - Gary M. Ginsberg
- Hebrew University–Hadassah Braun School of Public Health, Jerusalem, Israel
| | | | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Ultimo, Australia
| | - Herbert H. Loong
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, China
| | - Boon Cher Goh
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Kelvin K. W. Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, Canada
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - Francesco Perrone
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS Fondazione Pascale, Napoli, Italy
| | - Peter S. Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, United Kingdom
| | - Alona Zer
- Institute of Oncology, Rambam Medical Center, Haifa, Israel
| | - Eli Rosenbaum
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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12
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Mitchell AP, Goldstein DA. Cost Savings and Increased Access With Ultra-Low-Dose Immunotherapy. J Clin Oncol 2023; 41:170-172. [PMID: 36265102 PMCID: PMC9839306 DOI: 10.1200/jco.22.01711] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 01/19/2023] Open
Affiliation(s)
- Aaron P. Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel A. Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv-Yafo, Israel
- Optimal Cancer Care Alliance, Ann Arbor, MI
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13
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Peer CJ, Schmidt KT, Arisa O, Richardson WJ, Paydary K, Goldstein DA, Gulley JL, Figg WD, Ratain MJ. In Silico Re-Optimization of Atezolizumab Dosing Using Population Pharmacokinetic Simulation and Exposure-Response Simulation. J Clin Pharmacol 2023; 63:672-680. [PMID: 36624662 PMCID: PMC10175103 DOI: 10.1002/jcph.2203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Atezolizumab, a humanized monoclonal antibody against programmed cell death ligand 1 (PD-L1), was initially approved in 2016, around the same time that the sponsor published the minimum serum concentration to maintain the saturation of receptor occupancy (6 μg/mL). The initially approved dose regimen of 1200 mg every 3 weeks (q3w) was subsequently modified to 840 mg q2w or 1680 mg q4w through pharmacokinetic simulations. Yet, each standard regimen yields steady-state trough concentrations (CMIN,SS ) far exceeding (≈ 40-fold) the stated target concentration. Additionally, the steady-state area under the plasma drug concentration-time curve (AUCSS ) at 1200 mg q3w was significantly (P = .027) correlated with the probability of adverse events of special interest (AESIs) in patients with non-small cell lung cancer (NSCLC) and, coupled with excess exposure, this provides incentive to explore alternative dose regimens to lower the exposure burden while maintaining an effective CMIN,SS . In this study, we first identified 840 mg q6w as an extended-interval regimen that could robustly maintain a serum concentration of 6 μg/mL (≥99% of virtual patients simulated, n = 1000), then applied this regimen to an approach that administers 2 "loading doses" of standard-interval regimens for a future clinical trial aiming to personalize dose regimens. Each standard dose was simulated for 2 loading doses, then 840 mg q6w thereafter; all yielded cycle-7 CMIN,SS values of >6 μg/mL in >99% of virtual patients. Further, the AUCSS from 840 mg q6w resulted in a flattening (P = .63) of the exposure-response relationship with adverse events of special interest (AESIs). We next aim to verify this in a clinical trial seeking to validate extended-interval dosing in a personalized approach using therapeutic drug monitoring.
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Affiliation(s)
- Cody J Peer
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Keith T Schmidt
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Oluwatobi Arisa
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - William J Richardson
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Koosha Paydary
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Clalit Health Services, Tel Aviv, Israel
| | - James L Gulley
- Genitourinary Malignancies Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - William D Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark J Ratain
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
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14
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Margalit O, Harmsen WS, Shacham-Shmueli E, Voss MM, Boursi B, Wagner AD, Cohen R, Olswold CL, Saltz LB, Goldstein DA, Hurwitz H, Tebbutt NC, Kabbinavar FF, Adams RA, Chibaudel B, Grothey A, Yoshino T, Zalcberg J, de Gramont A, Shi Q, Lenz HJ. Evaluating sex as a predictive marker for response to bevacizumab in metastatic colorectal carcinoma: Pooled analysis of 3,369 patients in the ARCAD database. Eur J Cancer 2023; 178:162-170. [PMID: 36446161 DOI: 10.1016/j.ejca.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Previous studies suggest a possible sex-specific response to bevacizumab in metastatic colorectal carcinoma (mCRC), showing a benefit in males, while the effect in females is less significant. METHODS Data from 3369 patients with mCRC enrolled on four first-line randomised trials testing chemotherapy with or without bevacizumab (2000-2007) were pooled. Association between sex and progression-free survival and overall survival (OS) was evaluated by stratified Cox regression model, adjusted for potential confounders. Predictive value was evaluated by interaction effect between sex and treatment. In a pre-planned secondary analysis, analyses were stratified using an age cut point of 60 years to evaluate the possible role of menopausal-related effects. RESULTS Bevacizumab was associated with an improved median OS in males and females, with a 2.3- and 0.6-months benefit, respectively. Stratified by age, bevacizumab resulted in improved OS in males at both age categories. In females at or above the age of 60 (n = 731), bevacizumab resulted in improved OS. However, in females below the age of 60 (n = 634), OS benefit did not reach statistical significance (adjusted hazard ratio = 0.94, 95% confidence interval 0.74-1.20). CONCLUSIONS Our results confirmed the OS benefit from the addition of bevacizumab to first-line chemotherapy in mCRC in both sexes. Among females, the benefit was less than 1 month. For females under the age of 60, there was no survival benefit. These findings could be used to relieve financial toxicity or be redistributed within healthcare systems for other health-related purposes.
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Affiliation(s)
- Ofer Margalit
- Sheba Medical Center, Ramat-Gan, Israel; Tel-Aviv University, Tel-Aviv, Israel.
| | - William S Harmsen
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA
| | | | - Molly M Voss
- Department of Quantitative Science Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Ben Boursi
- Sheba Medical Center, Ramat-Gan, Israel; Tel-Aviv University, Tel-Aviv, Israel
| | - Anna D Wagner
- Department of Oncology, Division of Medical Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Romain Cohen
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA; Sorbonne University, Department of Medical Oncology, Saint-Antoine Hospital, AP-HP, F-75012 Paris, France; Sorbonne University, INSERM, Unité Mixte de Recherche Scientifique 938, Centre de Recherche Saint-Antoine, Equipe Instabilité des Microsatellites et Cancer, Equipe labellisée par la Ligue Nationale contre le Cancer, F-75012 Paris, France
| | - Curtis L Olswold
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Niall C Tebbutt
- University of Melbourne, Australia; Austin Health, Heidelberg, Victoria, Australia
| | - Fairooz F Kabbinavar
- David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Benoist Chibaudel
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | | | - Takayuki Yoshino
- Department of Gastrointestinal Oncology, National Cancer Center Hospital East, Japan
| | - John Zalcberg
- Department of Medical Oncology, Alfred Health and School of Public Health, Monash University, Melbourne, Australia
| | - Aimery de Gramont
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - Qian Shi
- Department of Quantitative Science Research, Mayo Clinic, Rochester, MN, USA
| | - Heinz-Josef Lenz
- Department of Gastrointestinal Oncology, Keck School of Medicine at USC, Los Angeles, CA, USA
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15
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Hessinger JD, Etingen B, Larsen SE, Hunley HA, Goldstein DA, Day AM, Mayberry M, Weber DJ, Dolgin R, Beyer JA, Maieritsch KP. Improving engagement and retention to treatment within VHA PTSD specialty care: Evolution of an outpatient program design. Psychol Serv 2022; 20:241-247. [PMID: 36066853 DOI: 10.1037/ser0000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Veteran's Health Administration (VA) and Department of Defense (DoD) posttraumatic stress disorder (PTSD) clinical practice guidelines (2017) recommend individual, trauma-focused therapy as the gold standard of treatment for PTSD (i.e., evidence-based practices [EBP]). Moreover, these guidelines encourage the use of individual shared decision-making (SDM) to increase engagement and completion of EBPs for PTSD in line with current literature. This study retrospectively evaluated three models of program design of a VA PTSD specialty clinic over the past 8 years. In line with previous literature, the study hypothesized that leveraging individualized SDM in the clinic design would lead to increased completion of EBPs for PTSD. Analyses indicated an impact as the models shifted from a group-based model to an individualized model. Specifically, as compared to veterans who completed a group-based design, a greater proportion of those enrolled in the clinic were more likely to complete an EBP. These results may suggest that individualized, patient-centered treatment planning may be related to patient engagement in EBPs for PTSD in contrast with group-based models. Other programmatic changes, such as changes in treatment options presented to patients, a movement to focus on EBPs for PTSD, and expanded clinic hours and telehealth options, possibly impacted veteran engagement and completion in EBPs. The study highlights the potential impacts of a changing patient population within the clinic over a relatively short period. The observations are discussed, and limitations are highlighted. The study shares the hope for additional randomized prospective studies of program designs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Junior VA Hospital
| | | | | | | | - Anne M Day
- Trauma Services Program, Edward Hines Junior VA Hospital
| | - Megan Mayberry
- Trauma Services Program, Edward Hines Junior VA Hospital
| | - Dana J Weber
- Trauma Services Program, Edward Hines Junior VA Hospital
| | - Ron Dolgin
- Trauma Services Program, Edward Hines Junior VA Hospital
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16
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Washington C, Goldstein DA, Moore A, Gardner U, Deville C. Health Disparities in Prostate Cancer and Approaches to Advance Equitable Care. Am Soc Clin Oncol Educ Book 2022; 42:1-6. [PMID: 35671436 DOI: 10.1200/edbk_350751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The American Cancer Society estimates approximately 268,490 new cases of prostate cancer and approximately 34,500 deaths caused by prostate cancer in the United States for 2022. Globally, a total of 1,414,259 new cases of prostate cancer and 375,304 related deaths were reported in 2020. Well-documented health disparities and inequities exist along the continuum of care for prostate cancer management-from screening to diagnostic and staging work-up, surveillance, and treatment-ultimately impacting clinical outcomes. This session-based article discusses innovative patient-centered approaches to advance equitable prostate cancer care. It begins with a review of domestic health disparities in diagnostic imaging and radiotherapy for prostate cancer, and it summarizes barriers and solutions to achieving health equity, such as equity metrics and practice quality improvement projects. Next, a global perspective is provided that describes approaches to address financial and geographic barriers to prostate cancer care, including specific examples of strategies that emphasize the use of the cheapest method of care delivery while maintaining outcomes for drug delivery and radiotherapy.
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Affiliation(s)
- Cyrus Washington
- Department of Radiation Oncology, University of Miami School of Medicine, Miami, FL
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Assaf Moore
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ulysses Gardner
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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17
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Tachiki LML, Williams Silva K, Hippe DS, Fritzsche D, Raczka A, Perdue A, Majovski J, Spallone A, Goldstein DA, Nghiem P, Thompson JA, Hall ET, Bhatia S. Extended duration of anti-PD-1 therapy, using reduced frequency dosing, in patients with advanced melanoma and Merkel cell carcinoma. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.2588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2588 Background: Optimal duration of treatment (DoT) with immune checkpoint inhibitors (ICI) in patients with metastatic melanoma (Mel) and Merkel cell carcinoma (MCC) is unclear. ICI discontinuation in Mel patients, especially those without CR, may be associated with a higher rate of progression over time, as compared to ICI continuation. Thus, extending DoT could improve outcomes. However, indefinite continuation at standard frequency doses (SFD) is not logistically or financially viable. Based on data from phase I studies suggesting sustained PD-1 receptor occupancy beyond 3 months after a single dose of nivolumab, we employed reduced frequency dosing (RFD) of anti-PD-1 antibodies every 2-3 months, to extend ICI duration beyond 2 years. Methods: This retrospective study analyzes patients in our skin cancer clinic with metastatic Mel and MCC who experienced initial clinical benefit with anti-PD-1 administered at SFD and then transitioned to RFD. We analyzed safety and efficacy endpoints including progression free survival (PFS) and rates of immune-related adverse events (irAE) with RFD. We also compared the pharmaceutical costs and patient-centered costs between 2 years of treatment at SFD versus extended DoT at RFD. Results: From 2014 – 2021, 23 patients with either metastatic Mel (N = 18) or MCC (N = 5) received anti-PD-1 therapy at RFD. Median DoT at SFD in this cohort was 1.1 years (range 0.2 – 2.2) with best objective tumor responses of CR (N =6), PR (N = 11), SD (N = 6). Median DoT at RFD was 1.2 years (range 0.2 – 3.5). The median follow-up for the entire cohort is 3.7 years (range 0.7 – 6.3) after ICI initiation. The 3-year PFS in Mel patients was 100% in those with CR (3/3), 89% with PR (8/9), and 50% with SD (3/6). The 3-year PFS in MCC was 100% in all 5 patients, including patients with CR (3/3) and with PR (2/2). Any-grade irAEs occurred in 43% of patients by 3 years on RFD, and grade 3/4 irAEs presented in 15%. Among the subset of 15 patients with DoT >2 years (median 3.4 yr, range 2.0 – 5.0), total savings amounted to $1.1 million in drugs costs and 384 hours of clinic and travel time despite the increased DoT, as compared to the calculated values for 2-year DoT at SFD. Conclusions: RFD may provide an alternative approach to extending DoT in patients receiving ICI without additional logistical and financial burden, while preserving outcomes. Efficacy and safety data suggest sustained biologic activity of ICI with RFD administration. PK/PD analyses on patient samples are ongoing to further characterize the RFD approach. The RFD approach could be utilized to expand ICI access to communities with limited healthcare resources, thereby impacting cancer outcomes at a global scale.
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Affiliation(s)
| | | | - Daniel S Hippe
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Dane Fritzsche
- University of Washington and Seattle Cancer Care Alliance, Seattle, WA
| | | | - Andrea Perdue
- University of Washington and Seattle Cancer Care Alliance, Seattle, WA
| | - Julia Majovski
- University of Washington and Seattle Cancer Care Alliance, Seattle, WA
| | | | | | - Paul Nghiem
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA
| | - John A. Thompson
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA
| | - Evan Thomas Hall
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA
| | - Shailender Bhatia
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA
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18
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Goldstein DA, Harvey RD, Chan KKW. Enabling the Sharing of Single-Dose Vials Through Risk Mitigation to Decrease Financial Toxicity. JAMA Oncol 2022; 8:821-822. [PMID: 35446351 DOI: 10.1001/jamaoncol.2022.0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Israel
| | - R Donald Harvey
- Winship Cancer Institute of Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Kelvin K W Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.,Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
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19
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Peer CJ, Heiss BL, Goldstein DA, Goodell JC, Figg WD, Ratain MJ. Pharmacokinetic Simulation Analysis of Less Frequent Nivolumab and Pembrolizumab Dosing: Pharmacoeconomic Rationale for Dose Deescalation. J Clin Pharmacol 2022; 62:532-540. [PMID: 34648187 PMCID: PMC9749861 DOI: 10.1002/jcph.1984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 10/09/2021] [Indexed: 12/16/2022]
Abstract
Nivolumab and pembrolizumab, anti-programmed cell death protein 1 monoclonal antibodies, have revolutionized oncology but are expensive. Using an interventional pharmacoeconomic approach, these drugs can be administered less often to reduce costs and increase patient convenience while maintaining efficacy. Both drugs are good candidates for less frequent dosing because of long half-lives and no evidence of a relationship of dose to efficacy. Established population pharmacokinetic models for both nivolumab and pembrolizumab were used to simulate profiles for multiple dosing regimens on 1000 randomly generated virtual patients. Simulations were initially performed on standard dose regimens to validate these in silico predictions. Next, simulations of nivolumab 0.3 mg/kg every 3 weeks revealed that >95% of patients maintained ≥1.5 μg/mL at steady state, which was inferred as the minimum effective concentration (MEC) for both drugs. Various alternative dosing regimens were simulated for both drugs to determine which regimen(s) can maintain this MEC in >95% of patients. Extended dosing regimens of nivolumab 240 mg every 4 weeks and 480 mg every 8 weeks along with pembrolizumab 200 mg every 6 weeks were simulated, showing that >95% of patients maintained MEC or greater. These simulations demonstrate the potential to reduce drug exposure by at least 50%, thus substantially reducing patient visits (as well as costs), while maintaining equivalent efficacy. These models provide the scientific justification for an ongoing prospective randomized clinical trial comparing standard interval fixed dosing with extended interval fixed dosing, and ultimately an efficacy-driven comparative trial.
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Affiliation(s)
- Cody J. Peer
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Brian L. Heiss
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
| | - Daniel A. Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Tel Aviv, Israel,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jennifer C. Goodell
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - William D. Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark J. Ratain
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
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20
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Ratain MJ, Peer CJ, Figg WD, Goldstein DA. Dose Optimization of Pembrolizumab: Less May Be More. Clin Pharmacol Ther 2021; 111:993. [PMID: 34854077 DOI: 10.1002/cpt.2490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Cody J Peer
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - William D Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Daniel A Goldstein
- Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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21
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Affiliation(s)
- Garth W Strohbehn
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.,Optimal Cancer Care Alliance, Ann Arbor, MI, USA.,Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI, USA
| | - Alec J Kacew
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA.,Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Robin C Feldman
- Center for Innovation, University of California Hastings College of the Law, San Francisco, CA, USA.
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA. .,Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
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22
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Gordon N, Goldstein DA, Tadmor B, Stemmer SM, Greenberg D. Factors Associated With Off-Label Oncology Prescriptions: The Role of Cost and Financing in a Universal Healthcare System. Front Pharmacol 2021; 12:754390. [PMID: 34737706 PMCID: PMC8560680 DOI: 10.3389/fphar.2021.754390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose: Various solutions have been put forward for prescribing and reimbursing treatments outside their registered indications within universal healthcare systems. However, most off-label oncology prescriptions are not reimbursed by health funds. This study characterized the financing sources of off-label oncology use and the predictors of the decision to forego treatment. Materials and Methods: All 708 off-label oncology requests submitted for approval in a large tertiary cancer center in Israel between 2016 and 2018 were examined for disease and patient sociodemographic characteristics, costs and financing sources, and the factors predicting actual off-label drug administration using multivariate logistic regression analysis. Results: The mean monthly cost of a planned off-label treatment was ILS54,703 (SD = ILS61,487, median = ILS39,928) (approximately US$ 15,500). The main sources of funding were private health insurance (25%) and expanded access pharma company plans (30%). Approximately one third (31%) of the requests did not have a financing source at the time of approval. Of the 708 requests, 583 (or 82%) were filled and treatment was initiated. Predictors for forgoing treatment were the impossibility of out-of-pocket payments or the lack of a financing solution (OR = 0.407; p = 0.005 and OR = 0.400; p < 0.0005). Conclusion: Although off-label recommendations are widespread and institutional approval is often granted, a large proportion of these prescriptions are not filled. In a universal healthcare system, the financing sources for off-label treatments are likely to influence access.
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Affiliation(s)
- Noa Gordon
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel.,Institute of Oncology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel A Goldstein
- Institute of Oncology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Clalit Health Services, Tel-Aviv, Israel
| | - Boaz Tadmor
- Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Salomon M Stemmer
- Institute of Oncology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
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Jacobi O, Landman Y, Reinhorn D, Icht O, Sternschuss M, Rotem O, Finkel I, Allen AM, Dudnik E, Goldstein DA, Zer A. The Relationship of Diabetes Mellitus to Efficacy of Immune Checkpoint Inhibitors in Patients with Advanced Non-Small Cell Lung Cancer. Oncology 2021; 99:555-561. [PMID: 34247166 DOI: 10.1159/000516671] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/21/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICI) are the new standard therapy in patients with metastatic NSCLC (mNSCLC). Metformin, previously associated with improved chemotherapy efficacy in diabetic and nondiabetic cancer patients, was recently associated with increased ICI efficacy. In this study, we aimed to explore the correlations between diabetes mellitus (DM), metformin use, and benefit from ICI in mNSCLC patients. METHODS All mNSCLC patients treated with ICI in our center between February 2015 and April 2018 were identified. Demographic and clinical data were extracted retrospectively. Cox proportional hazards regression, t tests, and χ2 tests were employed to evaluate associations of progression-free survival (PFS), overall survival (OS), overall response rate (ORR), and disease control rate (DCR), with DM status, metformin use, and HbA1c levels, as appropriate. RESULTS Of 249 mNSCLC patients treated with ICI, 57 (22.8%) had DM. Thirty-seven (64.9% of all diabetic patients) patients were treated with metformin. A significant negative correlation of DM with PFS and OS was demonstrated (HR 1.5 [1.01-2.06], p = 0.011, and HR 1.5 [1.08-2.08], p = 0.017, respectively). Metformin exposure had no significant correlation with PFS or OS in diabetic mNSCLC patients (HR 1.08 [0.61-1.93], p = 0.79, and HR 1.29 [0.69-2.39], p = 0.42, respectively). There were no differences between groups with respect to ORR and DCR. CONCLUSION Our data show a potential negative relationship between DM and ICI efficacy in mNSCLC patients. In contrast to reports with chemotherapy, we found no positive relationship between metformin use and ICI therapy in diabetic patients with mNSCLC. Further studies are needed to evaluate the effect of metformin in nondiabetic mNSCLC patients.
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Affiliation(s)
- Oded Jacobi
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | - Yosef Landman
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | - Daniel Reinhorn
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | - Oded Icht
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | | | - Ofer Rotem
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | - Inbar Finkel
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | - Aaron M Allen
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | - Elizabeth Dudnik
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
| | | | - Alona Zer
- Davidoff Cancer Center, Rabin Medical Center, Petach-Tiqwa, Israel
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24
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Moore A, Bar Y, Maurice-Dror C, Finkel I, Goldvaser H, Dudnik E, Goldstein DA, Gordon N, Billan S, Gutfeld O, Wolf I, Popovtzer A. Next-generation sequencing in thyroid cancers: do targetable alterations lead to a therapeutic advantage?: A multicenter experience. Medicine (Baltimore) 2021; 100:e26388. [PMID: 34160418 PMCID: PMC8238320 DOI: 10.1097/md.0000000000026388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/29/2021] [Accepted: 05/25/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Radioiodine-refractory thyroid cancers (IRTCs) are uncommon and have a poor prognosis. Treatment options for radioiodine-refractory and anaplastic tumors (ATCs) are limited. Although the genomic landscape of thyroid cancer has been studied, there is little evidence on whether next-generation sequencing (NGS) findings translate to tumor control.We analyzed all patients with IRTC and ATC who underwent commercially available NGS in 3 cancer centers.Twenty-two patients were identified, 16 patients with IRTCs and 6 patients with ATCs. Eighteen (82%) had targetable findings in NGS, nine patients were treated accordingly. Median progression-free survival for targeted treatment was 50 months [95% confidence interval (CI95%) 9.8-66.6] and2 months (CI95% 0.2-16.5) for IRTC and ATC, respectively. Of 4 patients who achieved durable responses of 7 to 50 months, 2 are ongoing. The estimated median OS of IRTC receiving targeted treatment was not reached (CI95% 89.7-111.4 months) and was 77.8 months (CI95% 52.5-114.6) for patients treated conventionally (P = .3).NGS may detect clinically significant genetic alterations and benefit patients with advanced thyroid cancers.
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Affiliation(s)
- Assaf Moore
- Institute of Oncology, Davidoff Center, Rabin Medical Center – Beilinson Hospital, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University
| | - Yael Bar
- Sackler Faculty of Medicine, Tel Aviv University
- Oncology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv
| | - Corinne Maurice-Dror
- Institute of Oncology, Rambam Health Care Campus
- Ruth & Bruce Rappaport, Faculty of Medicine, Technion Israel Institute of Technology, Haifa
| | - Inbar Finkel
- Institute of Oncology, Davidoff Center, Rabin Medical Center – Beilinson Hospital, Petach Tikva
| | - Hadar Goldvaser
- Oncology Institute, Shaare Zedek Medical Center
- The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Elizabeth Dudnik
- Institute of Oncology, Davidoff Center, Rabin Medical Center – Beilinson Hospital, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University
| | - Daniel A. Goldstein
- Institute of Oncology, Davidoff Center, Rabin Medical Center – Beilinson Hospital, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University
| | - Noa Gordon
- Institute of Oncology, Davidoff Center, Rabin Medical Center – Beilinson Hospital, Petach Tikva
| | - Salem Billan
- Institute of Oncology, Rambam Health Care Campus
- Ruth & Bruce Rappaport, Faculty of Medicine, Technion Israel Institute of Technology, Haifa
| | - Orit Gutfeld
- Sackler Faculty of Medicine, Tel Aviv University
- Oncology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv
| | - Ido Wolf
- Sackler Faculty of Medicine, Tel Aviv University
- Oncology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv
| | - Aron Popovtzer
- Institute of Oncology, Davidoff Center, Rabin Medical Center – Beilinson Hospital, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University
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25
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Gordon N, Goldstein DA, Tadmor B, Stemmer SM, Greenberg D. Factors associated with off-label (OL) drug use in oncology: The role of cost and financing in a universal healthcare system. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18825 Background: In recent years, OL use in oncology has become widespread, with estimates ranging up to 50-75% of all prescriptions. Most OL use is not publicly reimbursed within universal healthcare systems. We aimed to characterize the financing sources of OL use and to identify predictors for forgoing such treatment. Methods: We studied 708 oncology OL prescription requests submitted for approval to the Institutional Drug Committee in Rabin Medical Center, a large tertiary center in Israel, between January 2016 and December 2018. We included only requests for patients that were alive for more than 60 days following prescription approval. For each indication we extracted the level of supporting evidence at the time of prescription (sufficient, limited, inadequate). We also examined patients’ disease and sociodemographic properties, treatment costs, and financing sources. We used univariable logistic regression to ascertain these variables’ effects on actual OL drug initiation. We then used multivariable logistic regression to explore predicting factors for drug initiation. Results: The median monthly cost of a planned OL treatment was ILS39,928 (approximately US$ 11,500). Approximately one third (31%) of the treatments did not have a financing source at the time of request approval. The primary financing sources were patient access plans (30%) and private health insurance (25%). Of 708 approved OL requests, only 583 (82.3%) treatments were initiated. The proportion of requests that were eventually initiated was higher in the metastatic versus adjuvant setting (84.9% vs. 76.5%; p= .008). The estimated median OS for metastatic patients was 9.9 months, significantly higher in patients that did initiate treatment versus patients that did not (10.4 vs. 7.2 months; p= .048). Although not significant, median costs of initiated treatments were higher compared to treatments that were not (ILS41,686 vs. ILS24,670). Prescriptions for the metastatic setting and immunotherapy as well as ones with sufficient evidence had higher odds for treatment initiation (OR = 1.73; p= .007, OR = 1.69; p= .013 and OR = 1.62; p= .016). Prescriptions with limited supporting evidence and with no planned financing source had lower odds for treatment initiation (OR = 0.59; p= .012, OR = 0.37; p< .0005). A multivariable logistic regression showed that if no financing plan was in place at the time of request, there was a 2.5 times higher likelihood of not initiating the treatment (OR = 2.5; p< .0005). Conclusions: While OL recommendation is widespread and institutional approval is granted, a substantial proportion of treatments are not initiated. Although cost was not associated with treatment initiation, having a planned financing source was a strong predictor for OL treatment initiation. This study elucidates the financing sources of OL treatments in a universal healthcare system and identifies access barriers.
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Affiliation(s)
- Noa Gordon
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | - Salomon M. Stemmer
- Davidoff Center, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Greenberg
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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26
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Gordon N, Goldstein DA, Tadmor B, Stemmer SM, Greenberg D. Prospects of off-label (OL) drug use in oncology: Identifying predicting variables for registration and universal healthcare reimbursement. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18842 Background: Many cancer drugs used OL, eventually complete clinical development and are registered and reimbursed, while others are not. We aimed to describe OL indications' registration and reimbursement prospects in a universal healthcare system and identify groups of treatments that remain OL longer. Methods: We studied 612 OL oncology prescription requests for 115 unique indications and 29 drugs. All requests were approved by the Institutional Drug Committee in Rabin Medical Center, a tertiary center in Israel, between January 2016 and December 2018. OL indications were not registered by the Israeli Ministry of Health (MOH) and were not included in the Israeli National List of Health Services (NLHS) for reimbursement at the time of prescription. Additionally, 459 requests for 100 indications were not approved by the FDA at the time of prescription. We explored the subsequent regulatory and reimbursement milestones in the timeline following each prescription. We identified three temporal events: FDA indication approval, MOH indication registration, and NLHS indication inclusion of reimbursement. We then defined three time-to-event variables from the OL prescription to each of the three milestones. We applied Kaplan-Meier analysis and multivariable Cox regression to identify drug and indication properties, which are predictors for registration and reimbursement. Results: With a median follow-up of 34.5 months, 10.4% of indications were eventually registered in Israel, and 6% were included in the NLHS. 7% of non-FDA approved indications were subsequently approved. For MOH registration, positive predictors were immunotherapy, sufficient evidence (ESMO-MCBS A-B, 5-4), and a patient access program at the time of prescription (HR = 21.99; p< .0005, HR = 3.4; p= .02 and HR = 2.73; p< .0005, respectively). Negative predictors were metastatic setting and lung and gastrointestinal (GI) cancers (HR = 0.42; p= .002, HR = 0.17; p= .001, and HR = 0.24; p= .043, respectively). For NLHS inclusion, positive predictors were immunotherapy, sufficient evidence, and an access program (HR = 9.03, HR = 6.24, and HR = 2.56, respectively, all p< .0005). Negative predictors were lung and GI cancers and orphan disease designation (HR = 0.07; p= .002, HR = 0.14; p= .021, and HR = 0.13; p= .009, respectively). For FDA approval, positive predictors were immunotherapy, sufficient evidence, and a patient access program (HR = 12.11; p< .0005, HR = 4.34; p= .002, and HR = 2.25; p= .001, respectively). Negative predictors were metastatic setting, lung cancer, and orphan disease (HR = 0.43; p= .003, HR = 0.25; p= .006, and HR = 0.08; p= .018, respectively). Conclusions: Few OL indications are subsequently approved and reimbursed, usually due to clinical futility and insufficient evidence. However, we identified factors related to lack of initiative for further clinical development and registration.
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Affiliation(s)
- Noa Gordon
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | - Salomon M. Stemmer
- Davidoff Center, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Greenberg
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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27
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Affiliation(s)
- Daniel A Goldstein
- Davidoff Center, Rabin Medical Center, Petach Tikvah, Israel.,Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina, Chapel Hill
| | - Mark J Ratain
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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28
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Bhanvadia SK, Psutka SP, Burg ML, de Wit R, Dhillon HM, Gyawali B, Morgans AK, Goldstein DA, Smith AB, Sun M, Penson DF. Financial Toxicity Among Patients with Prostate, Bladder, and Kidney Cancer: A Systematic Review and Call to Action. Eur Urol Oncol 2021; 4:396-404. [PMID: 33820747 DOI: 10.1016/j.euo.2021.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/03/2021] [Accepted: 02/26/2021] [Indexed: 11/30/2022]
Abstract
CONTEXT Financial toxicity (FT) refers to the detrimental effects of financial strain caused by a cancer diagnosis on the well-being of patients and their families. It is highly prevalent among cancer patients and has been associated with inferior clinical outcomes. OBJECTIVE To summarize the literature regarding FT among patients with prostate, bladder, and kidney cancer, and to propose a framework for future FT investigations. EVIDENCE ACQUISITION Primary manuscripts and abstracts reporting FT as a primary or secondary outcome or a covariate in patients with prostate, bladder, or kidney cancer, published before May 2020, were retrieved using the PubMed, Scopus, Embase, CINAHL, and Cochrane databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 629 titles identified, 19, ten, and two studies met the inclusion criteria for prostate, bladder, and kidney cancer, respectively, and were included (24 unique articles). EVIDENCE SYNTHESIS Significant heterogeneity was observed in covariates, methodology, and measure of FT. Factors commonly associated with FT included younger age at diagnosis, black race, low socioeconomic status, low education attainment, and rurality. FT was commonly associated with lower quality of life and nonadherence. FT was common among patients in countries with universal health coverage as well as those without, although the nature of these costs differed. CONCLUSIONS Despite paucity of literature, it is suggested that FT is common among patients with prostate and bladder cancer, and remains uncharacterized in kidney cancer patients. Future work will benefit from the incorporation of a formal FT framework, utilization of validated FT instruments to characterize FT consistently, and inclusion of FT measures in outcomes reported by patients with genitourinary cancers. PATIENT SUMMARY Financial toxicity affects many prostate, bladder, and kidney cancer patients; however, this toxicity is understudied. It is associated with decreased quality of life and lower medication and treatment adherence.
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Affiliation(s)
- Sumeet K Bhanvadia
- USC Norris Cancer Center, Keck Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Sarah P Psutka
- Department of Urology, University of Washington Seattle Cancer Care Alliance.
| | - Madeleine L Burg
- USC Norris Cancer Center, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Ronald de Wit
- Dept Medical Oncology Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Haryana M Dhillon
- Centre for Medical Psychology & Evidence-based Decision-making, School of Psychology, Faculty of Science, University of SydneyANZUP Cancer Trials Group, Sydney, Australia
| | - Bishal Gyawali
- Departments of Oncology and Public Health Sciences, Queen's University, Kingston, Canada
| | | | | | - Angela B Smith
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center
| | - Maxine Sun
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
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29
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Tannock IF, Ratain MJ, Goldstein DA, Lichter AS, Rosner GL, Saltz LB. Near-Equivalence: Generating Evidence to Support Alternative Cost-Effective Treatments. J Clin Oncol 2021; 39:950-955. [DOI: 10.1200/jco.20.02768] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Briggs AH, Goldstein DA, Kirwin E, Meacock R, Pandya A, Vanness DJ, Wisløff T. Estimating (quality-adjusted) life-year losses associated with deaths: With application to COVID-19. Health Econ 2021; 30:699-707. [PMID: 33368853 DOI: 10.1002/hec.4208] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/26/2020] [Accepted: 11/26/2020] [Indexed: 05/10/2023]
Abstract
Many epidemiological models of the COVID-19 pandemic have focused on preventing deaths. Questions have been raised as to the frailty of those succumbing to the COVID-19 infection. In this paper we employ standard life table methods to illustrate how the potential quality-adjusted life-year (QALY) losses associated with COVID-19 fatalities could be estimated, while adjusting for comorbidities in terms of impact on both mortality and quality of life. Contrary to some suggestions in the media, we find that even relatively elderly patients with high levels of comorbidity can still lose substantial life years and QALYs. The simplicity of the method facilitates straightforward international comparisons as the pandemic evolves. In particular, we compare five different countries and show that differences in the average QALY losses for each COVID-19 fatality is driven mainly by differing age distributions for those dying of the disease.
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Affiliation(s)
- Andrew H Briggs
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel A Goldstein
- Department of Oncology, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erin Kirwin
- Institute of Health Economics, Edmonton, Alberta, Canada
- Health, Organisation, Policy, and Economics (HOPE) Group, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Health, Organisation, Policy, and Economics (HOPE) Group, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - David J Vanness
- Department of Health Policy and Administration, Pennsylvania State University, Pennsylvania, USA
| | - Torbjørn Wisløff
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
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31
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Peer CJ, Goldstein DA, Goodell JC, Nguyen R, Figg WD, Ratain MJ. Opportunities for using in silico-based extended dosing regimens for monoclonal antibody immune checkpoint inhibitors. Br J Clin Pharmacol 2020; 86:1769-1777. [PMID: 32424951 PMCID: PMC7444775 DOI: 10.1111/bcp.14369] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 03/10/2020] [Accepted: 04/26/2020] [Indexed: 12/21/2022] Open
Abstract
Therapeutic drug monitoring (TDM) involves frequent measurements of drug concentrations to ensure levels remain within a therapeutic window, and it is especially useful for drugs with narrow therapeutic indices or extensive interindividual pharmacokinetic variability. This technique has never been applied to immuno-oncology drugs, but, given recent examinations of clinical data (both exposure and response) on a number of these drugs, further investigations into TDM may be justified to reduce costs as well as potentially reducing the severity and/or duration of immune-related adverse events. Specifically, all but one of the approved PD-1 and PD-L1 inhibitors (pembrolizumab, nivolumab, cemiplimab-rwlc, atezolizumab, avelumab, durvalumab) have been shown to exhibit a plateaued exposure-response (E-R) curve at doses evaluated extensively to date, as well as time-dependent changes in drug exposure. Furthermore, responders have a greater decrease in drug clearance over time and would, therefore, have supratherapeutic serum concentrations. With frequent trough measurements, it is possible to use pharmacokinetic modelling and simulation to estimate drug clearance via Bayesian methods. Based on patient-specific estimates for clearance, optimal alternative dosing strategies can be simulated to lower drug and cost burden yet maintain therapeutic levels, especially as the clearance of the drug decreases over time. This review will comprehensively discuss each of the FDA approved PD-1, PD-L1/2 and CTLA-4 inhibitors regarding their indications and current recommended dosing, with evidence supporting the investigation of these types of TDM strategies.
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Affiliation(s)
- Cody J. Peer
- Clinical Pharmacology ProgramNational Cancer InstituteBethesdaMDUSA
| | | | | | - Ryan Nguyen
- Clinical Pharmacology ProgramNational Cancer InstituteBethesdaMDUSA
| | - William D. Figg
- Clinical Pharmacology ProgramNational Cancer InstituteBethesdaMDUSA
| | - Mark J. Ratain
- Department of Medicine, Center for Personalized Therapeutics, and Comprehensive Cancer CenterThe University of ChicagoChicagoILUSA
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Borisovsky G, Goldstein DA, Eliakim-Raz N, Tamir SR. Transitional Cell Carcinoma and Pseudocirrhosis— A Case Report and Review of the Literature. Journal of Gastrointestinal and Abdominal Radiology 2020. [DOI: 10.1055/s-0040-1713829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractPseudocirrhosis is the occurrence of capsular retraction in patients with metastatic liver disease, usually of breast origin. It usually appears in these patients following chemotherapy and may result from shrinkage of the tumor, with scarring and nodular regeneration. In this article, we describe the first case of pseudocirrhosis, following treatment of transitional cell carcinoma metastatic to the liver. Portal vein thrombosis, a rare complication in pseudocirrhosis, was also detected in this patient.
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Affiliation(s)
- Gilad Borisovsky
- Radiology Department, Rabin Medical Center, Petah Tikva, Israel, affliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A. Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel, affliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Eliakim-Raz
- Internal Medicine E, Rabin Medical Center, Petah Tikva, Israel, affliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomit R. Tamir
- Radiology Department, Rabin Medical Center, Petah Tikva, Israel, affliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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33
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Ben-Aharon O, Magnezi R, Leshno M, Goldstein DA. Mature Versus Registration Studies of Immuno‐Oncology Agents: Does Value Improve With Time? JCO Oncol Pract 2020; 16:e779-e790. [DOI: 10.1200/jop.19.00725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE: A unique feature of immuno-oncology agents is the potential for durable survival for a subset of patients; however, this benefit usually cannot not be seen in the early published data used for regulatory approval. Value frameworks developed by ASCO and the European Society for Medical Oncology (ESMO) assess the clinical benefit demonstrated in clinical trials. Proven benefit may change with time as more mature data are available. Our objective was to evaluate the impact of mature data for immuno-oncology agents on ASCO and ESMO scores and to examine the concordance of these frameworks using more mature data. METHODS: We reviewed Food and Drug Administration (FDA) approvals for immuno-oncology agents between 2011 and 2017, calculated the ASCO-Net Health Benefit (NHB) score and ESMO-Magnitude of Clinical Benefit Score (MCBS), checked which agents fulfilled the criteria of being rewarded for durable survival, assessed the concordance between models using the Spearman correlation test, and compared the initial results of registration studies with mature follow-up data from the same studies. RESULTS: The FDA approved 27 solid tumor indications for immuno-oncology agents between 2011 and 2017. The correlation between ASCO-NHB score and ESMO-MCBS was high (0.88). Mature follow-up data were available for 13 of these indications, in which 6 studies were found to have improved in the grade of ASCO and/or ESMO value frameworks, whereas 2 cases were downgraded in the scale. CONCLUSION: Despite different approaches, the high concordance between ASCO and ESMO value frameworks indicates that both models reward treatments as beneficial for the same immuno-oncology agents. Mature data with longer follow-up reaffirmed most of the findings found in the evaluation in the initially published registration studies.
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Affiliation(s)
- Omer Ben-Aharon
- Department of Management, Health System Management Program, Bar-Ilan University, Ramat Gan, Israel
| | - Racheli Magnezi
- Department of Management, Health System Management Program, Bar-Ilan University, Ramat Gan, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A. Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Petah Tiqva, Israel
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC
- Department of Oncology, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Goldstein DA, Ratain MJ. Safety, Clinical Activity, and Biological Correlates of Response in Patients with Metastatic Melanoma: Results from a Phase I Trial of Atezolizumab—Letter. Clin Cancer Res 2020; 26:2435. [DOI: 10.1158/1078-0432.ccr-19-3408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/26/2019] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
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Serritella AV, Strohbehn GW, Goldstein DA, Lichter AS, Ratain MJ. Interventional Pharmacoeconomics: A Novel Mechanism for Unlocking Value. Clin Pharmacol Ther 2020; 108:487-493. [DOI: 10.1002/cpt.1853] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/29/2020] [Indexed: 01/22/2023]
Affiliation(s)
| | - Garth W. Strohbehn
- Department of Medicine The University of Chicago Chicago Illinois USA
- Value in Cancer Care Consortium Ann Arbor Michigan USA
| | - Daniel A. Goldstein
- Value in Cancer Care Consortium Ann Arbor Michigan USA
- Tel Aviv University Tel Aviv Israel
- Davidoff Cancer CenterRabin Medical Center Petah Tikva Israel
- Department of Health Policy and Management Gillings School of Public Health University of North Carolina Chapel Hill North Carolina USA
| | | | - Mark J. Ratain
- Department of Medicine The University of Chicago Chicago Illinois USA
- Value in Cancer Care Consortium Ann Arbor Michigan USA
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Goldstein DA, Mayer C, Shochat T, Reinhorn D, Moore A, Sarfaty M, Yerushalmi R, Goldvaser H. The concordance of treatment decision guided by OncotypeDX and the PREDICT tool in real-world early-stage breast cancer. Cancer Med 2020; 9:4603-4612. [PMID: 32372569 PMCID: PMC7333833 DOI: 10.1002/cam4.3088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/19/2022] Open
Abstract
Background Decision‐making regarding adjuvant chemotherapy for early‐stage breast cancer can be guided by genomic assays such as OncotypeDX. The concordance of expected clinical decisions guided by OncotypeDX and prognostication online tools such as PREDICT is unknown. Methods We performed a retrospective single‐center cohort study comprising all women with estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative, node negative disease, whose tumors were sent for OncotypeDX analysis. Expected decision on adjuvant chemotherapy was evaluated using OncotypeDX and using PREDICT. The concordance between these two tools was calculated. The impact on concordance of prespecified features was assessed, including age, tumor size, intensity of ER and progesterone receptor (PR), grade, Ki67 and perineural and lymphovascular invasion. Results A total of 445 women were included. Overall concordance was 75% (K = 0.284). The concordance was significantly higher for grade 1 disease compared to grade 2‐3 (93% vs 72%, P < .001), tumor ≤ 1 cm compared to >1 cm (85% vs 72%, P = .009), PR positive compared to PR negative (78% vs 58%, P < .001) and ki67 < 10% compared to ≥10% (92% vs 63%, P < .001). The intensity of ER and the presence of perineural or lymphovascular invasion had no significant impact on concordance. Conclusions Compared to PREDICT, using OncotypeDx in node negative, ER positive disease is expected to change the clinical decision in a quarter of patients. The concordance between OncotypeDx and PREDICT is influenced by pathological features. In patients with very low risk, treatment decisions may be made based solely on clinical risk assessment.
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Affiliation(s)
- Daniel A Goldstein
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chen Mayer
- Department of Pathology, Sheba Medical Center, Ramat Gan, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel
| | - Daniel Reinhorn
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Moore
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Sarfaty
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rinat Yerushalmi
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Goldvaser
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Reinhorn D, Jacobi O, Icht O, Dudnik E, Rotem O, Zer A, Goldstein DA. Treatment beyond progression with immune checkpoint inhibitors in non-small-cell lung cancer. Immunotherapy 2020; 12:235-243. [PMID: 32189549 DOI: 10.2217/imt-2019-0131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aim: The treatment paradigm of advanced non-small-cell lung cancer has recently changed with the introduction of immune checkpoint inhibitors (ICIs). It is common practice to continue treatment beyond progression (TBP) in selected cases. The aim of this study was to evaluate real life practice and outcomes related to TBP. Materials & methods: We retrospectively evaluated advanced non-small-cell lung cancer patients treated with ICI therapy and identified patients who were treated beyond progression. Results: Of 207 patients included in this analysis, 22% patients received TBP. A total of 36% achieved a clinical benefit. A total of 27% patients had a progression-free interval over 6 months after receiving TBP. Conclusion: A subset of patients who were treated beyond progression with ICI achieved a clinically meaningful response with durable disease control.
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Affiliation(s)
- Daniel Reinhorn
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Oded Jacobi
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Oded Icht
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Elizabeth Dudnik
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Rotem
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Alona Zer
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, NC 27599-7400, USA
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Ammazzalorso S, Gruen D, Regis M, Camera S, Ando S, Fornengo N, Bechtol K, Bridle SL, Choi A, Eifler TF, Gatti M, MacCrann N, Omori Y, Samuroff S, Sheldon E, Troxel MA, Zuntz J, Carrasco Kind M, Annis J, Avila S, Bertin E, Brooks D, Burke DL, Carnero Rosell A, Carretero J, Castander FJ, Costanzi M, da Costa LN, De Vicente J, Desai S, Diehl HT, Dietrich JP, Doel P, Everett S, Flaugher B, Fosalba P, García-Bellido J, Gaztanaga E, Gerdes DW, Giannantonio T, Goldstein DA, Gruendl RA, Gutierrez G, Hollowood DL, Honscheid K, James DJ, Jarvis M, Jeltema T, Kent S, Kuropatkin N, Lahav O, Li TS, Lima M, Maia MAG, Marshall JL, Melchior P, Menanteau F, Miquel R, Ogando RLC, Palmese A, Plazas AA, Romer AK, Roodman A, Rykoff ES, Sánchez C, Sanchez E, Scarpine V, Serrano S, Sevilla-Noarbe I, Smith M, Soares-Santos M, Sobreira F, Suchyta E, Swanson MEC, Tarle G, Thomas D, Vikram V, Zhang Y. Detection of Cross-Correlation between Gravitational Lensing and γ Rays. Phys Rev Lett 2020; 124:101102. [PMID: 32216401 DOI: 10.1103/physrevlett.124.101102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/14/2019] [Accepted: 01/13/2020] [Indexed: 06/10/2023]
Abstract
In recent years, many γ-ray sources have been identified, yet the unresolved component hosts valuable information on the faintest emission. In order to extract it, a cross-correlation with gravitational tracers of matter in the Universe has been shown to be a promising tool. We report here the first identification of a cross-correlation signal between γ rays and the distribution of mass in the Universe probed by weak gravitational lensing. We use data from the Dark Energy Survey Y1 weak lensing data and the Fermi Large Area Telescope 9-yr γ-ray data, obtaining a signal-to-noise ratio of 5.3. The signal is mostly localized at small angular scales and high γ-ray energies, with a hint of correlation at extended separation. Blazar emission is likely the origin of the small-scale effect. We investigate implications of the large-scale component in terms of astrophysical sources and particle dark matter emission.
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Affiliation(s)
- S Ammazzalorso
- Dipartimento di Fisica, Università degli Studi di Torino, via Pietro Giuria 1, 10125 Torino, Italy
- INFN-Istituto Nazionale di Fisica Nucleare, Sezione di Torino, via Pietro Giuria 1, 10125 Torino, Italy
| | - D Gruen
- Kavli Institute for Particle Astrophysics and Cosmology, P. O. Box 2450, Stanford University, Stanford, California 94305, USA
- SLAC National Accelerator Laboratory, Menlo Park, California 94025, USA
| | - M Regis
- Dipartimento di Fisica, Università degli Studi di Torino, via Pietro Giuria 1, 10125 Torino, Italy
- INFN-Istituto Nazionale di Fisica Nucleare, Sezione di Torino, via Pietro Giuria 1, 10125 Torino, Italy
| | - S Camera
- Dipartimento di Fisica, Università degli Studi di Torino, via Pietro Giuria 1, 10125 Torino, Italy
- INFN-Istituto Nazionale di Fisica Nucleare, Sezione di Torino, via Pietro Giuria 1, 10125 Torino, Italy
- INAF-Istituto Nazionale di Astrofisica, Osservatorio Astrofisico di Torino, strada Osservatorio 20, 10025 Pino Torinese, Italy
- Department of Physics and Astronomy, University of the Western Cape, Cape Town 7535, South Africa
| | - S Ando
- GRAPPA Institute, University of Amsterdam, 1098 XH Amsterdam, The Netherlands
- Kavli Institute for the Physics and Mathematics of the Universe, University of Tokyo, Kashiwa, Chiba 277-8583, Japan
| | - N Fornengo
- Dipartimento di Fisica, Università degli Studi di Torino, via Pietro Giuria 1, 10125 Torino, Italy
- INFN-Istituto Nazionale di Fisica Nucleare, Sezione di Torino, via Pietro Giuria 1, 10125 Torino, Italy
| | - K Bechtol
- LSST, 933 North Cherry Avenue, Tucson, Arizona 85721, USA
- Physics Department, 2320 Chamberlin Hall, University of Wisconsin-Madison, 1150 University Avenue Madison, Wisconsin 53706-1390, USA
| | - S L Bridle
- Jodrell Bank Center for Astrophysics, School of Physics and Astronomy, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom
| | - A Choi
- Center for Cosmology and Astro-Particle Physics, The Ohio State University, Columbus, Ohio 43210, USA
| | - T F Eifler
- Department of Astronomy and Steward Observatory, University of Arizona, 933 North Cherry Avenue, Tucson, Arizona 85721-0065, USA
- Jet Propulsion Laboratory, California Institute of Technology, 4800 Oak Grove Drive, Pasadena, California 91109, USA
| | - M Gatti
- Institut de Física d'Altes Energies (IFAE), The Barcelona Institute of Science and Technology, Campus UAB, 08193 Bellaterra, Barcelona, Spain
| | - N MacCrann
- Center for Cosmology and Astro-Particle Physics, The Ohio State University, Columbus, Ohio 43210, USA
- Department of Physics, The Ohio State University, Columbus, Ohio 43210, USA
| | - Y Omori
- Kavli Institute for Particle Astrophysics and Cosmology, P. O. Box 2450, Stanford University, Stanford, California 94305, USA
| | - S Samuroff
- Department of Physics, Carnegie Mellon University, Pittsburgh, Pennsylvania 15312, USA
| | - E Sheldon
- Brookhaven National Laboratory, Building 510, Upton, New York 11973, USA
| | - M A Troxel
- Department of Physics, Duke University Durham, North Carolina 27708, USA
| | - J Zuntz
- Institute for Astronomy, University of Edinburgh, Edinburgh EH9 3HJ, United Kingdom
| | - M Carrasco Kind
- Department of Astronomy, University of Illinois at Urbana-Champaign, 1002 West Green Street, Urbana, Illinois 61801, USA
- National Center for Supercomputing Applications, 1205 West Clark Street, Urbana, Illinois 61801, USA
| | - J Annis
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - S Avila
- Instituto de Fisica Teorica UAM/CSIC, Universidad Autonoma de Madrid, 28049 Madrid, Spain
| | - E Bertin
- CNRS, UMR 7095, Institut d'Astrophysique de Paris, F-75014 Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7095, Institut d'Astrophysique de Paris, F-75014 Paris, France
| | - D Brooks
- Department of Physics and Astronomy, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - D L Burke
- Kavli Institute for Particle Astrophysics and Cosmology, P. O. Box 2450, Stanford University, Stanford, California 94305, USA
- SLAC National Accelerator Laboratory, Menlo Park, California 94025, USA
| | - A Carnero Rosell
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), 28040 Madrid, Spain
- Laboratório Interinstitucional de e-Astronomia-LIneA, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
| | - J Carretero
- Institut de Física d'Altes Energies (IFAE), The Barcelona Institute of Science and Technology, Campus UAB, 08193 Bellaterra, Barcelona, Spain
| | - F J Castander
- Institut d'Estudis Espacials de Catalunya (IEEC), 08034 Barcelona, Spain
- Institute of Space Sciences (ICE, CSIC), Campus UAB, Carrer de Can Magrans, s/n, 08193 Barcelona, Spain
| | - M Costanzi
- INAF-Osservatorio Astronomico di Trieste, via Giambattista Tiepolo 11, 34143 Trieste, Italy
- IFPU-Institute for Fundamental Physics of the Universe, Via Beirut 2, 34014 Trieste, Italy
| | - L N da Costa
- Laboratório Interinstitucional de e-Astronomia-LIneA, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
- Observatório Nacional, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
| | - J De Vicente
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), 28040 Madrid, Spain
| | - S Desai
- Department of Physics, IIT Hyderabad, Kandi, Telangana 502285, India
| | - H T Diehl
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - J P Dietrich
- Excellence Cluster Origins, Boltzmannstrasse 2, 85748 Garching, Germany
- Faculty of Physics, Ludwig-Maximilians-Universität, Scheinerstrasse 1, 81679 Munich, Germany
| | - P Doel
- Department of Physics and Astronomy, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - S Everett
- Santa Cruz Institute for Particle Physics, Santa Cruz, California 95064, USA
| | - B Flaugher
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - P Fosalba
- Institut d'Estudis Espacials de Catalunya (IEEC), 08034 Barcelona, Spain
- Institute of Space Sciences (ICE, CSIC), Campus UAB, Carrer de Can Magrans, s/n, 08193 Barcelona, Spain
| | - J García-Bellido
- Instituto de Fisica Teorica UAM/CSIC, Universidad Autonoma de Madrid, 28049 Madrid, Spain
| | - E Gaztanaga
- Institut d'Estudis Espacials de Catalunya (IEEC), 08034 Barcelona, Spain
- Institute of Space Sciences (ICE, CSIC), Campus UAB, Carrer de Can Magrans, s/n, 08193 Barcelona, Spain
| | - D W Gerdes
- Department of Astronomy, University of Michigan, Ann Arbor, Michigan 48109, USA
- Department of Physics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - T Giannantonio
- Institute of Astronomy, University of Cambridge, Madingley Road, Cambridge CB3 0HA, United Kingdom
- Kavli Institute for Cosmology, University of Cambridge, Madingley Road, Cambridge CB3 0HA, United Kingdom
| | - D A Goldstein
- California Institute of Technology, 1200 East California Boulevard, MC 249-17, Pasadena, California 91125, USA
| | - R A Gruendl
- Department of Astronomy, University of Illinois at Urbana-Champaign, 1002 West Green Street, Urbana, Illinois 61801, USA
- National Center for Supercomputing Applications, 1205 West Clark Street, Urbana, Illinois 61801, USA
| | - G Gutierrez
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - D L Hollowood
- Santa Cruz Institute for Particle Physics, Santa Cruz, California 95064, USA
| | - K Honscheid
- Center for Cosmology and Astro-Particle Physics, The Ohio State University, Columbus, Ohio 43210, USA
- Department of Physics, The Ohio State University, Columbus, Ohio 43210, USA
| | - D J James
- Center for Astrophysics, Harvard-Smithsonian, 60 Garden Street, Cambridge, Massachusetts 02138, USA
| | - M Jarvis
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - T Jeltema
- Santa Cruz Institute for Particle Physics, Santa Cruz, California 95064, USA
| | - S Kent
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
- Kavli Institute for Cosmological Physics, University of Chicago, Chicago, Illinois 60637, USA
| | - N Kuropatkin
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - O Lahav
- Department of Physics and Astronomy, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - T S Li
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
- Kavli Institute for Cosmological Physics, University of Chicago, Chicago, Illinois 60637, USA
| | - M Lima
- Laboratório Interinstitucional de e-Astronomia-LIneA, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
- Departamento de Física Matemática, Instituto de Física, Universidade de São Paulo, CP 66318, São Paulo, SP, 05314-970, Brazil
| | - M A G Maia
- Laboratório Interinstitucional de e-Astronomia-LIneA, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
- Observatório Nacional, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
| | - J L Marshall
- George P. and Cynthia Woods Mitchell Institute for Fundamental Physics and Astronomy, and Department of Physics and Astronomy, Texas A&M University, College Station, Texas 77843, USA
| | - P Melchior
- Department of Astrophysical Sciences, Princeton University, Peyton Hall, Princeton, New Jersey 08544, USA
| | - F Menanteau
- Department of Astronomy, University of Illinois at Urbana-Champaign, 1002 West Green Street, Urbana, Illinois 61801, USA
- National Center for Supercomputing Applications, 1205 West Clark Street, Urbana, Illinois 61801, USA
| | - R Miquel
- Institut de Física d'Altes Energies (IFAE), The Barcelona Institute of Science and Technology, Campus UAB, 08193 Bellaterra, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, E-08010 Barcelona, Spain
| | - R L C Ogando
- Laboratório Interinstitucional de e-Astronomia-LIneA, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
- Observatório Nacional, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
| | - A Palmese
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - A A Plazas
- Department of Astrophysical Sciences, Princeton University, Peyton Hall, Princeton, New Jersey 08544, USA
| | - A K Romer
- Department of Physics and Astronomy, Pevensey Building, University of Sussex, Brighton BN1 9QH, United Kingdom
| | - A Roodman
- Kavli Institute for Particle Astrophysics and Cosmology, P. O. Box 2450, Stanford University, Stanford, California 94305, USA
- SLAC National Accelerator Laboratory, Menlo Park, California 94025, USA
| | - E S Rykoff
- Kavli Institute for Particle Astrophysics and Cosmology, P. O. Box 2450, Stanford University, Stanford, California 94305, USA
- SLAC National Accelerator Laboratory, Menlo Park, California 94025, USA
| | - C Sánchez
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - E Sanchez
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), 28040 Madrid, Spain
| | - V Scarpine
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
| | - S Serrano
- Institut d'Estudis Espacials de Catalunya (IEEC), 08034 Barcelona, Spain
- Institute of Space Sciences (ICE, CSIC), Campus UAB, Carrer de Can Magrans, s/n, 08193 Barcelona, Spain
| | - I Sevilla-Noarbe
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), 28040 Madrid, Spain
| | - M Smith
- School of Physics and Astronomy, University of Southampton, Southampton SO17 1BJ, United Kingdom
| | - M Soares-Santos
- Brandeis University, Physics Department, 415 South Street, Waltham, Massachusetts 02453, USA
| | - F Sobreira
- Laboratório Interinstitucional de e-Astronomia-LIneA, Rua General José Cristino 77, Rio de Janeiro, RJ-20921-400, Brazil
- Instituto de Física Gleb Wataghin, Universidade Estadual de Campinas, 13083-859 Campinas, São Paulo, Brazil
| | - E Suchyta
- Computer Science and Mathematics Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee 37831, USA
| | - M E C Swanson
- National Center for Supercomputing Applications, 1205 West Clark Street, Urbana, Illinois 61801, USA
| | - G Tarle
- Department of Physics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - D Thomas
- Institute of Cosmology and Gravitation, University of Portsmouth, Portsmouth PO1 3FX, United Kingdom
| | - V Vikram
- Argonne National Laboratory, 9700 South Cass Avenue, Lemont, Illinois 60439, USA
| | - Y Zhang
- Fermi National Accelerator Laboratory, P. O. Box 500, Batavia, Illinois 60510, USA
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Mitchell AP, Rotter JS, Patel E, Richardson D, Wheeler SB, Basch E, Goldstein DA. Association Between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review. JAMA Oncol 2020; 5:893-899. [PMID: 30605222 DOI: 10.1001/jamaoncol.2018.6196] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use. Objective To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns. Evidence Review Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018. Findings Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians' choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy. Conclusions and Relevance To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jason S Rotter
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill
| | - Esita Patel
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina
| | - Daniel Richardson
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.,Department of Hematology/Oncology, University of North Carolina at Chapel Hill School of Medicine.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Ethan Basch
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Department of Hematology/Oncology, University of North Carolina at Chapel Hill School of Medicine.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Daniel A Goldstein
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel
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Moore A, Den RB, Popovtzer A, Goldvaser H, Gordon N, Goldstein DA. Fractionation scheme and treatment planning method for early glottic cancer in the United States: Economic impact of different medical decisions. Head Neck 2020; 42:1713-1720. [PMID: 31976607 DOI: 10.1002/hed.26082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/01/2020] [Accepted: 01/10/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Early glottic cancers are often treated with radiotherapy (RT). We assessed the economic impact of fractionation scheme and planning method for payers in the United States. METHODS A population-based analysis of the total cost of RT for early glottic cancers in the United States was performed annually. The target population was calculated using the Surveillance, Epidemiology, and End Results database. RT costs were based on 2019 pricing by Medicare. RESULTS We estimate that 3794 patients with early glottic cancers are treated with RT annually. The cost of RT per patient ranges between US $13 964 and $26 599 by fractionation and planning method. Hypofractionation reduces costs by 9% to 14%, while Intensity-modulated radiotherapy (IMRT) increases costs by 65% to 72%. IMRT-based standard fractionation leads to an excess cost of $47 937 076 compared with 3D-based hypofractionation. CONCLUSIONS 3D-based hypofractionated RT is the current standard of care. It would be reasonable for public and private payers to consider evidence-based policies for radiation reimbursement.
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Affiliation(s)
- Assaf Moore
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert B Den
- Department of Radiation Oncology, Sindey Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Aaron Popovtzer
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Goldvaser
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Gordon
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Israel
| | - Daniel A Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina
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Shlomai A, Leshno M, Goldstein DA. Cabozantinib for patients with advanced hepatocellular carcinoma: a cost-effectiveness analysis. Therap Adv Gastroenterol 2019; 12:1756284819878304. [PMID: 31579104 PMCID: PMC6759721 DOI: 10.1177/1756284819878304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 09/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS The multi-kinase inhibitor sorafenib is a first-line drug for patients with advanced hepatocellular carcinoma (HCC). Treatment options for patients whose disease has progressed on sorafenib are limited. In a recent randomized controlled trial (CELESTIAL trial), patients with advanced HCC who had failed prior systemic therapy had moderate progression-free survival and overall survival advantages when treated with the multi-kinase inhibitor cabozantinib. However, since this treatment is costly and is accompanied by significant adverse events in a large proportion of patients, its cost-effectiveness in these patients should be determined. METHODS We developed a Markov model incorporating health outcomes, measured by life-years and quality-adjusted life-years (QALYs) to evaluate the cost-effectiveness of cabozantinib compared with placebo in patients who have failed prior systemic therapy. RESULTS Treatment with cabozantinib results in a mean gain of 11.6 weeks of life (0.22 life-years) as compared with placebo. When quality of life was incorporated, treatment with cabozantinib produced a gain of 0.16 QALYs. The total mean incremental cost of cabozantinib was US$76,406 per patient. The incremental cost-effectiveness ratio for cabozantinib compared with best supportive care was US$469,374/QALY using the recommended dose of 60 mg cabozantinib daily. CONCLUSION Our results suggest that the use of cabozantinib in patients with advanced HCC who have progressed on prior treatment, results in a modest incremental benefit with high incremental costs, suggesting that it is not cost-effective at conventional willingness to pay thresholds.
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Affiliation(s)
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A. Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach-Tikva, Israel,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Affiliation(s)
- Bishal Gyawali
- Institute of Cancer Policy, King's College, London, England.,Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston
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Ben-Aharon O, Magnezi R, Leshno M, Goldstein DA. Association of Immunotherapy With Durable Survival as Defined by Value Frameworks for Cancer Care. JAMA Oncol 2019; 4:326-332. [PMID: 29285547 DOI: 10.1001/jamaoncol.2017.4445] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Modern immuno-oncology agents have generated great excitement because of their potential to provide durable survival for some patients. However, there is concern regarding the cost of cancer care, and multiple frameworks have been developed to assess value. The American Society of Clinical Oncology (ASCO) framework awards bonus points if substantial durable survival is demonstrated. Objective To assess whether modern immuno-oncology agents reach defined efficacy thresholds in value frameworks. Design, Setting, and Participants In this analysis, all US Food and Drug Administration (FDA) approvals for immuno-oncology agents between March 2011 and August 2017 were reviewed. Data required for the ASCO framework were collected, specifically improvement in proportion of patients alive with the test regimen and survival rate with standard treatment. Main Outcomes and Measures Awarding of bonus points for durable survival based on the ASCO criteria. Results Twenty-three metastatic indications for 6 immuno-oncology agents (ipilimumab, pembrolizumab, nivolumab, atezolizumab, avelumab, and durvalumab) were approved by the FDA from March 2011 to August 2017. Ten (43%) of the approvals were based on survival end points, while 13 (57%) were based on response rates. Only 3 drug indications fulfilled the threshold defined for the survival rate of patients receiving standard care (minimum 20%). Nine indications achieved the required level of improvement in proportion to patients alive in the test regimen compared with the standard (above 50%). There was overlap between these 2 criteria for 3 drug indications, allowing them to gain the durable survival bonus points awarded by the ASCO framework. Conclusions and Relevance Durable survival and response rates of modern immuno-oncology agents are rarely recognized as significant by current oncology value frameworks. This may be due to insufficient demonstration of efficacy of such agents or inappropriately calibrated value frameworks.
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Affiliation(s)
- Omer Ben-Aharon
- Department of Management, Health System Management Program, Bar Ilan University, Ramat Gan, Israel
| | - Racheli Magnezi
- Department of Management, Health System Management Program, Bar Ilan University, Ramat Gan, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
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Affiliation(s)
- Daniel A Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel.,Winship Cancer Institute, Emory University, Atlanta, Georgia
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Moore A, Den RB, Gordon N, Sarfaty M, Kundel Y, Brenner B, Goldstein DA. The Financial Impact of Fractionation Scheme and Treatment Planning Method for Rectal Cancer in the United States. Clin Colorectal Cancer 2019; 18:209-217. [DOI: 10.1016/j.clcc.2019.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/14/2019] [Accepted: 05/28/2019] [Indexed: 01/11/2023]
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Affiliation(s)
- Mark J. Ratain
- Department of Medicine, The University of Chicago, Chicago, Illinois
- Value in Cancer Care Consortium, Ann Arbor, Michigan
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Gabbay IE, Gabbay U, Goldstein DA, Nahum Y. Should every candidate for cataract extraction be scheduled to the preoperative clinic? The Rabin Medical Center experience. Eur J Ophthalmol 2019; 30:1268-1271. [PMID: 31353952 DOI: 10.1177/1120672119865842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cataract surgery is one of the most common elective surgeries. We present a novel approach of preoperative triage using community-based ophthalmologist referral letters for scheduling surgery, thus reducing both patient and physician time prior to surgery. Since most patients are not routinely examined in a preoperative clinic, day of surgery cancelations are a possibility. The aim of this study is to evaluate the efficiency of our triage system. METHODS Historical prospective study in which the end point was day-of-surgery cancelation. The main outcome measure of this study was the rate of cancelations which could have been prevented by a preoperative visit. Patients' records were reviewed for reasons for cancelation and demographics. RESULTS During the study period, 1030 patients underwent cataract surgery, 171 patients (16.6%) were examined in the preoperative clinic. Forty-five patients (4.4%) were canceled on the day of surgery due to various reasons. The main reason for cancelation (13 cases, 28.9%) was non-availability of operating theater. In 20 cases (1.9% of total patients, 44.4% of cancelations), the cancelations could have been prevented by a preoperative clinic visit. CONCLUSION Our results suggests that most cataract patients do not require preoperative visit prior to the day of surgery. The cooperation of community-based ophthalmologists and the availability of senior surgeons in the operating theater allows for the proper implementation of our system. Direct referral to surgery could shorten both costs and time to surgery and provide timely treatment for cataracts in a cost-aware environment.
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Affiliation(s)
- Itay Elimelech Gabbay
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Gabbay
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Quality Assurance and Risk Management, Rabin Medical Center, Petach Tikva, Israel
| | - Daniel A Goldstein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel.,Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Yoav Nahum
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ben-Aharon O, Magnezi R, Leshno M, Goldstein DA. Median Survival or Mean Survival: Which Measure Is the Most Appropriate for Patients, Physicians, and Policymakers? Oncologist 2019; 24:1469-1478. [PMID: 31320502 DOI: 10.1634/theoncologist.2019-0175] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Understanding the efficacy of treatments is crucial for patients, physicians, and policymakers. Median survival, the most common measure used in the outcome reporting of oncology clinical trials, is easy to understand; however, it describes only a single time point. The interpretation of the hazard ratio is difficult, and its underlying statistical assumptions are not always met. The objective of this study was to evaluate alternative measures based on the mean benefit of novel oncology treatments. MATERIALS AND METHODS We reviewed all U.S. Food and Drug Administration (FDA) approvals for oncology agents between 2013 and 2017. We digitized survival curves as reported in the clinical trials used for the FDA approvals and implemented statistical transformations to calculate for each trial the restricted mean survival time (RMST), as well as the mean survival using Weibull distribution. We compared the mean survival with the median survival benefit in each clinical trial. RESULTS The FDA approved 83 solid tumor indications for oncology agents between 2013 and 2017, of which 27 approvals based on response rates, whereas 49 approvals were based on survival endpoints (progression-free survival and overall survival). The average improvement in median overall survival or progression-free survival was 4.6 months versus 3.6 months improvement in the average RMST and 6.1 months improvement in mean survival using Weibull distribution. CONCLUSION Mean survival may supply valuable information for different stakeholders. Its inclusion should be considered in the reporting of prospective clinical trials. IMPLICATIONS FOR PRACTICE Mean survival may supply valuable information for different stakeholders. Its inclusion should be considered in the reporting of clinical trials.
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Affiliation(s)
- Omer Ben-Aharon
- Department of Management, Health System Management Program, Bar Ilan University, Ramat Gan, Israel
| | - Racheli Magnezi
- Department of Management, Health System Management Program, Bar Ilan University, Ramat Gan, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Petah Tiqva, Israel
- Department of Oncology, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
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Goldstein DA, Meyers K, Endsley M, Zerth EO. Measurement-based care implementation in a Veterans Affairs primary care-mental health integration program. Psychol Serv 2019; 17:323-331. [PMID: 31318239 DOI: 10.1037/ser0000370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Measurement-based care (MBC) in behavioral health is the systematic use of validated measurement tools to guide clinical decision making and collaborative treatment planning. Although benefits of MBC for clinicians and patients have been supported by research, it appears to be underutilized in clinical settings. This study examined the effectiveness of a MBC implementation plan informed by the theory of planned behavior in a large, integrated primary care program at a Veterans Affairs hospital over 18 months. Multiple methods, including self-report clinician data and aggregated clinic data, were used to examine change in clinician MBC-related behaviors over time. Results demonstrated both an increase in symptom measures administered per clinical encounter and per individual patient treated. Additionally, the ratio of individuals receiving at least one symptom rating measure to total number of patients treated decreased over time, demonstrating increased use of MBC by integrated primary care clinicians. Survey data demonstrated upward trends in administering measures at initial assessment and at treatment termination, and clinician attitudes toward MBC were generally positive. Results corroborate the theory of planned behavior as a model in which to guide systematic MBC implementation. MBC implementation challenges and recommendations are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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