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Krämer A, Bochtler T, Pauli C, Baciarello G, Delorme S, Hemminki K, Mileshkin L, Moch H, Oien K, Olivier T, Patrikidou A, Wasan H, Zarkavelis G, Pentheroudakis G, Fizazi K. Cancer of unknown primary: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2023; 34:228-246. [PMID: 36563965 DOI: 10.1016/j.annonc.2022.11.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- A Krämer
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Center (DKFZ) Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - T Bochtler
- Clinical Cooperation Unit Molecular Haematology/Oncology, German Cancer Research Center (DKFZ) Heidelberg, Germany; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Medical Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg, Heidelberg, Germany
| | - C Pauli
- Department of Pathology and Molecular Pathology, University Hospital Zurich (USZ), Zurich, Switzerland; Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - G Baciarello
- Medical Oncology Department, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - S Delorme
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg
| | - K Hemminki
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and Biomedical Center, Charles University, Pilsen, Czech Republic
| | - L Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - H Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich (USZ), Zurich, Switzerland; Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - K Oien
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - T Olivier
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - A Patrikidou
- Department of Cancer Medicine, Institute Gustave Roussy, University of Paris Saclay, Villejuif, France
| | - H Wasan
- Department of Cancer Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - G Zarkavelis
- Department of Medical Oncology, University of Ioannina, Ioannina, Greece
| | | | - K Fizazi
- Department of Cancer Medicine, Institute Gustave Roussy, University of Paris Saclay, Villejuif, France
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Zarkavelis G, Amylidi AL, Verbaanderd C, Cherny NI, Metaxas Y, de Vries EGE, Zygoura P, Amaral T, Jordan K, Strijbos M, Dafni U, Latino N, Galotti M, Lordick F, Giuliani R, Pignatti F, Pentheroudakis G. Off-label despite high-level evidence: a clinical practice review of commonly used off-patent cancer medicines. ESMO Open 2023; 8:100604. [PMID: 36870739 PMCID: PMC10024100 DOI: 10.1016/j.esmoop.2022.100604] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 08/30/2022] [Accepted: 09/10/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Off-label use of medicines is generally discouraged. However, several off-patent, low-cost cancer medicines remain off-label for indications in which they are commonly used in daily practice, supported by high-level evidence based on results of phase III clinical trials. This discrepancy may generate prescription and reimbursement obstacles as well as impaired access to established therapies. METHODS A list of cancer medicines that remain off-label in specific indications despite the presence of high-level evidence was generated and subjected to European Society for Medical Oncology (ESMO) expert peer review to assess for accountability of reasonableness. These medicines were then surveyed on approval procedures and workflow impact. The most illustrative examples of these medicines were reviewed by experts from the European Medicines Agency to ascertain the apparent robustness of the supporting phase III trial evidence from a regulatory perspective. RESULTS A total of 47 ESMO experts reviewed 17 cancer medicines commonly used off-label in six disease groups. Overall, high levels of agreement were recorded on the off-label status and the high quality of data supporting the efficacy in the off-label indications, often achieving high ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scores. When prescribing these medicines, 51% of the reviewers had to implement a time-consuming process associated with additional workload, in the presence of litigation risks and patient anxiety. Finally, the informal regulatory expert review identified only 2 out of 18 (11%) studies with significant limitations that would be difficult to overcome in the context of a potential marketing authorisation application without additional studies. CONCLUSIONS We highlight the common use of off-patent essential cancer medicines in indications that remain off-label despite solid supporting data as well as generate evidence on the adverse impact on patient access and clinic workflows. In the current regulatory framework, incentives to promote the extension of indications of off-patent cancer medicines are needed for all stakeholders.
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Affiliation(s)
- G Zarkavelis
- University of Ioannina-Department of Medical Oncology, Ioannina, Greece
| | - A L Amylidi
- University of Ioannina-Department of Medical Oncology, Ioannina, Greece
| | - C Verbaanderd
- European Medicines Agency, Amsterdam, the Netherlands
| | - N I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Y Metaxas
- Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - E G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - P Zygoura
- Frontier Science Foundation-Hellas, Athens, Greece
| | - T Amaral
- Skin Cancer Center, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany; Department of Hematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany
| | - M Strijbos
- GZA Ziekenhuizen Campus Sint-Augustinus, Antwerp, Belgium
| | - U Dafni
- Frontier Science Foundation-Hellas, Athens, Greece; Laboratory of Biostatistics, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - N Latino
- ESMO Head Office, Lugano, Switzerland
| | - M Galotti
- ESMO Head Office, Lugano, Switzerland
| | - F Lordick
- Department of Oncology, Gastroenterology, Hepatology, Pulmonology and Infectious Diseases, University Cancer Center Leipzig (UCCL), Leipzig University Medical Center, Leipzig, Germany
| | - R Giuliani
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - F Pignatti
- European Medicines Agency, Amsterdam, the Netherlands
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Spathas N, Goussia A, Koliou G, Gogas H, Zagouri F, Bobos M, Pectasides D, Galani E, Koutras A, Zarkavelis G, Saloustros E, Bafaloukos D, Karanikiotis C, Aravantinos G, Psyrri A, Razis E, Koumarianou A, Res E, Linardou H, Fountzilas G. 27P Association between CD8+ tumor infiltrating lymphocytes and the clinical outcome of patients with operable breast cancer treated with adjuvant dose-dense chemotherapy: A 10-year follow up report of a Hellenic Cooperative Oncology Group observational study. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Vlachou MS, Mauri D, Zarkavelis G, Ntellas P, Tagkas C, Gkoura S, Pentheroudakis G. Plasma ctDNA RAS status selects patients for anti-EGFR treatment rechallenge in metastatic colorectal cancer: a meta-analysis. Exp Oncol 2021; 43:252-256. [PMID: 34591420 DOI: 10.32471/exp-oncology.2312-8852.vol-43-no-3.16592] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recently one randomized trial and several phase II studies underscored that patients with metastatic colorectal cancer who progressed after an initial clinical benefit from anti-epidermal growth factor receptor (EGFR) treatment may further benefit from rechallenge with anti-EGFR therapy. Testing circulating tumor DNA (ctDNA) RAS status prior to anti-EGFR rechallenge seems a promising non-invasive method to predict and monitor response to anti-EGFR readministration. AIM To assess the capability of liquid biopsy ctDNA in exploring RAS status and in predicting outcome of metastatic colorectal cancer patients treated with anti-EGFR monoclonal antibody rechallenge. MATERIALS AND METHODS Systematic review of literature and meta-analysis of the available evidence. RESULTS Data from four studies involving 117 patients were available. All patients harbored RAS wild type tumors and derived benefit from first line anti-EGFR therapy. Of these, 65 underwent plasma ctDNA before anti-EGFR treatment rechallenge and were eligible for analyses: 35 patients had RAS wild type ctDNA, and 30 RAS mutated, indicating that 46% of patients underwent RAS status conversion after primary anti-EGFR therapy. Anti-EGFR rechallenge among patients with plasma ctDNA RAS wild type status was associated with a consistent benefit in progression free survival (hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.22-0.70; p = 0.001; I2 = 0) and overall survival (HR 0.37, 95% CI 0.16-0.85; p = 0.02; I2 = 74%) when compared to its use among patients with plasma ctDNA RAS mutation. Patients with plasma ctDNA RAS wild type profile also performed statistically better in term of disease control rate, risk for disease progression at 3 and 6 months, and risk for death at 6 and 12 months. CONCLUSION RAS status assessment continues to be useful in predicting benefit for anti-EGFR treatment.
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Affiliation(s)
- M S Vlachou
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - D Mauri
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - G Zarkavelis
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - P Ntellas
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - C Tagkas
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - S Gkoura
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - G Pentheroudakis
- Dept Medical Oncology, University Hospital of Ioannina, 455 00 Ioannina, Greece
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Kastrisiou M, Zarkavelis G, Kougioumtzi A, Tzallas C, Tselikou E, Mantziou A, Gkrepi K, Fountzilas E, Nasioulas G, Batistatou A, Magklara A, Pentheroudakis G. P-173 Customisation of therapeutic strategy in metastatic colorectal cancer by use of liquid biopsies: Final results of an observational study. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.05.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Gyawali B, de Vries EGE, Dafni U, Amaral T, Barriuso J, Bogaerts J, Calles A, Curigliano G, Gomez-Roca C, Kiesewetter B, Oosting S, Passaro A, Pentheroudakis G, Piccart M, Roitberg F, Tabernero J, Tarazona N, Trapani D, Wester R, Zarkavelis G, Zielinski C, Zygoura P, Cherny NI. Biases in study design, implementation, and data analysis that distort the appraisal of clinical benefit and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scoring. ESMO Open 2021; 6:100117. [PMID: 33887690 PMCID: PMC8086024 DOI: 10.1016/j.esmoop.2021.100117] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
Background The European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is a validated, widely used tool developed to score the clinical benefit from cancer medicines reported in clinical trials. ESMO-MCBS scores assume valid research methodologies and quality trial implementation. Studies incorporating flawed design, implementation, or data analysis may generate outcomes that exaggerate true benefit and are not generalisable. Failure to either indicate or penalise studies with bias undermines the intention and diminishes the integrity of ESMO-MCBS scores. This review aimed to evaluate the adequacy of the ESMO-MCBS to address bias generated by flawed design, implementation, or data analysis and identify shortcomings in need of amendment. Methods As part of a refinement of the ESMO-MCBS, we reviewed trial design, implementation, and data analysis issues that could bias the results. For each issue of concern, we reviewed the ESMO-MCBS v1.1 approach against standards derived from Helsinki guidelines for ethical human research and guidelines from the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, the Food and Drugs Administration, the European Medicines Agency, and European Network for Health Technology Assessment. Results Six design, two implementation, and two data analysis and interpretation issues were evaluated and in three, the ESMO-MCBS provided adequate protections. Seven shortcomings in the ability of the ESMO-MCBS to identify and address bias were identified. These related to (i) evaluation of the control arm, (ii) crossover issues, (iii) criteria for non-inferiority, (iv) substandard post-progression treatment, (v) post hoc subgroup findings based on biomarkers, (vi) informative censoring, and (vii) publication bias against quality-of-life data. Conclusion Interpretation of the ESMO-MCBS scores requires critical appraisal of trials to understand caveats in trial design, implementation, and data analysis that may have biased results and conclusions. These will be addressed in future iterations of the ESMO-MCBS. We reviewed trial design, implementation, and data analysis issues that could bias the results of trials. These issues could skew the results of ESMO-MCBS scores. Six design, two implementation, and two analysis issues were reviewed, and seven shortcomings were identified. These issues will be addressed in future versions of the MCBS scale. Interpretation of MCBS scores requires critical appraisal of trials.
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Affiliation(s)
- B Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada.
| | - E G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - U Dafni
- Laboratory of Biostatistics, School of Health Sciences, National and Kapodistrian University of Athens, Athens; Frontier Science Foundation-Hellas, Athens, Greece
| | - T Amaral
- Skin Cancer Center, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - J Barriuso
- The Christie NHS Foundation Trust and Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - J Bogaerts
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - A Calles
- Medical Oncology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan, Milan; European Institute of Oncology, IRCCS, Milan, Italy
| | - C Gomez-Roca
- Institut Universitaire du Cancer de Toulouse (IUCT), Toulouse, France
| | - B Kiesewetter
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - S Oosting
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Passaro
- Division of Thoracic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - M Piccart
- Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - F Roitberg
- WHO Cancer Management Consultant, Geneva, Switzerland; Instituto do Cancer do Estado de São Paulo (ICESP HCFMUSP), São Paulo, Brazil
| | - J Tabernero
- Vall d'Hebron Hospital Campus and Institute of Oncology (VHIO), UVic-UCC, IO-Quiron, Barcelona, Spain
| | - N Tarazona
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, CIBERONC, University of Valencia, Valencia, Spain
| | - D Trapani
- European Institute of Oncology, IRCCS, Milan, Italy
| | - R Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - G Zarkavelis
- University of Ioannina-Department of Medical Oncology, Ioannina, Greece
| | - C Zielinski
- Central European Cooperative Oncology Group and Central European Cancer Center, Wiener Privatklinik, Vienna, Austria
| | - P Zygoura
- Frontier Science Foundation-Hellas, Athens, Greece
| | - N I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
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Fountzilas E, Eliades A, Koliou G, Achilleos A, Pectasides D, Sgouros J, Papakostas P, Psyrri A, Papadimitriou C, Oikonomopoulos G, Ferentinos K, Koumarianou A, Zarkavelis G, Dervenis C, Aravantinos G, Kosmidis P, Theochari M, Rigakos G, Nikolaidi A, Christopoulou A, Fountzilas G, Patsalis P. SO-2 Prevalence and prognostic role of inherited germline mutations in cancer predisposing genes in unselected patients with pancreatic cancer. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Zarkavelis G, Kastrisiou M, Papadopoulou E, Nasioulas G, Tselikou E, Mantziou A, Tzallas C, Batistatou A, Magklara A, Pentheroudakis G. P-264 Clinical validation of next-generation sequencing as a liquid biopsy for the monitoring of patients with metastatic colorectal cancer. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.04.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kastrisiou M, Zarkavelis G, Kougioumtzi A, Tzallas C, Saloustros E, Kotsakis A, Papadopoulou E, Nasioulas G, Batistatou A, Magklara A, Pentheroudakis G. Customisation of therapeutic strategy in metastatic colorectal cancer by use of liquid biopsies: Updated results of an observational study. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz413.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pauli C, Bochtler T, Mileshkin L, Baciarello G, Losa F, Ross J, Pentheroudakis G, Zarkavelis G, Yalcin S, Özgüroğlu M, Beringer A, Foser S, Scarato J, Mueller-Ohldach M, Moch H, Krämer A. A challenging task – Identifying carcinoma of unknown primary (CUP) patients according to ESMO guidelines: The CUPISCO trial experience. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz269.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pentheroudakis G, Kotoula V, Koliou GA, Papadopoulou K, Samantas E, Makatsoris T, Karavasilis V, Mauri D, Efstratiou I, Bafaloukos D, Papakostas P, Psyrri A, Papatsibas G, Zarkavelis G, Goussia A, Bompolaki I, Oikonomopoulos G, Christopoulou A, Pectasides D, Fountzilas G. Predictive significance of tumour angiogenic and anti-angiogenic VEGF-A splice variants in patients with metastatic colorectal cancer. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy303.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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