Building a National Reassessment Process for Oncology Drugs: Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration through a Simulated Reassessment Exercise

The CanREValue Collaboration established the Reassessment & Uptake Working Group to develop a preliminary process to reassess funded cancer drugs in Canada. A simulated exercise was conducted to evaluate the proposed reassessment process using a real-world case. We invited 32 attendees including representatives from Health Canada and Health Technology Assessment (HTA) agencies, along with payers, clinicians, academics, and patient representatives. A case was developed using a real-world study on a publicly funded cancer drug. In facilitated group sessions, participants were asked to deliberate upon the evidence presented in the case to issue reassessment recommendations. Several themes were identified through the deliberation discussions. While the generalizability of real-world evidence (RWE) is perceived as a strength, trust in the RWE depends largely on the source of the real-world data. The attendees suggested several improvements to the proposed reassessment process including evidence requirement for reassessment, recommendation categories, and a priori study protocols. This exercise generated important insights on the evidence required for conducting reassessment and considerations for improvements of the proposed reassessment process. Building upon lessons from this exercise, future work would continue to refine the reassessment process as part of the overall CanREValue framework.

The Influence of Low-intensity Millimeter-Wave Radiation on the Growth of Cress Roots

An inhibition of growth in cress roots (Lepidium sativum L.) by irradiation with low-intensity millimeter-waves was found using a computer controlled optical system which is capable of measuring nearly continuously the length of the roots to an accuracy of ± 2 jam. The effect is reversible and, for a power density of 6 mWcm-2, results in completely halting the root growth. It occurs within about 100 s after the onset of irradiation. The microwave-induced temperature increase at the surface of the root tip was found to be less than 0.3 °C at this power density. The effect did not show a sharp frequency dependence however it depended strongly on the polariza­tion of the microwaves with respect to the root orientation.

The sensitivity of the root growth to the ambient temperature was examined. Only a weak temperature dependence was found which could not explain the observed effects. However simulating the microwave-induced temperature increase at the surface of the root tip with (incoherent) far-infrared light (λ≥20 μm) resulted in similar effects as with microwaves. Hence one can conclude that the observed effects are primarily caused by the small local irradiation induced thermal gradients across the surface of the root tip.

An expert on every street corner? Methods for eliciting distributions in geographically dispersed opinion pools

Recent publications outline developments in eliciting probabilistic opinions from clinical experts with which to inform structural assumptions and parameter estimates in health economic models. We outline approaches taken to date to elicit probabilistic distributions from experts within the health economic literature and outline the appropriate considerations and the resulting process in developing a new elicitation program with the aim of allowing low-cost elicitation of expert opinion from a heterogeneous and geographically dispersed opinion pool while preserving the essential features of good practice elicitation methods.

The cost-effectiveness of a law banning the use of cellular phones by drivers

OBJECTIVE

To assess the cost-effectiveness of a law banning the use of cellular phones by drivers in the Canadian province of Alberta.

METHOD

Cost-effectiveness analysis using a probabilistic decision-analytic model and publicly available data. We adopted a societal perspective. Health gains were measured in terms of quality-adjusted life-years. Costs include those associated with awareness raising, enforcement and the welfare loss associated with the reduction in cellular phone use, less savings in health care and other costs associated with automobile accidents.

RESULTS

A ban promotes health and releases resources worth more than the costs. There is an 80% chance that a ban will be 'cost saving', and a 94% chance that a ban will cost less than Can$50,000/QALY. The results are sensitive to the additional risk posed by cellular phone use while driving, and the rate and pattern with which drivers comply with a ban.

CONCLUSION

Under our base line assumptions a cellular phone ban is likely to be cost saving from a societal perspective. The results are sensitive to parameters for which there is very little information or for which the available information is contradictory.

Phase I/II study of hepatic arterial therapy with floxuridine and dexamethasone in combination with intravenous irinotecan as adjuvant treatment after resection of hepatic metastases from colorectal cancer

PURPOSE

Patients who undergo resection of liver metastases from colorectal cancer have an average 2-year survival of 65%. With hepatic arterial infusion (HAI) plus systemic fluorouracil and leucovorin, 2-year survival increased to 86%. For further improvement in both local and systemic control, combinations of new systemic drugs with HAI are being explored. The purpose of this study was to determine the maximum-tolerated dose (MTD) of systemic irinotecan (CPT-11) and HAI floxuridine (FUDR) plus dexamethasone (DEX) as combination adjuvant therapy after liver resection.

PATIENTS AND METHODS

Ninety-six patients who underwent complete resection of liver metastases from colorectal cancer were treated with six monthly cycles of HAI FUDR plus DEX for 14 days of each 4-week cycle plus escalating doses of systemic CPT-11. The primary end points of the phase I/II study were the MTD and efficacy of this regimen.

RESULTS

The MTD for combined systemic CPT-11 and HAI FUDR was CPT-11 at 200 mg/m2 every other week and FUDR at 0.12 mg/kg x pump volume / pump flow rate. The dose-limiting toxicities were diarrhea and neutropenia. With a median follow-up time of 26 months, the 2-year survival rate is 89%. All of the 27 patients who were treated at the MTD are alive.

CONCLUSION

In patients who undergo resection of liver metastases from colorectal cancer, adding systemic CPT-11 to HAI therapy in an adjuvant regimen is feasible. This regimen seems to have comparable activity to fluorouracil and leucovorin, but further studies are needed to assess whether it improves local control or decreases extrahepatic recurrences.

Inept reasoners or pragmatic virtuosos? Relevance and the deontic selection task

Most individuals fail the selection task, selecting P and Q cases, when they have to test descriptive rules of the form "If P, then Q". But they solve it, selecting P and not-Q cases, when they have to test deontic rules of the form "If P, then must Q". According to relevance theory, linguistic comprehension processes determine intuitions of relevance that, in turn, determine case selections in both descriptive and deontic problems. We tested the relevance theory predictions in a within-participants experiment. The results showed that the same rule, regardless of whether it is tested descriptively or deontically, can be made to yield more P and Q selections or more P and not-Q selections. We conclude that the selection task does not provide a tool to test general claims about human reasoning.

Relevance theory explains the selection task

We propose a general and predictive explanation of the Wason Selection Task (where subjects are asked to select evidence for testing a conditional "rule"). Our explanation is based on a reanalysis of the task, and on Relevance Theory. We argue that subjects' selections in all true versions of the Selection Task result from the following procedure. Subjects infer from the rule directly testable consequences. They infer them in their order of accessibility, and stop when the resulting interpretation of the rule meets their expectations of relevance. Subjects then select the cards that may test the consequences they have inferred from the rule. Order of accessibility of consequences and expectations of relevance vary with rule and context, and so, therefore, does subjects' performance. By devising appropriate rule-context pairs, we predict that correct performance can be elicited in any conceptual domain. We corroborate this prediction with four experiments. We argue that past results properly reanalyzed confirm our account. We discuss the relevance of the Selection Task to the study of reasoning.

Impact of parental terminal cancer on adolescents

Psychological and emotional concerns of adolescents during a parent's terminal cancer are described. Compared to younger children, the adolescents' greater cognitive and emphatic capacities allowed them to be more aware of losses and of the parent's physical and emotional pain. Parental illness also precipitated conflict around issues of developmentally appropriate separation. The capacity to use intellectual defenses, search for meaning and deeper understanding, and seek help were potent coping abilities. Contrary to the prevailing view, most of the adolescents coped with stress without resorting to severe acting out.

Impact of parental terminal cancer on latency-age children

The underlying psychological and emotional components of distress were examined in 87 children with a parent in the terminal phase of cancer. Common fears, concerns, misperceptions, and behavioral consequences are analyzed, as are more severe psychological and behavioral reactions. Implications for psychoeducational parent-guidance intervention are discussed.

Influence of high steady magnetic fields on the electrical activity of the electric fish Apteronotus

We have investigated the influence of strong dc. magnetic fields--ranging up to 10 Tesla--on the weak sinusoidal electric signals which the electro-fish Apteronotus is known to emit. We made the following observations: 1. The amplitude of the sinusoidal electric signals rises with the application of the dc. magnetic fields, increasing by about 8% in a field of 10 Tesla. 2. The frequency of the signals of about 570 Hz was not at all affected by the field but remained constant in fields up to 10 Tesla. Since the electric signals of Apteronotus are of neural origin our experiments indicate an influence of strong dc. magnetic fields on the nervous system of this electric fish.