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Gordan LN, Ray D, Ijioma SC, Dranitsaris G, Warner A, Heritage T, Fink M, Wenk D, Chadwick P, Khrystolubova N, Peles S. Impact of a Best Practices Program in Patients with Relapsed/Refractory Multiple Myeloma Receiving Selinexor. Curr Oncol 2024; 31:501-510. [PMID: 38248119 PMCID: PMC10814155 DOI: 10.3390/curroncol31010034] [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: 11/22/2023] [Revised: 12/31/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Best practice (BP) in cancer care consists of a multifaceted approach comprising individualized treatment plans, evidence-based medicine, the optimal use of supportive care and patient education. We investigated the impact of a BP program in patients with relapsed/refractory multiple myeloma (RRMM) receiving selinexor. Features of the BP program that were specific to selinexor were initiating selinexor at doses ≤80 mg once weekly and the upfront use of standardized antiemetics. Study endpoints included time to treatment failure (TTF), duration of therapy, dose limiting toxicities and overall survival. Comparative analysis on TTF and duration of therapy was conducted using a log-rank test and multivariate Cox proportional hazard regression. Over the ensuing 12-month post-BP period, 41 patients received selinexor-based therapy compared to 68 patients who received selinexor-based therapy pre-BP implementation. Patients treated in the post-BP period had reductions in TTF (hazard ratio [HR] = 0.50; 95% CI: 0.27 to 0.92). Patients in the pre-BP period were four times more likely to stop therapy than those in the post-period (odds ratio [OR] = 4.0, 95% CI: 1.75 to 9.3). The findings suggest a BP program tailored to selinexor could increase the time to treatment failure, increase treatment duration and lower the incidence of drug limiting toxicities.
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Affiliation(s)
- Lucio N. Gordan
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
| | - David Ray
- Karyopharm Therapeutics Inc., Newton, MA 02459, USA
| | | | - George Dranitsaris
- Department of Public Health, Syracuse University, Syracuse, NY 13244, USA
| | - Amanda Warner
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
| | - Trevor Heritage
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
| | - Matthew Fink
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
| | - David Wenk
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
| | - Paul Chadwick
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
| | | | - Shachar Peles
- Florida Cancer Specialists and Research Institute, Tampa, FL 33609, USA
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Dranitsaris G, Neuhalfen H, Peevyhouse A, Powell D, Miller K, Green T, Graff T. Diagnosis and management of systemic mastocytosis in a community hematology setting. J Oncol Pharm Pract 2023:10781552231221149. [PMID: 38151028 DOI: 10.1177/10781552231221149] [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] [Indexed: 12/29/2023]
Abstract
BACKGROUND Systemic mastocytosis (SM) is a rare and potentially severe hematologic disorder characterized by the clonal proliferation of mast cells (MCs) into various organs. The clinical manifestations of advanced SM are caused by the uncontrolled release of cytokines and vasoactive amines from MC and disease-induced organ dysfunction. Patients with SM typically present with symptoms such as flushing, pruritus, diarrhea, and headaches, but outcomes following active treatment have not been well characterized. In this study, the clinical characteristics, treatment patterns, and natural history of an SM patient cohort diagnosed and treated within a community hematology network in the United States is described. METHODS We identified 105 patients who were diagnosed and managed in one of 19 community hematology clinics up to an index date of 1 October 2022. Data collection included patient and disease characteristics, baseline biochemistry and hematology, SM diagnostic criteria being met, biomarkers tested, CD2 and/or CD25 expression in MCs as well as serum tryptase levels at presentation. Data abstraction also included supportive care drugs and anticancer therapy used, treatment response, reason for discontinuation, and overall survival by disease subtype. RESULTS A total of 105 SM patients were identified who met the inclusion criteria. The specific SM subtypes were indolent (47.6%), aggressive (9.5%), SM with an associated hematological neoplasm (19.0%), MC leukemia (1.9%), and subtype not documented (21.9%). Regardless of subtype, approximately 62% of patients did not receive SM-directed active therapy. Only 26% of patients with indolent systemic mastocytosis (ISM) received treatment compared to 65.6% with advanced subtypes. Relative to ISM cohort, the relative risk of death in patients with the advanced SM subtypes was approximately 15 times greater (hazard ratio = 15.0; 95% confidence interval: 3.3 to 66.5). CONCLUSIONS SM patients present with multiple underlying symptoms, within various disease subtypes that are difficult to diagnose in a timely manner. As a result, many patients do not receive active drug therapy for their disease. Therefore, greater disease awareness is required as well as new tools for earlier disease detection.
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Affiliation(s)
- George Dranitsaris
- Real World Data, Quality Cancer Care Alliance, Tacoma, WA, USA
- Department of Public Health, Syracuse University, NY, USA
| | | | | | | | - Kerri Miller
- Blueprint Medicines Corporation, Cambridge, MA, USA
| | - Teresa Green
- Blueprint Medicines Corporation, Cambridge, MA, USA
| | - Tara Graff
- Mission Cancer and Blood, Des Moines, IA, USA
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Dranitsaris G, Peevyhouse A, Wood T, Kreychman Y, Neuhalfen H, Moezi M. Fostamatinib or Thrombopoietic Receptor Agonists for the Treatment of Chronic Immune Thrombocytopenia in Adult Patients: A Real-World Assessment of Safety, Effectiveness and Cost. Acta Haematol 2023:000533175. [PMID: 37778326 DOI: 10.1159/000533175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/20/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Chronic immune thrombocytopenia purpura (ITP) in adults is a serious autoimmune disease in which platelets are prematurely destroyed, leaving the patient vulnerable to bruising and bleeding. Initial treatment is with corticosteroids. In patients who become resistant or intolerant to corticosteroids, the thrombopoietic agents (TPOs), consisting of romiplostim (ROM), eltrombopag (ELT) and avatrombopag (AVA) or the spleen tyrosine kinase inhibitor fostamatinib (FOS), are appropriate next lines of therapy. In this study, the comparative safety, effectiveness and cost of care between fostamatinib vs. the TPOs was evaluated in a real-world setting. METHODS A retrospective analysis from 17 community hematology practices across the United States was conducted to identify adult ITP patients who received one of the four agents. Data collection consisted of patient demographics, disease characteristics, as well as number and type of prior treatments. From the first day until the end of treatment, data were also collected on platelet (PLT) counts, adverse events, the use of rescue IVIG, platelet transfusions and corticosteroids. Multivariable logistic regression analysis was used to compare PLT related endpoints between agents. RESULTS A sample of 179 ITP patients who had received at least one of the four agents was identified. This resulted in a final sample of 51, 87, 127 and 44 patients who received FOS, ELT, ROM or AVA respectively. At month six, there were no significant differences between FOS vs. the TPOs in terms of the proportion of patients with the PLT count being ≥ 30 x 103/μL, ≥ 50 x 103/μL as well as the proportion of patients whose PLTs levels doubled relative to baseline. The frequency of thromboembolic events (TEs) was 3.9% in FOS patients compared to 9.2%, 4.7% and 11.4% in the ELT, ROM and AVA groups. The mean cost per patient with FOS was $99,209 (95%CI: $59,595 to $115,074) compared to $92,341 (95:CI$68,331 to $115,519), $108,482 (95%CI: $84,782 to $132,182) and $131,050 (95%CI: $83,327 to $179,897) for ELT, ROM or AVA respectively. CONCLUSIONS In this real-world analysis, FOS was comparable to the TPOs in maintaining PLTs at clinically beneficial levels. Given these findings, the choice of therapy should be based on overall patient safety, preexisting risk factors for TEs and cost effectiveness.
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Dranitsaris G, Zhang Q, Mu L, Weyrer C, Drysdale E, Neumann P, Atri A, Monfared AAT. Therapeutic preference for Alzheimer's disease treatments: a discrete choice experiment with caregivers and neurologists. Alzheimers Res Ther 2023; 15:60. [PMID: 36964606 PMCID: PMC10037811 DOI: 10.1186/s13195-023-01207-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) is a major global health crisis in need of more effective therapies. However, difficult choices to optimize value-based care will need to be made. While identifying preferred therapeutic attributes of new AD therapies is necessary, few studies have explored how preferences may vary between the stakeholders. In this study, the trade-offs among key attributes of amyloid plaque-lowering therapies for AD were assessed using a discrete choice experiment (DCE) and compared between caregivers and neurologists. METHODS An initial pilot study was conducted to identify the potentially relevant features of a new therapy. The DCE evaluated seven drug attributes: clinical effects in terms of delay in AD progression over the standard of care (SOC), variation in clinical effects, biomarker response (achieving amyloid plaque clearance on PET scan), amyloid-related imaging abnormalities-edema (ARIA-E), duration of therapy, need for treatment titration as well as route, and frequency of drug administration. Respondents were then randomly presented with 12 choice sets of treatment options and asked to select their preferred option in each choice set. Hierarchical Bayesian regression modeling was used to estimate weighted preference attributes, which were presented as mean partial utility scores (pUS), with higher scores suggesting an increased preference. RESULTS Both caregivers (n = 137) and neurologists (n = 161) considered clinical effects (mean pUS = 0.47 and 0.82) and a 5% incremental in ARIA-E (mean pUS = - 0.26 and - 0.52) to be highly impactful determinants of therapeutic choice. In contrast, variation in clinical effects (mean pUS = 0.12 and 0.14) and treatment duration (mean pUS = - 0.02 and - 0.13) were the least important characteristics of any new treatment. Neurologists' also indicated that subcutaneous drug delivery (mean pUS = 0.42 vs. 0.07) and administration every 4 weeks (mean pUS = 1.0 vs. 0.20) are highly desirable therapeutic features. Respondents were willing to accept up to a 9% increment in ARIA-E for one additional year of delayed progression. CONCLUSIONS Caregivers and neurologists considered incremental clinical benefit over SOC and safety to be highly desirable qualities for a new drug that could clear amyloid plaques and delay clinical progression and indicated a willingness to accept incremental ARIA-E to achieve additional clinical benefits.
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Affiliation(s)
- George Dranitsaris
- Department of Public Health, Falk College, Syracuse University, 150 Crouse Dr., Syracuse, NY, 13244, USA.
| | | | - Lin Mu
- Boston Consulting Group, Boston, MA, USA
| | | | | | | | - Alireza Atri
- Banner Sun Health Research Institute, Sun City, AZ, USA
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Dranitsaris G, Zhang Q, Quill A, Mu L, Weyrer C, Dysdale E, Neumann P, Tahami Monfared AA. Treatment Preference for Alzheimer's Disease: A Multicriteria Decision Analysis with Caregivers, Neurologists, and Payors. Neurol Ther 2022; 12:211-227. [PMID: 36422822 PMCID: PMC9837350 DOI: 10.1007/s40120-022-00423-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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Alzheimer's disease (AD) is a chronic neurodegenerative disorder associated with a high burden of illness. New therapies under development include agents that target amyloid-beta (Aβ), a key component in AD pathogenesis. Understanding the decision-making process for new AD drugs would help determine if such therapies should be adopted by society. Multicriteria decision analysis (MCDA) was applied to three key stakeholder groups to assess treatment alternatives for AD based on a multitude of decision trade-offs covering main components of care. METHODS AD caregivers (n = 117), neurologists (n = 90), and payors (n = 90) from the USA received an online survey. The decision problem was broken down into four decision criterion and 12 subcriteria for two treatment scenarios: an Aβ-targeted therapy vs. the standard of care (SOC). Respondents were asked to indicate how much they preferred one option over another on a scale from 1 (equal preference) to 9 (high preference) based on each criterion and subcriterion. The decision criteria and subcriteria were weighted and presented as partial utility scores (pUS), with higher scores suggesting an increased preference for that decision-making component. RESULTS Caregivers and payors applied the highest value to need for intervention (mean pUS = 0.303 and 0.259) and clinical outcomes (mean pUS = 0.286 and 0.377). In contrast, neurologists placed the highest value on clinical outcomes and types of benefits (mean pUS = 0.436 and 0.248). When decision subcriteria were examined, efficacy (mean pUS = 0.115, 0.219, and 0.166) and the type of patient benefits (mean pUS = 0.135, 0.178, and 0.126) were among the most valued by caregivers, neurologists, and payors. CONCLUSION All groups placed the highest value on drug efficacy and types of benefit derived by patients. In contrast, cost implications were among the least important aspects in their decision-making.
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Affiliation(s)
- George Dranitsaris
- Department of Public Health, Falk College, Syracuse University, 150 Crouse Dr, Syracuse, NY, 13244, USA.
| | | | | | - Lin Mu
- Boston Consulting Group, Boston, MA USA
| | | | | | - Peter Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA USA
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Molasiotis A, Aapro M, Alonzi A, Chrápavá M, Jordan K, Roeland E, Schwartzberg L, Terrasanta C, Olivari S, Dranitsaris G. 295TiP Assessing the benefit of NEPA (fixed combination of netupitant/palonosetron) for preventing chemotherapy-induced nausea and vomiting (CINV) in patients at increased emetic risk receiving moderately emetogenic chemotherapy. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.10.320] [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: 12/07/2022] Open
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Riazi S, Bersselaar LRVD, Islander G, Heytens L, Snoeck MMJ, Bjorksten A, Gillies R, Dranitsaris G, Hellblom A, Treves S, Kunst G, Voermans NC, Jungbluth H. Pre-operative exercise and pyrexia as modifying factors in malignant hyperthermia (MH). Neuromuscul Disord 2022; 32:628-634. [PMID: 35738978 DOI: 10.1016/j.nmd.2022.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 03/09/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
Malignant hyperthermia (MH) is a life-threatening reaction triggered by volatile anesthetics and succinylcholine. MH is caused by mutations in the skeletal muscle ryanodine receptor (RYR1) gene, as is rhabdomyolysis triggered by exertion and/or pyrexia. The discrepancy between the prevalence of risk genotypes and actual MH incidence remains unexplained. We investigated the role of pre-operative exercise and pyrexia as potential MH modifying factors. We included cases from 5 MH referral centers with 1) clinical features suggestive of MH, 2) confirmation of MH susceptibility on Contracture Testing (IVCT or CHCT) and/or RYR1 genetic testing, and a history of 3) strenuous exercise within 72 h and/or pyrexia >37.5 °C prior to the triggering anesthetic. Characteristics of MH-triggering agents, surgery and succinylcholine use were collected. We identified 41 cases with general anesthesias resulting in an MH event (GA+MH, n = 41) within 72 h of strenuous exercise and/or pyrexia. We also identified previous general anesthesias without MH events (GA-MH, n = 51) in the index cases and their MH susceptible relatives. Apart from pre-operative exercise and/or pyrexia, trauma and acute abdomen as surgery indications, emergency surgery and succinylcholine use were also more common with GA+MH events. These observations suggest a link between pre-operative exercise, pyrexia and MH.
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Affiliation(s)
- Sheila Riazi
- Department of Anesthesia, Malignant Hyperthermia Investigation Unit, University Health Network, University of Toronto, Toronto, Canada
| | | | | | - Luc Heytens
- Department of Anaesthesiology, University Hospital Antwerp, Edegem, Belgium
| | - Marc M J Snoeck
- Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Andrew Bjorksten
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Robyn Gillies
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - George Dranitsaris
- Department of Anesthesia, Malignant Hyperthermia Investigation Unit, University Health Network, University of Toronto, Toronto, Canada
| | - Anna Hellblom
- Department of Intensive and Perioperative Medicine, Skane University Hospital, Lund, Sweden; Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Susan Treves
- Department of Biomedicine, Basel University Hospital, Basel University, Basel, Switzerland
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Therapy, King's College Hospital, London, UK; School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Nicol C Voermans
- Department of Neurology, Radboud University, Nijmegen, The Netherlands
| | - Heinz Jungbluth
- Randall Centre Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK; Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, London, UK.
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Lacouture ME, Pan A, Dranitsaris G, Harris U, Chandarlapaty S, Dang CT, Gajria D, Gordon A, Iyengar NM, Robson ME, Razavi P, Rosen E, Wong STL, Jain M, Moy A, Markova A. Interim analysis of a single-center, single-arm, prospective phase 2 study to evaluate the efficacy and safety of benralizumab for alpelisib rash in metastatic PIK3CA-mutant, hormone receptor–positive breast cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12100] [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
12100 Background: Rash associated with increased peripheral eosinophils develops in approximately 50% of metastatic breast cancer patients receiving alpelisib. Antihistamines and corticosteroids have limited benefit. Refractory rash may lead to decreased dose intensity and affect clinical outcome. Benralizumab is an anti-IL-5Rα chimeric monoclonal antibody that depletes peripheral eosinophils and has demonstrated benefit in eosinophilic asthma and hypereosinophilic syndrome. We investigate the efficacy and safety of benralizumab for the treatment of alpelisib rash. Methods: We performed a single-center, single-arm, prospective phase 2 study to evaluate the efficacy and safety of benralizumab in cancer patients who developed CTCAE grade 2/3 skin events resulting from immunotherapy or targeted therapies with absolute blood eosinophil counts of ≥300/mcl. While remaining on culprit drugs, patients were treated with benralizumab 30mg once every 4 weeks for the first 3 doses followed by once every 8 weeks for 3 additional doses (approved dosing for eosinophilic asthma). Primary endpoint was clinical response measured as reduction in CTCAE grade 2/3 skin event to grade ≤1 by week 4. Secondary endpoints were patient quality of life (QoL) measured by skindex16, safety data, need for supportive oral corticosteroids, and changes in cytokines and eosinophil biomarkers. This interim analysis focuses on patients with PIK3CA-mutant metastatic breast cancer receiving alpelisib. Results: Between September 16th 2020 and January 1st 2022, we enrolled 10 metastatic breast cancer patients with grade 2/3 rash attributed to alpelisib (5 pts with G3). All patients had a reduction of rash to grade ≤1 (n = 10, p < 0.0001), and a decrease in peripheral absolute eosinophils (mean 500/mcl to 0, p < 0.0001). Of these, 6 patients had been on prophylactic oral antihistamines and 2 had oral steroid coadministration. QoL significantly improved (Skindex16 mean score 58 to 16, p = 0.0001) and eosinophils in skin histology decreased per HPF (mean 6.25 to 0.25, n = 8, p = 0.2) by week 4. An increase in IL-5 > 600% and reduction IL-6 and TNF-α > 50% were reported by week 4 and 8. Grade 1/2 mucositis in 4 patients were reported as adverse events. Conclusions: Our findings suggest that benralizumab is safe and effective for the treatment of grade 2/3 rash with eosinophilia related to alpelisib in patients with breast cancer. A reduction in rash severity was evidenced in all patients, along with improved QoL. Larger controlled studies are in development to evaluate the efficacy of benralizumab for the prevention of alpelisib rash. Clinical trial information: NCT04552288.
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Affiliation(s)
| | - Alexander Pan
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Devika Gajria
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Allison Gordon
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neil M. Iyengar
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ezra Rosen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Manu Jain
- Memorial Sloan Kettering Cancer Center, Manhattan, NY
| | - Andrea Moy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, New York, NY
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Nocco S, Andriano TM, Bose A, Chilov M, Godwin K, Dranitsaris G, Wu S, Lacouture ME, Roeker LE, Mato AR, Markova A. Ibrutinib-associated dermatologic toxicities: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2022; 174:103696. [PMID: 35523374 DOI: 10.1016/j.critrevonc.2022.103696] [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: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
The scope of dermatologic adverse events to ibrutinib has not been systematically described. We sought to determine the incidence and severity of ibrutinib-associated dermatologic toxicities and provide management recommendations. We conducted a systematic literature search of clinical trials and cohorts investigating ibrutinib monotherapy for cancer or chronic graft-versus-host disease through June 2020. Thirty-two studies with 2258 patients were included. The incidence of all-grade toxicities included cutaneous bleeds (24.8%; 95%CI, 18.6-31.0%), mucocutaneous infections (4.9%; 95%CI, 2.9-7.0%), rash (10.8%; 95%CI. 6.1-15.5%), mucositis (6%; 95%CI, 3.6-8.5%), edema (15.9%; 95%CI, 11.1-20.6%), pruritus (4.0%; 95%CI, 0.0-7.9%), xerosis (9.2%; 95%CI, 5.5-13.0%), nail changes (17.8%; 95%CI, 4.1-31.5%), and hair changes (7.9%; 95%CI, 0.0-21.3%). The incidence of high-grade toxicities included mucocutaneous infection (1.3%; 95%CI, 0.5-2.2%), rash (0.1%; 95%CI, 0.0-0.2%), mucositis (0.1%; 95%CI, 0.0-0.3%), and edema (0.1%; 95%CI, 0.0-0.2%). It is imperative that clinicians familiarize themselves with ibrutinib-associated dermatologic toxicities to learn how to manage them, prevent discontinuation, and improve patient outcomes.
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Affiliation(s)
- Sarah Nocco
- Weill Cornell Medical College, New York, NY, USA; Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Arpita Bose
- Weill Cornell Medical College, New York, NY, USA
| | - Marina Chilov
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kendra Godwin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Shenhong Wu
- Division of Medical Oncology, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA; Division of Hematology and Oncology, Department of Medicine, Northport VA Medical Center, Northport, NY, USA
| | - Mario E Lacouture
- Weill Cornell Medical College, New York, NY, USA; Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lindsay E Roeker
- Weill Cornell Medical College, New York, NY, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony R Mato
- Weill Cornell Medical College, New York, NY, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alina Markova
- Weill Cornell Medical College, New York, NY, USA; Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Dranitsaris G, Moezi M, Dobson K, Phelan R, Blau S. A real-world study to evaluate the safety and efficacy of three injectable neurokinin-1 receptor antagonist formulations for the prevention of chemotherapy-induced nausea and vomiting in cancer patients. Support Care Cancer 2022; 30:6649-6658. [PMID: 35499619 PMCID: PMC9213362 DOI: 10.1007/s00520-022-07082-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/20/2022] [Indexed: 10/31/2022]
Abstract
Abstract
Background
Three different injectable neurokinin-1 (NK-1) receptor antagonist formulations (CINVANTI® [C] vs. intravenous Emend® [E] vs. generic formulations of fosaprepitant [GFF]) were compared with respect to nausea and vomiting control, use of rescue therapy, and the development of infusion reactions over multiple cycles of chemotherapy.
Methods
A retrospective analysis from 17 community oncology practices across the USA was conducted on patients who received moderately or highly emetogenic chemotherapy. The co-primary endpoints were the control of chemotherapy-induced nausea and vomiting (CINV) from days 1 to 5 over all cycles and the frequency of infusion-related reactions. Propensity score weighted multivariable logistic regression analysis was used to compare complete CINV control, the use of rescue therapy, and the risk of infusion reactions between groups.
Results
The study enrolled 294 patients (C = 101, E = 101, GFF = 92) who received 1432 cycles of chemotherapy. Using CINVANTI® as the reference group, comparative effectiveness was suggested in CINV control over all chemotherapy cycles (odds ratio (OR): E vs. C = 1.00 [0.54 to 1.86] and GFF vs. C = 1.12 [0.54 to 2.32]). However, use of rescue therapy was significantly higher in the EMEND® group relative to CINVANTI® (OR = 2.69; 95%CI: 1.06 to 6.84). Infusion reactions were also numerically higher in the EMEND® group, but the difference did not reach statistical significance (OR = 4.35; 95%CI: 0.83 to 22.8).
Conclusions
In this real-world analysis, patients receiving CINVANTI® had a reduced need for CINV rescue therapy and a numerically lower incidence of infusion reactions.
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Bartoszko J, Dranitsaris G, Wilcox ME, Del Sorbo L, Mehta S, Peer M, Parotto M, Bogoch I, Riazi S. Development of a repeated-measures predictive model and clinical risk score for mortality in ventilated COVID-19 patients. Can J Anaesth 2022; 69:343-352. [PMID: 34931293 PMCID: PMC8687635 DOI: 10.1007/s12630-021-02163-3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/13/2021] [Accepted: 10/04/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The COVID-19 pandemic has caused intensive care units (ICUs) to reach capacities requiring triage. A tool to predict mortality risk in ventilated patients with COVID-19 could inform decision-making and resource allocation, and allow population-level comparisons across institutions. METHODS This retrospective cohort study included all mechanically ventilated adults with COVID-19 admitted to three tertiary care ICUs in Toronto, Ontario, between 1 March 2020 and 15 December 2020. Generalized estimating equations were used to identify variables predictive of mortality. The primary outcome was the probability of death at three-day intervals from the time of ICU admission (day 0), with risk re-calculation every three days to day 15; the final risk calculation estimated the probability of death at day 15 and beyond. A numerical algorithm was developed from the final model coefficients. RESULTS One hundred twenty-seven patients were eligible for inclusion. Median ICU length of stay was 26.9 (interquartile range, 15.4-52.0) days. Overall mortality was 42%. From day 0 to 15, the variables age, temperature, lactate level, ventilation tidal volume, and vasopressor use significantly predicted mortality. Our final clinical risk score had an area under the receiver-operating characteristics curve of 0.9 (95% confidence interval [CI], 0.8 to 0.9). For every ten-point increase in risk score, the relative increase in the odds of death was approximately 4, with an odds ratio of 4.1 (95% CI, 2.9 to 5.9). CONCLUSION Our dynamic prediction tool for mortality in ventilated patients with COVID-19 has excellent diagnostic properties. Notwithstanding, external validation is required before widespread implementation.
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, University Health Network, 323-200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - George Dranitsaris
- Department of Public Health, Falk College, Syracuse University, Syracuse, NY, USA
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine (Critical Care Medicine), University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine (Critical Care Medicine), University Health Network, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Miki Peer
- Department of Anesthesia and Pain Management, University Health Network, 323-200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Matteo Parotto
- Department of Anesthesia and Pain Management, University Health Network, 323-200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Isaac Bogoch
- Division of General Internal Medicine and Infectious Diseases, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sheila Riazi
- Department of Anesthesia and Pain Management, University Health Network, 323-200 Elizabeth St, Toronto, ON, M5G 2C4, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Filipovic A, Wainber Z, Wang J, Bendell J, Janku F, Sharma M, Mahipal A, Bolen J, Elenko E, Korth C, Dranitsaris G. 482 Phase1/2 study of an anti-galectin-9 antibody, LYT-200, in patients with metastatic solid tumors. J Immunother Cancer 2021. [DOI: 10.1136/jitc-2021-sitc2021.482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BackgroundGalectin-9 (gal-9) acts as a pivotal immuno-suppressor that disables immune mediated activity through modulation of T cells, macrophages and other immune functions. As such it has emerged as a powerful biological target for cancer immunotherapy and a potential biomarker of response and/or prognosis. Patients exhibiting high gal-9 expression in tumors and blood often have poor prognosis and tumors with aggressive and immunosuppressed molecular features (Chen L. et al, AACR 2020-LB-350). LYT-200 is a fully human IgG4 monoclonal antibody targeting gal-9. LYT-200 has high affinity, high specificity, stability, and blocks galectin-9 interactions with its binding partners in biochemical and human cell-based assays. In murine models of melanoma and pancreatic cancer, LYT-200 significantly reduced tumor growth, extended survival and modulated the intra-tumoral immune microenvironment. LYT-200 treated patient derived tumor organoids showed an increase in T cell activation (Chen L. et al, SITC 2019-P765).MethodsLYT-200 is now being evaluated in the USA, in the first part of an adaptive Phase 1/2 trial (NCT04666688) in relapsed/refractory solid tumors. Patients with solid tumor malignancy that is metastatic or unresectable and refractory to prior therapy are included. Patients are treated with LYT-200 by IV infusion, every 2 weeks (Q2W), until disease progression or toxicity. Phase 1 of the study uses the continuous reassessment design (CRM), and entails recruiting two patients per dosing level. Starting dose level was 0.2mg/kg Q2W. Additionally, the protocol stipulates six patients must be treated at the dose level intended to be declared recommended phase 2 dose (RP2D), for more robust assessment of safety/tolerability. RP2D may be the maximum tolerated dose or the optimal biological dose. The primary objective of the ongoing Phase 1 is to assess the safety and tolerability of LYT-200 and to identify the RP2D. The Phase 1 is also assessing LYT-200’s pharmacokinetics, immunogenicity and pharmacodynamics (measuring circulating gal-9 and cytokine levels, immunophenotyping peripheral blood mononuclear cells and tumor tissue). Preliminary efficacy is captured as an exploratory endpoint in Phase 1. Phase 2 expansion cohorts would implement the Simon’s two-stage design to further assess LYT-200 as a single agent and/or in combination with chemotherapy and tislelizumab. Phase 2 is currently planned in pancreatic cancer and other/different tumor types for Phase 2 may be guided by results of the Phase 1.AcknowledgementsAll clinical trial sites participating in the LYT-200 study. Shohei Koide, Linxiao Chen and George Miller and their teams at New York University Langone Health & New York University School of Medicine, NY for all the preclinical work on LYT-200.Trial RegistrationNCT04666688
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Riazi S, van den Bersselaar L, Islander G, Heytens L, Snoeck M, Bjorksten A, Gillies R, Dranitsaris G, Hellblom A, Treves S, Voermans N, Jungbluth H. CLINICAL RESEARCH. Neuromuscul Disord 2021. [DOI: 10.1016/j.nmd.2021.07.023] [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: 11/16/2022]
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Dranitsaris G, DeAngelis C, Pearson B, McDermott L, Pohlmann-Eden B. Opioid Prescribing in Canada following the Legalization of Cannabis: A Clinical and Economic Time-Series Analysis. Appl Health Econ Health Policy 2021; 19:537-544. [PMID: 33491149 DOI: 10.1007/s40258-021-00638-4] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2021] [Indexed: 06/12/2023]
Abstract
PURPOSE On 17 October 2018 recreational cannabis became legal in Canada, thereby increasing access and reducing the stigma associated with its use for pain management. This study assessed total opioid prescribing volumes and expenditures prior to and following cannabis legalization. METHODS National monthly claims data for public and private payers were obtained from January 2016 to June 2019. The drugs evaluated consisted of morphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, oxycodone, tramadol, and the non-opioids gabapentin and pregabalin. All opioid volumes were converted to a mean morphine equivalent dose (MED)/claim, which is analogous to a prescription from a physician. Gabapentin and pregabalin claims data were analyzed separately from the opioids. Time-series regression modelling was undertaken with dependent variables being mean MED/claim and total monthly spending. The slopes of the time-series curves were then compared pre- versus post-cannabis legalization. RESULTS Over the 42-month period, the mean MED/claim declined within public plans (p < 0.001). However, the decline in MED/claim was 5.4 times greater in the period following legalization (22.3 mg/claim post vs. 4.1 mg/claim pre). Total monthly opioid spending was also reduced to a greater extent post legalization ($Can267,000 vs. $Can95,000 per month). The findings were similar for private drug plans; however, the absolute drop in opioid use was more pronounced (76.9 vs. 30.8 mg/claim). Over the 42-month period, gabapentin and pregabalin usage also declined. CONCLUSIONS Our findings support the hypothesis that easier access to cannabis for pain may reduce opioid use for both public and private drug plans.
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Affiliation(s)
- George Dranitsaris
- Augmentium Pharma Consulting Inc., 445 Danforth Ave, Suite 448, Toronto, ON, M4K 1N2, Canada.
| | - Carlo DeAngelis
- Odette Cancer Centre, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Blake Pearson
- Opioid Reduction Strategy, Local Health Integration Network, Erie St. Clair, Chatham, Canada
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15
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Alzahrani MJ, Dranitsaris G, Sienkiewicz M, Vandermeer L, Clemons M. Clinical utility of a prediction tool to differentiate between breast cancer patients at high or low risk of chemotherapy-induced nausea and vomiting. Support Care Cancer 2021; 29:7837-7843. [PMID: 34176018 DOI: 10.1007/s00520-021-06358-8] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND A personalized risk model (PRM) that can categorize patients into high or low risk of ≥ grade 2 acute and/or delayed chemotherapy-induced nausea and vomiting (CINV) was previously developed. The current study assessed whether the PMR could accurately stratify patients' risk for other commonly used CINV endpoints. METHODS Data was pooled from a previously reported trial evaluating CINV in patients with breast cancer (BC) receiving neo/adjuvant anthracycline-cyclophosphamide or carboplatin-based chemotherapy. The predictive ability of the PRM was compared to patient experience of any self-reported significant nausea, any vomiting, complete cycle response, and use of rescue medications, over all cycles of chemotherapy. RESULTS Data was available from 242 patients over 819 chemotherapy cycles. Irrespective of the chosen antiemetics, significant nausea was common when evaluated across repeated cycles of treatment with an overall incidence of 24.2% in low-risk patients and 34.6% in high-risk patients. Patients identified as high risk of CINV using the PRM were 4.73 (p = 0.011) times more likely to develop significant nausea than those identified as low risk. The PRM did not show any significant statistical differences between both groups in overall vomiting, complete cycle response, or rescue medications use. CONCLUSION The PRM was able to identify patients at greater risk of significant nausea but not the other CINV endpoints. As nausea remains a pertinent issue for patients with BC, the PRM could be used to identify these patients a priori for innovative treatment strategies.
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Affiliation(s)
- Mashari Jemaan Alzahrani
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | | | - Marta Sienkiewicz
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark Clemons
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada.
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Montazeri K, Dranitsaris G, Thomas JD, Curran C, Preston MA, Steele GS, Kilbridge KL, Mantia C, Ravi P, McGregor BA, Mossanen M, Sonpavde G. An economic analysis comparing health care resource use and cost of dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin versus gemcitabine and cisplatin as neoadjuvant therapy for muscle invasive bladder cancer. Urol Oncol 2021; 39:834.e1-834.e7. [PMID: 34162500 DOI: 10.1016/j.urolonc.2021.04.032] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/11/2021] [Accepted: 04/23/2021] [Indexed: 12/09/2022]
Abstract
PURPOSE To compare healthcare resource utilization (HRU) and costs associated with dose-dense methotrexate, vinblastine, doxorubicin, cisplatin (ddMVAC) and gemcitabine, cisplatin (GC) as neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC). METHODS Patient treated at Dana-Farber Cancer Institute from 2010 to 2019 were identified. HRU data on chemotherapy administered, supportive medications, patient monitoring, clinic, infusion, emergency department (ED) visits and hospitalization were collected retrospectively. Unit costs for HRU components were obtained from the Centers for Medicare and Medicaid Website and HRU was compared between groups using quantile regression analysis. RESULTS 137 patients were included; 51 received ddMVAC and 86 GC. Baseline characteristics were similar, except lower mean age (P < 0.001) and higher proportion of ECOG-PS = 0 (P < 0.001) for ddMVAC. ddMVAC required more granulocyte-colony stimulating factor support (P < 0.001), central line placement (P = 0.017), cardiac imaging (P < 0.001), and infusion visits (P < 0.001), whereas GC required more clinic visits. ED visits were higher for ddMVAC (P = 0.048), while chemotherapy cycle delays and hospitalization days were higher for GC (P = 0.008). After adjusting for ECOG-PS and age, the cost per patient was approximately 41% lower (95%CI: 28% to 52%; P < 0.001) for GC vs. ddMVAC, which translated to a median adjusted cost savings of $7,410 (95%CI: $5,474-$9,347) per patient. CONCLUSIONS Although excess HRU did not clearly favor one regimen, adjusting for PS and age indicated lower costs with GC vs. ddMVAC. Given the similar cumulative cisplatin delivery with both regimens, the associated values and costs supports the preferential selection of GC in the neoadjuvant setting of MIBC.
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Affiliation(s)
- K Montazeri
- Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - J D Thomas
- Beth Israel Deaconess Medical Center, Boston, MA
| | - C Curran
- Beth Israel Deaconess Medical Center, Boston, MA
| | - M A Preston
- Department of Urology, Brigham and Women's Hospital, Boston, MA
| | - G S Steele
- Department of Urology, Brigham and Women's Hospital, Boston, MA
| | - K L Kilbridge
- Department of Urology, Brigham and Women's Hospital, Boston, MA
| | - C Mantia
- Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute, Boston, MA
| | - P Ravi
- Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute, Boston, MA
| | - B A McGregor
- Beth Israel Deaconess Medical Center, Boston, MA
| | - M Mossanen
- Department of Urology, Brigham and Women's Hospital, Boston, MA
| | - G Sonpavde
- Beth Israel Deaconess Medical Center, Boston, MA.
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Chiarotto JA, Dranitsaris G. A Community Hospital-Based Study: A Prespecified Neutrophil Count with Adjuvant mFOLFOX6 Associated with Increased Delays, Increased G-CSF Use, and Reduced Dose Intensity. Cancer Manag Res 2021; 13:4087-4094. [PMID: 34040446 PMCID: PMC8141389 DOI: 10.2147/cmar.s307713] [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: 02/21/2021] [Accepted: 04/28/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose To look at how the absolute neutrophil count (ANC) is used by community oncologists as the main factor in ordering adjuvant mFOLFOX6 for colorectal cancer. This study reports on how this decision impacts chemotherapy delays, effects received dose intensity (RDI), and increases the use of granulocyte-colony-stimulating factor (G-CSF). Methods A retrospective chart review was conducted for all patients receiving adjuvant mFOLFOX6 for colorectal cancer at a two-site community hospital in Toronto, Ontario, Canada, between July 2013 and March 2019. Seven physicians treated 140 patients, who made 1636 clinic visits to receive 1461 cycles of prescribed chemotherapy. Results The mean ANC per physician associated with a decision to give chemotherapy ranged from 1.05×109/L (95% CI 0.98-1.13×109/L) to 1.5x109/L with a decision to delay if the ANC was lower. Subsequent cycles were then supported by G-CSF with very similar ANC decision levels for dose delay. Physicians were more likely to prescribe chemotherapy with higher pretreatment ANC, r=0.3 (p<0.000). G-CSF was used in 24.6% of cycles and usage had grown to 44.2% by the 12th cycle; physician use ranged from 0.36% to 54.2% of cycles. Secondary prophylaxis was the indication in 94.7% of cases. There was an inverse relationship between the frequency of G-CSF use and the RDI of continuous infusion 5FU, r=-0.26 (p<0.001). There were delays for 8.8% of visits for cycles not supported by G-CSF and, surprisingly, 15.9% of visits for cycles supported by G-CSF. Neutropenia caused 61.6% of delays for chemotherapy cycles not supported by G-CSF and 44.1% for cycles supported by G-CSF. Conclusion Physicians required a pretreatment ANC of 1.05-1.5×109/L before prescribing mFOLFOX6 chemotherapy. When ANC was low, a dose delay and secondary prophylaxis with G-CSF failed to consistently achieve the much sought after ANC. This then caused more delay, reduced RDI and increased expense for both patients and the system. Fewer delays, less G-CSF and increased RDI would have resulted with reduced reliance on ANC and adoption of chemotherapy dose reduction.
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Affiliation(s)
- James A Chiarotto
- Department of Medicine, The Scarborough Health Network, Toronto, Ontario, Canada
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Pasic I, Alanazi W, Dranitsaris G, Lieberman L, Viswabandya A, Kim DDH, Lipton JH, Michelis FV. Subcutaneous immunoglobulin in allogeneic hematopoietic cell transplant patients: A prospective study of feasibility, safety, and healthcare resource use. Hematol Oncol Stem Cell Ther 2021; 14:302-310. [PMID: 33684377 DOI: 10.1016/j.hemonc.2021.01.001] [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: 10/22/2020] [Revised: 12/15/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND We evaluated feasibility, safety, and total resource use of subcutaneous immunoglobulin (SCIG) in a pilot study of patients who underwent allogeneic hematopoietic cell transplant (HCT) over a 6-month period. METHODS A total of 20 eligible patients were treated with SCIG at 0.1 g/kg/week for up to 6 months. Patients were matched to 20 concurrent intravenous immunoglobulin (IVIG) controls. Clinical outcomes measured included adverse reactions, healthcare resource use, patient satisfaction, and quality of life (QOL). (ClinicalTrials.gov Identifier: NCT03401268.) RESULTS: Groups were comparable in terms of age, weight, sex, transplant indication, donor type, and conditioning intensity. All 20 IVIG patients completed 6 consecutive months of therapy compared with 13/20 (65%) SCIG patients. There were no adverse reactions in IVIG patients, compared with six (30%) SCIG patients. All adverse reactions in SCIG patients were grade I, transient, and required no medical intervention. Median overall cost per patient was lower with SCIG than with IVIG ($9,756 vs. $13,780, p = .046). Among patients who completed 6 months of SCIG, median preference and satisfaction scores were 100%. Over the 6-month period, QOL scores remained stable in SCIG patients. CONCLUSIONS In a subgroup of patients, SCIG was associated with high patient satisfaction and a reduction in total healthcare costs compared with IVIG in a cohort of HCT patients.
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Affiliation(s)
- Ivan Pasic
- Hans Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Wael Alanazi
- Hans Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Auro Viswabandya
- Hans Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Dennis Dong Hwan Kim
- Hans Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jeffrey H Lipton
- Hans Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fotios V Michelis
- Hans Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
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Stebbing J, Sánchez Nievas G, Falcone M, Youhanna S, Richardson P, Ottaviani S, Shen JX, Sommerauer C, Tiseo G, Ghiadoni L, Virdis A, Monzani F, Rizos LR, Forfori F, Avendaño Céspedes A, De Marco S, Carrozzi L, Lena F, Sánchez-Jurado PM, Lacerenza LG, Cesira N, Caldevilla Bernardo D, Perrella A, Niccoli L, Méndez LS, Matarrese D, Goletti D, Tan YJ, Monteil V, Dranitsaris G, Cantini F, Farcomeni A, Dutta S, Burley SK, Zhang H, Pistello M, Li W, Romero MM, Andrés Pretel F, Simón-Talero RS, García-Molina R, Kutter C, Felce JH, Nizami ZF, Miklosi AG, Penninger JM, Menichetti F, Mirazimi A, Abizanda P, Lauschke VM. JAK inhibition reduces SARS-CoV-2 liver infectivity and modulates inflammatory responses to reduce morbidity and mortality. Sci Adv 2021; 7:eabe4724. [PMID: 33187978 PMCID: PMC7775747 DOI: 10.1126/sciadv.abe4724] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/28/2020] [Indexed: 05/16/2023]
Abstract
Using AI, we identified baricitinib as having antiviral and anticytokine efficacy. We now show a 71% (95% CI 0.15 to 0.58) mortality benefit in 83 patients with moderate-severe SARS-CoV-2 pneumonia with few drug-induced adverse events, including a large elderly cohort (median age, 81 years). An additional 48 cases with mild-moderate pneumonia recovered uneventfully. Using organotypic 3D cultures of primary human liver cells, we demonstrate that interferon-α2 increases ACE2 expression and SARS-CoV-2 infectivity in parenchymal cells by greater than fivefold. RNA-seq reveals gene response signatures associated with platelet activation, fully inhibited by baricitinib. Using viral load quantifications and superresolution microscopy, we found that baricitinib exerts activity rapidly through the inhibition of host proteins (numb-associated kinases), uniquely among antivirals. This reveals mechanistic actions of a Janus kinase-1/2 inhibitor targeting viral entry, replication, and the cytokine storm and is associated with beneficial outcomes including in severely ill elderly patients, data that incentivize further randomized controlled trials.
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Affiliation(s)
- Justin Stebbing
- Department of Surgery and Cancer, Imperial College, London, UK.
| | - Ginés Sánchez Nievas
- Department of Rheumatology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Marco Falcone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sonia Youhanna
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Joanne X Shen
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Christian Sommerauer
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Science for Life Laboratory, Solna, Sweden
| | - Giusy Tiseo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Ghiadoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Monzani
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luis Romero Rizos
- Department of Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- CIBERFES, Ministerio de Economía y Competitividad, Madrid, Spain
| | - Francesco Forfori
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Pisa, University of Pisa, Italy
| | - Almudena Avendaño Céspedes
- Department of Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- CIBERFES, Ministerio de Economía y Competitividad, Madrid, Spain
| | - Salvatore De Marco
- Department of Internal Medicine, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Laura Carrozzi
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Pisa, University of Pisa, Italy
| | - Fabio Lena
- Department of Pharmaceutical Medicine, Misericordia Hospital, Grosseto, Italy
| | - Pedro Manuel Sánchez-Jurado
- Department of Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- CIBERFES, Ministerio de Economía y Competitividad, Madrid, Spain
| | | | - Nencioni Cesira
- Department of Medicine, Misericordia Hospital, Grosseto, Italy
| | | | | | - Laura Niccoli
- Department of Rheumatology, Hospital of Prato, Prato, Italy
| | - Lourdes Sáez Méndez
- Department of Internal Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Delia Goletti
- Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases-IRCCS, Rome, Italy
| | - Yee-Joo Tan
- University of Singapore, Infectious Diseases Programme, Immunology Programme, Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore and Institute of Molecular and Cell Biology (IMCB), A*STAR (Agency for Science, Technology and Research), Singapore, Singapore
| | - Vanessa Monteil
- Karolinska Institutet, Department of Laboratory Medicine, Unit of Clinical Microbiology, and SE-17177, Stockholm, Sweden
| | - George Dranitsaris
- Department of Hematology, School of Medicine, University of Ioannina, Ioannina, Greece
| | | | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome Tor Vergata, Rome Italy
| | - Shuchismita Dutta
- RCSB Protein Data Bank, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Stephen K Burley
- RCSB Protein Data Bank, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Haibo Zhang
- Departments of Anesthesia, Medicine, and Physiology, University of Toronto, Toronto, ON, Canada
| | - Mauro Pistello
- Virology Unit, Department of Translational Research, University of Pisa, Pisa, Italy
| | - William Li
- The Angiogenesis Foundation, Cambridge, MA, USA
| | - Marta Mas Romero
- Department of Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Fernando Andrés Pretel
- Department of Statistics, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Rafael García-Molina
- Department of Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Claudia Kutter
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Science for Life Laboratory, Solna, Sweden
| | | | | | | | - Josef M Penninger
- Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna, Austria
- Department of Medical Genetics, Life Science Institute, University of British Columbia, Vancouver, BC, Canada
| | - Francesco Menichetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ali Mirazimi
- Karolinska Institutet, Department of Laboratory Medicine, Unit of Clinical Microbiology, and SE-17177, Stockholm, Sweden
- National Veterinary Institute, Uppsala, Sweden
| | - Pedro Abizanda
- Department of Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- CIBERFES, Ministerio de Economía y Competitividad, Madrid, Spain
| | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Clemons M, Dranitsaris G, Sienkiewicz M, Sehdev S, Ng T, Robinson A, Mates M, Hsu T, McGee S, Freedman O, Kumar V, Fergusson D, Hutton B, Vandermeer L, Hilton J. A randomized trial of individualized versus standard of care antiemetic therapy for breast cancer patients at high risk for chemotherapy-induced nausea and vomiting. Breast 2020; 54:278-285. [PMID: 33242754 PMCID: PMC7695916 DOI: 10.1016/j.breast.2020.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 09/02/2020] [Revised: 10/26/2020] [Accepted: 11/03/2020] [Indexed: 02/08/2023] Open
Abstract
Purpose Despite triple antiemetic therapy use for breast cancer patients receiving emetogenic chemotherapy, nausea remains a clinical challenge. We evaluated adding olanzapine (5 mg) to triple therapy on nausea control in patients at high personal risk of chemotherapy-induced nausea and vomiting (CINV). Methods This multi-centre, placebo-controlled, double-blind trial randomized breast cancer patients scheduled to receive neo/adjuvant chemotherapy with anthracycline-cyclophosphamide or platinum-based chemotherapy to olanzapine (5 mg, days 1–4) or placebo. Primary endpoint was frequency of self-reported significant nausea, repeated for all cycles of chemotherapy. Secondary endpoints included: duration of nausea, overall total control of CINV, Health Related Quality of Life (HRQoL) using FLIE questionnaire, use of rescue mediation and treatment-related adverse events. Results 218 eligible patients were randomised to placebo (105) or olanzapine (113). From days 0–5 following each cycle of chemotherapy, 41.3% (95%CI: 36.1–46.7%) of patients in the placebo group reported significant nausea compared to 27.7% (95%CI: 23.2–32.4%) in the olanzapine group (p = 0.001). Across all cycles of chemotherapy, patients receiving olanzapine experienced a statistically significant improvement in HRQoL (p < 0.001). Grade 1/2 sedation was the most commonly side effect reported at 40.8% in the placebo group vs. 54.1% with olanzapine (p < 0.001). Conclusion In patients at high personal risk of CINV, the addition of olanzapine 5 mg daily to standard antiemetic therapy significantly improves the control of nausea, HRQoL, with no unexpected toxicities. Double-blind trial evaluated the addition of olanzapine to triple therapy in patients at high personal risk of CINV. Adding 5 mg olanzapine was associated with significantly improved nausea control with no unexpected toxicities. Olanzapine plus triple therapy should be considered standard of care for breast cancer patients at high risk of CINV.
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Affiliation(s)
- M Clemons
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada.
| | - G Dranitsaris
- Consultant Biostatistician, 283 Danforth Ave, Toronto, Canada
| | - M Sienkiewicz
- Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Sehdev
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - T Ng
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - A Robinson
- Cancer Centre of Southeastern Ontario, Kingston General Hospital, Kingston, ON, Canada
| | - M Mates
- Cancer Centre of Southeastern Ontario, Kingston General Hospital, Kingston, ON, Canada
| | - T Hsu
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - S McGee
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - O Freedman
- Division of Medical Oncology, Durham Regional Cancer Centre, Oshawa, Ontario, Canada
| | - V Kumar
- Markham Stouffville Hospital, Shakir Rehmatullah Cancer Clinic, Markham, Ontario, Canada
| | - D Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - B Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - L Vandermeer
- Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - J Hilton
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada; Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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21
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Chaudhry R, Dranitsaris G, Mubashir T, Bartoszko J, Riazi S. A country level analysis measuring the impact of government actions, country preparedness and socioeconomic factors on COVID-19 mortality and related health outcomes. EClinicalMedicine 2020; 25:100464. [PMID: 32838237 PMCID: PMC7372278 DOI: 10.1016/j.eclinm.2020.100464] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [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: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A country level exploratory analysis was conducted to assess the impact of timing and type of national health policy/actions undertaken towards COVID-19 mortality and related health outcomes. METHODS Information on COVID-19 policies and health outcomes were extracted from websites and country specific sources. Data collection included the government's action, level of national preparedness, and country specific socioeconomic factors. Data was collected from the top 50 countries ranked by number of cases. Multivariable negative binomial regression was used to identify factors associated with COVID-19 mortality and related health outcomes. FINDINGS Increasing COVID-19 caseloads were associated with countries with higher obesity (adjusted rate ratio [RR]=1.06; 95%CI: 1.01-1.11), median population age (RR=1.10; 95%CI: 1.05-1.15) and longer time to border closures from the first reported case (RR=1.04; 95%CI: 1.01-1.08). Increased mortality per million was significantly associated with higher obesity prevalence (RR=1.12; 95%CI: 1.06-1.19) and per capita gross domestic product (GDP) (RR=1.03; 95%CI: 1.00-1.06). Reduced income dispersion reduced mortality (RR=0.88; 95%CI: 0.83-0.93) and the number of critical cases (RR=0.92; 95% CI: 0.87-0.97). Rapid border closures, full lockdowns, and wide-spread testing were not associated with COVID-19 mortality per million people. However, full lockdowns (RR=2.47: 95%CI: 1.08-5.64) and reduced country vulnerability to biological threats (i.e. high scores on the global health security scale for risk environment) (RR=1.55; 95%CI: 1.13-2.12) were significantly associated with increased patient recovery rates. INTERPRETATION In this exploratory analysis, low levels of national preparedness, scale of testing and population characteristics were associated with increased national case load and overall mortality. FUNDING This study is non-funded.
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Affiliation(s)
- Rabail Chaudhry
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, 323-200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - George Dranitsaris
- Department of Hematology, School of Medicine, University of Ioannina, Ioannina 451 10 Greece
| | - Talha Mubashir
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), 7000 Fannin St, Houston, TX 77030, United States
| | - Justyna Bartoszko
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, 323-200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Sheila Riazi
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, 323-200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
- Corresponding author.
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22
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Gibson EJ, Begum N, Koblbauer I, Dranitsaris G, Liew D, McEwan P, Yuan Y, Juarez-Garcia A, Tyas D, Pritchard C. Economic Evaluation of Single versus Combination Immuno-Oncology Therapies: Application of a Novel Modelling Approach in Metastatic Melanoma. Clinicoecon Outcomes Res 2020; 12:241-252. [PMID: 32440174 PMCID: PMC7220542 DOI: 10.2147/ceor.s238725] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/26/2020] [Indexed: 01/18/2023] Open
Abstract
Background Existing economic model frameworks may not adequately capture the atypical treatment response patterns in immuno-oncology (I-O) compared with conventional therapies and thus may fail to represent the full clinical value associated with disease dynamics and improved survival. Objective A cost-effectiveness analysis (CEA) of the I-O Regimen (nivolumab/ipilimumab) versus ipilimumab alone in advanced melanoma was carried out by applying a 5-state partitioned survival model (PSM) as a case study, to explore the I-O treatment response and clinical outcomes. The findings were compared with those of a conventional 3-state PSM. Materials and Methods The case study extends the conventional 3-state PSM, by separating the pre-progression state into non-responders and responders, and the post-progression state into normal and I-O progression to account for delayed treatment effects preceding clinical response. Model states were populated using patient-level data (where possible), mapping from the best overall response (BOR), and survival analysis with flexible and traditional parametric methods. Survival functions were applied to progression-free survival (PFS) and overall survival (OS) endpoints across treatment arms using the 4-year follow-up data (data available at the time of the research; since then 5-year follow-up data have been published) from the CheckMate 067 trial. Information on BOR was used as a means of differentiating the I-O treatment response in addition to the outcomes of progression-free and progressed disease. A UK National Health Service and personal social services (NHS/PSS) perspective over a lifetime horizon was used with outcomes discounted at 3.5% annually. Results The 5-state PSM generated an increase in quality adjusted life years (QALYs) in both treatment arms and gave a more granular description of patients’ health profiles compared with the traditional 3-state PSM. The incremental QALY increased by 13% (from 2.62 to 2.95 QALYs) and the incremental cost decreased by 12% (£29,125 to £25,678) with the 5-state model. In both models, the Regimen had an incremental cost-effectiveness ratio (ICER) relative to ipilimumab alone within the lower bound of the National Institute for Health and Care Excellence (NICE) reference range (£20,000 per QALY gained). Conclusion A 5-state economic model, incorporating relevant I-O health states, can be more informative to gain insight into treatment response and progression differences that are not commonly captured in existing economic models. Clinical trial endpoints, including those relating to treatment response, which are not directly reported in ongoing I-O trials, can be mapped on to the proposed modelled health states (although assumptions are required to do so). Improvements in reporting treatment response in future I-O clinical trials could help to further validate and improve the proposed model framework.
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Affiliation(s)
| | | | | | | | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Yong Yuan
- Bristol-Myers Squibb, Lawrenceville, NJ, USA
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Montazeri K, Dranitsaris G, Curran C, Thomas JD, Ingham MD, Preston MA, Steele GS, Kilbridge KL, Wei XX, McGregor BA, Mossanen M, Sonpavde G. Resource utilization and cost efficacy analysis of dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (DD-MVAC) versus gemcitabine-cisplatin (GC) as neoadjuvant chemotherapy (NAC) for muscle invasive bladder cancer (MIBC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19390] [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
e19390 Background: DD-MVAC and GC are commonly used NAC regimens for MIBC. While efficacy across studies appears similar, resource utilization (RU) burden and cost efficacy have not been compared. Methods: We assessed RU and cost effectiveness of NAC with GC vs DD-MVAC among MIBC patients (pts) treated at Dana-Farber. Data on chemotherapy administered, supportive medications, relevant procedures, hospitalizations, clinic, infusion, and emergency room (ER) visits were collected retrospectively. Unit costs for each RU component were sought from the Centers for Medicare and Medicaid Website as well as relevant published sources. Utilization was compared between MVAC and GC using multivariate quantile regression (QR) analysis. Results: 147 pts were included; 51 received DD-MVAC and 86 GC. Baseline characteristics were similar, except lower mean age (59 vs 67 years, p < 0.001) and higher proportion of ECOG-PS = 0 (96.1% vs 60.5%, p < 0.001) for DD-MVAC. The mean cumulative cisplatin dosage was similar (DD-MVAC = 284 mg/m2, GC = 257 mg/m3). More DD-MVAC pts required G-CSF analogues (100% vs 32.6%, p < 0.001), central line placement (28.6% vs 11.8%, p = 0.017), and ER visits (35% vs 18%, p = 0.048). Infusion visits (12 vs 8/pt) and cardiac imaging (0.98 vs 0.58/pt, p < 0.001) were higher for DD-MVAC, whereas GC pts required more frequent clinic visits (mean of 9 vs 5/pt), chemotherapy cycle delays (30.2% vs 9.8%, p = 0.008) and hospitalization days (mean of 0.88 vs 0.49/pt). After adjusting for PS, the mean total cost/pt was higher for DD-MVAC ($17360 vs $12112, p < 0.001). Age was not statistically significant in the QR model (p = 0.628). Conclusions: DD-MVAC and GC exhibit different RU characteristics as NAC for MIBC. Although excess RU did not clearly favor one regimen, adjustment for PS indicated significant decrease in healthcare costs by approximately 30% using GC compared to DD-MVAC. Given that similar overall delivery of cumulative cisplatin dosage was feasible with both regimens, the values and costs affixed to different resources may impact the selection of DD-MVAC vs GC. Limitations were retrospective design and costs being specific to the US.
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Affiliation(s)
- Kamaneh Montazeri
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | - Kerry L. Kilbridge
- Lank Center for Genitourinary Malignancy, Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | - Guru Sonpavde
- Department of Genitourinary Oncology, Dana Farber Cancer Institute, Boston, MA
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24
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Montazeri K, Dranitsaris G, Curran C, Thomas JD, Ingham MD, Preston MA, Steele GS, Kilbridge KL, Wei XX, McGregor BA, Mossanen M, Sonpavde G. Resource utilization analysis of dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (DD-MVAC) versus gemcitabine-cisplatin (GC) as neoadjuvant chemotherapy (NAC) for muscle invasive bladder cancer (MIBC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.474] [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
474 Background: DD-MVAC and GC are commonly used NAC regimens for MIBC. While efficacy across studies appears similar, the resource utilization burdens have not been compared. Methods: We assessed the resource utilization and cost effectiveness of NAC with GC vs DD-MVAC for MIBC patients (pts) treated at Dana-Farber. Data on chemotherapy administered, supportive medications, relevant procedures, hospitalizations, clinic, infusion, and emergency room visits were collected retrospectively. Results: 147 patients were included, 51 in the DD-MVAC and 86 in the GC group. The two groups had similar baseline pt characteristics except lower mean age (59 vs 67 years, p<0.001) and higher proportion of ECOG-PS=0 (96.1% vs 60.5%, p<0.001) in the DD-MVAC group. The mean cumulative cisplatin dosages were similar (DD-MVAC=284 mg/m2, GC= 257 mg/m3). The DD-MVAC group exhibited a greater use of G-CSF analogues (100% vs 32.6%, p < 0.001), central line placement (28.6% vs 11.8%, p = 0.017), infusion visits/pt (12 vs 8), ER visits (35% vs 18%, p = 0.048), and cardiac imaging (0.98 vs 0.58/pt, p<0.001). Patients receiving GC were more likely to experience delayed chemotherapy cycles (30.2% vs 9.8%, p = 0.008) and required more frequent clinic visits (9 vs 5/pt). The frequency and duration of hospitalization (23.6% vs 13.7% and 0.88 vs 0.49 days/pt, p = 0.46) and rate of grade ≥3 toxicities (32.6% vs 45.1%, p = 0.18) were numerically but not statistically different between the GC and DD-MVAC group. Cost efficacy analysis is pending and will be presented. Conclusions: DD-MVAC and GC exhibit different characteristics in terms of resource utilization as NAC for MIBC. Importantly, excess resource utilization did not clearly favor one of the regimens, although the DD-MVAC group was younger with better ECOG-PS. Given that similar overall delivery of cumulative cisplatin dosage was feasible with both regimens, the values and costs affixed to different resources may impact the selection of DD-MVAC vs GC in different regions of the world.
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Affiliation(s)
- Kamaneh Montazeri
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | - Kerry L. Kilbridge
- Lank Center for Genitourinary Malignancy, Dana-Farber Cancer Institute, Boston, MA
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25
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Gibson EJ, Begum N, Koblbauer I, Dranitsaris G, Liew D, McEwan P, Yuan Y, Juarez-Garcia A, Tyas D, Pritchard C. Cohort versus patient level simulation for the economic evaluation of single versus combination immuno-oncology therapies in metastatic melanoma. J Med Econ 2019; 22:531-544. [PMID: 30638416 DOI: 10.1080/13696998.2019.1569446] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Model structure, despite being a key source of uncertainty in economic evaluations, is often not treated as a priority for model development. In oncology, partitioned survival models (PSMs) and Markov models, both types of cohort model, are commonly used, but patient responses to newer immuno-oncology (I-O) agents suggest that more innovative model frameworks should be explored. Objective: A discussion of the theoretical pros and cons of cohort level vs patient level simulation (PLS) models provides the background for an illustrative comparison of I-O therapies, namely nivolumab/ipilimumab combination and ipilimumab alone using patient level data from the CheckMate 067 trial in metastatic melanoma. PSM, Markov, and PLS models were compared on the basis of coherence with short-term clinical trial endpoints and long-term cost per QALY outcomes reported. Methods: The PSM was based on Kaplan-Meier curves from CheckMate 067 with 3-year data on progression free survival (PFS) and overall survival (OS). The Markov model used time independent transition probabilities based on the average trajectory of PFS and OS over the trial period. The PLS model was developed based on baseline characteristics hypothesized to be associated with disease as well as significant mortality and disease progression risk factors identified through a proportional hazards model. Results: The short-term Markov model outputs matched the 1-3 year clinical trial results approximately as well as the PSMs for OS but not PFS. The fixed (average) cohort PLS results corresponded as well as the PSMs for OS in the combination therapy arm and PFS in the monotherapy arm. Over the lifetime horizon, the PLS produced an additional 5.95 quality adjusted life years (QALYs) associated with combination therapy relative to ipilimumab alone, resulting in an incremental cost-effectiveness ratio (ICER) of £6,474 per QALY, compared with £14,194 for the PSMs which gave an incremental benefit of between 2.2 and 2.4 QALYs. The Markov model was an outlier (∼ £49,000 per QALY in the base case). Conclusions: The 4- and 5-state versions of the PSM cohort model estimated in this study deviate from the standard 3-state approach to better capture I-O response patterns. Markov and PLS approaches, by modeling state transitions explicitly, could be more informative in understanding I-O immune response, the PLS particularly so by reflecting heterogeneity in treatment response. However, both require a number of assumptions to capture the immune response effectively. Better I-O representation with surrogate endpoints in future clinical trials could yield greater model validity across all models.
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Affiliation(s)
| | | | | | | | - Danny Liew
- c Department of Epidemiology and Preventive Medicine , Monash University , Melbourne , Australia
| | - Phil McEwan
- d Health Economics and Outcomes Research Ltd , Cardiff , UK
| | - Yong Yuan
- e Bristol-Myers Squibb , Plainsboro , NJ , USA
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26
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Ryan P, McBride A, Ray D, Pulgar S, Ramirez RA, Elquza E, Favaro JP, Dranitsaris G. Lanreotide vs octreotide LAR for patients with advanced gastroenteropancreatic neuroendocrine tumors: An observational time and motion analysis. J Oncol Pharm Pract 2019; 25:1425-1433. [PMID: 30924737 PMCID: PMC6643159 DOI: 10.1177/1078155219839458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Indexed: 12/22/2022]
Abstract
BACKGROUND Lanreotide and octreotide acetate suspension for injectable (LAR) are both recommended for clinical use in patients with locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors. However, each agent possesses unique attributes in terms of their drug-delivery characteristics. The study objective was to compare overall drug-delivery efficiency between lanreotide and octreotide LAR in gastroenteropancreatic neuroendocrine tumor patients. METHODS This study employed an observational time and motion design among patients treated with lanreotide or octreotide LAR across five US cancer centers. Baseline patient data collection included age, disease grade and duration, prior therapies and performance status. Drug-delivery time (drug preparation and administration), total patient time and resource use data were collected for gastroenteropancreatic neuroendocrine tumors receiving lanreotide (n = 22) or octreotide LAR (n = 22). Following each administration, qualitative data on the drug-delivery experience was collected from patients and nurses. RESULTS Lanreotide was associated with a significant reduction in mean delivery time (2.5 min; 95% CI:2.0 to 3.1) compared to octreotide LAR (6.2 min; 95%CI: 4.4 to 7.9; p = 0.004). The mean total patient time for lanreotide and octreotide LAR was comparable between groups (32.1 vs. 36.6 minutes; p = 0.97). Nurses reported increased concerns with octreotide LAR related to needle clogging (p = 0.034) and device failures (p = 0.057). Overall, lanreotide had a median satisfaction score of 5.0 compared to a score of 4.0 with octreotide LAR (p = 0.03). CONCLUSIONS Lanreotide was associated with significant reductions in drug-delivery time compared to octreotide LAR, which contributed to an improvement in overall healthcare efficiency. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT03017690.
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Affiliation(s)
- P Ryan
- 1 Ochsner Medical Center, Kenner, LA, USA
| | - A McBride
- 2 University of Arizona Cancer Center, Tucson, AZ, USA
| | - D Ray
- 3 Ipsen Biopharmaceuticals, Inc., Basking Ridge, NJ, USA
| | - S Pulgar
- 3 Ipsen Biopharmaceuticals, Inc., Basking Ridge, NJ, USA
| | | | - E Elquza
- 2 University of Arizona Cancer Center, Tucson, AZ, USA
| | - J P Favaro
- 4 Oncology Specialists of Charlotte, Charlotte, NC, USA
| | - G Dranitsaris
- 5 Augmentium Pharma Consulting Inc., Toronto, Canada
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Edwards S, Abbott R, Dranitsaris G. Patient monitoring programs in oncology pharmacy practice: A survey of oncology pharmacists in Atlantic Canada. J Oncol Pharm Pract 2018; 25:891-895. [DOI: 10.1177/1078155218790801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background There has been a dramatic increase in new drug approvals in oncology, consisting of both small molecule inhibitors and monoclonal antibodies. However, Health Canada approval for many of the new agents was based on single randomized trials consisting of only a few hundred patients. As more patients get treated with these newer agents, there is the potential for new and discrete toxicities. Pharmacists are in an ideal position to identify, monitor, manage, and even preempt future events, given their close proximity to the patient. However, the extent of pharmacists’ involvement in formal patient programs is unknown. To address this knowledge gap, a survey of oncology pharmacists practicing in Atlantic Canada was conducted. Methods A structured mailing strategy was adopted as recommended by Dillman (1978). Standardized data collection forms were electronically mailed to 60 oncology pharmacists. Survey items consisted of respondent demographic information, practice setting, the existence of a formal patient monitoring program managed, and if patients are contacted by telephone following the completion of their anticancer cycle. Results Overall, 31 completed surveys were received, for an overall response rate of 50%. Respondents had a median age of 42 and a median of 18 years’ (range 1 to 25) professional experience as a pharmacist. Only 18 of the 31 (58%) respondents indicated that there was a formal monitoring and call back program managed by pharmacy available at their institution. For those without such programs, the main reasons were due to staffing issues and lack of adequately trained clinical personnel. Overall, 100% of respondents would favor the development of a formal monitoring program in hospitals with a high volume of anticancer drug prescribing. Conclusions Even though the number of new anticancer drugs being introduced into clinical pharmacy practice is increasing, formal patient monitoring and patient call back programs are not universal in Atlantic Canada hospitals.
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Affiliation(s)
- Scott Edwards
- Dr. H. Bliss Murphy Cancer Center, Eastern Health, St. John’s, Canada
- Memorial University, St. John’s, Canada
| | - Rick Abbott
- Dr. H. Bliss Murphy Cancer Center, St. John’s, Canada
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Dranitsaris G, Zhu X, Adunlin G, Vincent MD. Cost effectiveness vs. affordability in the age of immuno-oncology cancer drugs. Expert Rev Pharmacoecon Outcomes Res 2018; 18:351-357. [PMID: 29681201 DOI: 10.1080/14737167.2018.1467270] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 12/20/2022]
Abstract
INTRODUCTION After years of setback, cancer immunotherapy has begun to yield clinical dividends, which are changing the treatment landscape and offering cancer patients the potential for long-term survival, reduced treatment-related toxicity and improved quality-of-life. Using the immune system to treat cancer is known as 'Immuno-oncology' (IO) and agents are sub-classified by their ability to enhance anti-tumor response or to direct the immune system to attack cancer cells via tumor-associated antigens. Areas covered: Clinical trials have demonstrated the effectiveness of several IO agents in many disease sites such as early and advanced stage melanoma, advanced non-small cell lung cancer, bladder, head and neck, gastric, kidney as well as Hodgkin's lymphoma. Notwithstanding the therapeutic excitement generated for patients and clinicians alike, an important consideration is treatment cost, which can reach more than $US100,000 per patient annually. The cost of the drugs, coupled with high disease prevalence and the ever-expanding number of indications, means the current cost trajectory is untenable for most healthcare systems to sustain. Expert commentary: In this paper, the approved IO drugs and those in clinical development are reviewed. The issue of cost effectiveness vs. affordability is then addressed and suggestions that facilitate patient access and long-term sustainability are presented.
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Affiliation(s)
| | - Xiaofu Zhu
- b Cross Cancer Institute , Edmonton , Canada
| | - Georges Adunlin
- c School of Pharmacy , Samford University , Birmingham , AL , USA
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29
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Sonpavde G, Dranitsaris G, Necchi A. Improving the Cost Efficiency of PD-1/PD-L1 Inhibitors for Advanced Urothelial Carcinoma: A Major Role for Precision Medicine? Eur Urol 2018; 74:63-65. [PMID: 29653886 DOI: 10.1016/j.eururo.2018.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/21/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Guru Sonpavde
- Bladder Cancer Center, Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Andrea Necchi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
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Gibson EJ, Begum N, Koblbauer I, Dranitsaris G, Liew D, McEwan P, Tahami Monfared AA, Yuan Y, Juarez-Garcia A, Tyas D, Lees M. Modeling the economic outcomes of immuno-oncology drugs: alternative model frameworks to capture clinical outcomes. Clinicoecon Outcomes Res 2018; 10:139-154. [PMID: 29563820 PMCID: PMC5848668 DOI: 10.2147/ceor.s144208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Economic models in oncology are commonly based on the three-state partitioned survival model (PSM) distinguishing between progression-free and progressive states. However, the heterogeneity of responses observed in immuno-oncology (I-O) suggests that new approaches may be appropriate to reflect disease dynamics meaningfully. MATERIALS AND METHODS This study explored the impact of incorporating immune-specific health states into economic models of I-O therapy. Two variants of the PSM and a Markov model were populated with data from one clinical trial in metastatic melanoma patients. Short-term modeled outcomes were benchmarked to the clinical trial data and a lifetime model horizon provided estimates of life years and quality adjusted life years (QALYs). RESULTS The PSM-based models produced short-term outcomes closely matching the trial outcomes. Adding health states generated increased QALYs while providing a more granular representation of outcomes for decision making. The Markov model gave the greatest level of detail on outcomes but gave short-term results which diverged from those of the trial (overstating year 1 progression-free survival by around 60%). CONCLUSION Increased sophistication in the representation of disease dynamics in economic models is desirable when attempting to model treatment response in I-O. However, the assumptions underlying different model structures and the availability of data for health state mapping may be important limiting factors.
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Affiliation(s)
| | - N Begum
- Wickenstones Ltd, Didcot, UK
| | | | - G Dranitsaris
- Augmentium Pharma Consulting Inc, Toronto, ON, Canada
| | - D Liew
- Department of Epidemiology and Preventive Medicine, Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - P McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - AA Tahami Monfared
- Bristol-Myers Squibb Canada, Saint-Laurent, QC Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Y Yuan
- Bristol-Myers Squibb, Princeton, NJ, USA
| | | | - D Tyas
- Bristol-Myers Squibb, Uxbridge, UK
| | - M Lees
- Bristol-Myers Squibb, Rueil-Malmaison, France
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Dranitsaris G, Molassiotis A, Clemons M, Roeland E, Schwartzberg L, Dielenseger P, Jordan K, Young A, Aapro M. The development of a prediction tool to identify cancer patients at high risk for chemotherapy-induced nausea and vomiting. Ann Oncol 2018; 28:1260-1267. [PMID: 28398530 PMCID: PMC5452068 DOI: 10.1093/annonc/mdx100] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [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] [Indexed: 11/13/2022] Open
Abstract
Background Despite the availability of effective antiemetics and evidence-based guidelines, up to 40% of cancer patients receiving chemotherapy fail to achieve complete nausea and vomiting control. In addition to type of chemotherapy, several patient-related risk factors for chemotherapy-induced nausea and vomiting (CINV) have been identified. To incorporate these factors into the optimal selection of prophylactic antiemetics, a repeated measures cycle-based model to predict the risk of ≥ grade 2 CINV (≥2 vomiting episodes or a decrease in oral intake due to nausea) from days 0 to 5 post-chemotherapy was developed. Patients and methods Data from 1198 patients enrolled in one of the five non-interventional CINV prospective studies were pooled. Generalized estimating equations were used in a backwards elimination process with the P-value set at <0.05 to identify the relevant predictive factors. A risk scoring algorithm (range 0–32) was then derived from the final model coefficients. Finally, a receiver-operating characteristic curve (ROCC) analysis was done to measure the predictive accuracy of the scoring algorithm. Results Over 4197 chemotherapy cycles, 42.2% of patients experienced ≥grade 2 CINV. Eight risk factors were identified: patient age <60 years, the first two cycles of chemotherapy, anticipatory nausea and vomiting, history of morning sickness, hours of sleep the night before chemotherapy, CINV in the prior cycle, patient self-medication with non-prescribed treatments, and the use of platinum or anthracycline-based regimens. The ROC analysis indicated good predictive accuracy with an area-under-the-curve of 0.69 (95% CI: 0.67–0.70). Before to each cycle of therapy, patients with risk scores ≥16 units would be considered at high risk for developing ≥grade 2 CINV. Conclusions The clinical application of this prediction tool will be an important source of individual patient risk information for the oncology clinician and may enhance patient care by optimizing the use of the antiemetics in a proactive manner.
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Affiliation(s)
- G Dranitsaris
- The Ottawa Hospital Regional Cancer Centre, Ottawa, Canada
| | | | - M Clemons
- The Ottawa Hospital Regional Cancer Centre, Ottawa, Canada
| | - E Roeland
- UC San Diego Moores Cancer Center, La Jolla
| | | | - P Dielenseger
- Institut de Cancérologie Gustave Roussy, Villejuif, France
| | - K Jordan
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - A Young
- Cancer Research Center, University of Warwick, Conventry, UK
| | - M Aapro
- Cancer Center, Clinique de Genolier, Genolier, Switzerland
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Gibson E, Koblbauer I, Begum N, Dranitsaris G, Liew D, McEwan P, Tahami Monfared AA, Yuan Y, Juarez-Garcia A, Tyas D, Lees M. Modelling the Survival Outcomes of Immuno-Oncology Drugs in Economic Evaluations: A Systematic Approach to Data Analysis and Extrapolation. Pharmacoeconomics 2017; 35:1257-1270. [PMID: 28866758 PMCID: PMC5684270 DOI: 10.1007/s40273-017-0558-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND New immuno-oncology (I-O) therapies that harness the immune system to fight cancer call for a re-examination of the traditional parametric techniques used to model survival from clinical trial data. More flexible approaches are needed to capture the characteristic I-O pattern of delayed treatment effects and, for a subset of patients, the plateau of long-term survival. OBJECTIVES Using a systematic approach to data management and analysis, the study assessed the applicability of traditional and flexible approaches and, as a test case of flexible methods, investigated the suitability of restricted cubic splines (RCS) to model progression-free survival (PFS) in I-O therapy. METHODS The goodness of fit of each survival function was tested on data from the CheckMate 067 trial of monotherapy versus combination therapy (nivolumab/ipilimumab) in metastatic melanoma using visual inspection and statistical tests. Extrapolations were validated using long-term data for ipilimumab. RESULTS Modelled PFS estimates using traditional methods did not provide a good fit to the Kaplan-Meier (K-M) curve. RCS estimates fit the K-M curves well, particularly for the plateau phase. RCS with six knots provided the best overall fit, but RCS with one knot performed best at the plateau phase and was preferred on the grounds of parsimony. CONCLUSIONS RCS models represent a valuable addition to the range of flexible approaches available to model survival when assessing the effectiveness and cost-effectiveness of I-O therapy. A systematic approach to data analysis is recommended to compare the suitability of different approaches for different diseases and treatment regimens.
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Affiliation(s)
| | | | | | | | | | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Amir Abbas Tahami Monfared
- Bristol-Myers Squibb, Montreal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Yong Yuan
- Bristol-Myers Squibb, New Jersey, USA
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Chiarotto JA, Akbarali R, Bellotti L, Dranitsaris G. A structured group exercise program for patients with metastatic cancer receiving chemotherapy and CTNNB1 (β-catenin) as a biomarker of exercise efficacy. Cancer Manag Res 2017; 9:495-501. [PMID: 29075139 PMCID: PMC5648300 DOI: 10.2147/cmar.s147054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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] [Indexed: 12/14/2022] Open
Abstract
Introduction Exercise can improve the symptoms of cancer. However, is it a cancer treatment? We tested the feasibility of group exercise for metastatic cancer patients while on chemotherapy. A biomarker for exercise efficacy in colorectal cancer (CRC), β-catenin, was tested. Methods Patients undergoing palliative chemotherapy were eligible for a pre–post, single-arm study comprising an indefinite, weekly group exercise intervention using strength and aerobic training. The Functional Assessment of Chronic Illness Therapy (FACIT) and Piper Fatigue Scale (PFS) questionnaires were administered, and aerobic capacity assessed using the 6-minute walk test. Selection bias, as measured by invitation rate, as well as participation, compliance, and attrition rates, was measured. CRC patients had surgical sections stained for β-catenin and correlated to survival. The statistical analysis was primarily exploratory and hypothesis generating. Results Of the 124 eligible patients, 53 (43%) patients were invited and 35 (28%) patients participated. The median number of classes attended was 16, the compliance rate was 73.1% (95% confidence interval [CI] 67.0–79.4), and the modified attrition rate was 24%. There were no injuries. No significant improvements were seen in the FACIT or PFS at 30 weeks. Aerobic capacity significantly improved at 30 weeks. Participation of CRC patients in the exercise pilot vs nonparticipation was not associated with a change in survival (hazard ratio [HR] =0.98, 95% CI 0.32–2.97). For all CRC patients, strong nuclear staining for β-catenin, compared to weak, suggested a lower risk of mortality (HR =0.54, 95% CI 0.14–1.96). However, CRC participants in the exercise program with weak nuclear staining for β-catenin had a trend to lower mortality (HR =0.39, 95% CI 0.025–6.1). Conclusion Exercise for patients with metastatic cancer receiving chemotherapy is feasible and safe. β-Catenin is a potential biomarker for exercise anticancer effect in CRC.
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Affiliation(s)
| | - Riyad Akbarali
- Department of Cardiac Rehabilitation, Scarborough and Rouge Hospital
| | - Lara Bellotti
- Department of Cardiac Rehabilitation, Scarborough and Rouge Hospital
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Dranitsaris G, Jacobs I, Kirchhoff C, Popovian R, Shane LG. Drug tendering: drug supply and shortage implications for the uptake of biosimilars. Clinicoecon Outcomes Res 2017; 9:573-584. [PMID: 29033595 PMCID: PMC5628685 DOI: 10.2147/ceor.s140063] [Citation(s) in RCA: 26] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Due to the continued increase in global spending on health care, payers have introduced a number of programs, policies, and agreements on pharmaceutical pricing in order to control costs. While incentives to increase generic drug use have achieved significant savings, other cost-containment measures are required. Tendering is a formal procedure to purchase medications using competitive bidding for a particular contract. Although useful for cost containment, tendering can lead to decreased competition in a given market. Consequently, drug shortages can occur, resulting in changes to treatment plans to products that may have lower efficacy and/or an increased risk of adverse effects. Therefore, care must be taken to ensure that tendering does not negatively impact patient care or the health care system. A large and expanding portion of total pharmaceutical expenditure is for biologic therapies. These agents have revolutionized the treatment of many diseases, including cancer and inflammatory conditions; however, patient access to biologic drugs can be limited due to availability, insurance coverage, and cost. As branded biologic therapies reach the end of patent- and data-protection periods, biosimilars are being approved as lower-cost alternatives. Biosimilars are products that are highly similar to the originator product with no clinically meaningful differences in terms of safety, purity, or potency. As more biosimilars receive regulatory approval and adoption increases, these therapies are expected to have an impact on global health care spending and should result in overall savings. However, the use of tendering to maximize the potential benefits of biosimilars has varied across the world. Therefore, the objectives of this review are to examine the drug-tendering process and its implications on drug supply and drug shortages, as well as to describe biosimilars and how tendering may influence their uptake.
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Affiliation(s)
| | - Ira Jacobs
- Global Medical Affairs, Pfizer Inc, New York, NY
| | - Carol Kirchhoff
- Global Technology Services, Biotechnology and Aseptic Sciences Group, Pfizer Inc, Chesterfield, MO
| | | | - Lesley G Shane
- Outcomes and Evidence, Global Health and Value, Pfizer Inc, New York, NY, USA
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Dranitsaris G, Shane LG, Woodruff S. Low-molecular-weight heparins for the prevention of recurrent venous thromboembolism in patients with cancer: A systematic literature review of efficacy and cost-effectiveness. J Oncol Pharm Pract 2017; 25:68-75. [PMID: 28857713 PMCID: PMC6262601 DOI: 10.1177/1078155217727140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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] [Indexed: 01/03/2023]
Abstract
Background Patients with cancer have an elevated risk of venous thromboembolism. Importantly, patients with cancer, who have metastatic disease, renal insufficiency, or are receiving anticancer therapy, have an even higher risk of a recurrent event. Similarly, the risk of recurrent venous thromboembolism is higher than the risk of an initial event. To reduce the risk, extended duration of prophylaxis for up to six months with low-molecular-weight heparins such as dalteparin, enoxaparin, nadroparin, and tinzaparin is recommended by international guidelines. In this paper, the clinical and economic literature is reviewed to provide evidenced based recommendations based on clinical benefit and economic value. Methods A systematic review of major databases was conducted from January 1996 to October 2016 for randomized controlled trials evaluating the four distinct low-molecular-weight heparins against a vitamin K antagonists control group for the prevention of recurrent venous thromboembolism in patients with active cancer. This was then followed by the application of the National Institute of Health and Clinical Excellence guidance to assess the quality of all trials that met the inclusion criteria. Finally, the cost-effectiveness literature supporting the value proposition of each product was reviewed. Results Six randomized trials met the inclusion criteria. There were one, two, and three trials that compared dalteparin, tinzaparin, and enoxaparin to a vitamin K antagonists control group. However, there were no trials for nadroparin in the setting of secondary venous thromboembolism prevention. In addition, only the dalteparin and one of the tinzaparin trials were of high quality and adequately powered. Of the two studies, only the dalteparin trial reported a statistically significant benefit in terms of venous thromboembolism absolute risk reduction when compared to a vitamin K antagonists control group (HR = 0.48; p = 0.002). In addition, there was robust pharmacoeconomic data from Canada, the Netherlands, France, and Austria supporting the cost-effectiveness of dalteparin for this indication. There were no such studies for any of the other agents. Conclusions The totality of high-quality clinical and cost-effectiveness data supports the use of dalteparin over other low-molecular-weight heparins for preventing recurrent venous thromboembolism in patients with cancer.
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Thavorn K, Coyle D, Hoch JS, Vandermeer L, Mazzarello S, Wang Z, Dranitsaris G, Fergusson D, Clemons M. A cost-utility analysis of risk model-guided versus physician’s choice antiemetic prophylaxis in patients receiving chemotherapy for early-stage breast cancer: a net benefit regression approach. Support Care Cancer 2017; 25:2505-2513. [DOI: 10.1007/s00520-017-3658-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
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Dranitsaris G, Shane LG, Galanaud JP, Stemer G, Debourdeau P, Woodruff S. Dalteparin or vitamin K antagonists to prevent recurrent venous thromboembolism in cancer patients: a patient-level economic analysis for France and Austria. Support Care Cancer 2017; 25:2093-2102. [PMID: 28204995 DOI: 10.1007/s00520-017-3610-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 09/23/2016] [Accepted: 02/06/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND International guidelines recommend extended duration secondary prophylaxis in cancer patients who develop primary venous thromboembolism (VTE). Agent selection is guided in part by one large randomized trial (i.e., CLOT; Lee et al., N Engl J Med 349:146-53, 2003) which demonstrated that dalteparin reduced the relative risk of recurrence by 52% compared with oral vitamin K antagonists (VKA; HR = 0.48, 95% CI, 0.30 to 0.77). In a subgroup analysis from that same trial, patients with renal impairment also derived benefit with dalteparin (VTE rates = 3% vs. 17%; p = 0.011). To measure the economic value of secondary VTE prophylaxis with dalteparin, a patient-level pharmacoeconomic analysis was conducted from the Austrian and French healthcare system perspectives. METHODS Chapter 1 Healthcare resource use collected during the CLOT trial was extracted and converted into direct cost estimates. Incremental cost differences between the dalteparin and VKA groups were then combined with health state utilities to measure the cost per quality-adjusted life year (QALY) gained. RESULTS The dalteparin group had significantly higher costs than the VKA group in both countries (Austria: dalteparin = €2687 vs. VKA = €2012; France: dalteparin = €2053 vs. VKA = €1352: p < 0.001). However, when the incremental costs were combined with the utility gain, dalteparin had a cost of €6600 and €4900 per QALY gained in Austria and France, respectively. The analyses in patients with renal impairment suggested an even better economic profile, with the cost per QALY gained being less than €4000 in both countries. CONCLUSIONS Secondary prophylaxis with dalteparin is a cost-effective alternative to VKA for the prevention of recurrent VTE in patients with cancer.
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Affiliation(s)
- George Dranitsaris
- Augmentium Pharma Consulting Inc, 283 Danforth Ave, Suite 448 M4K 1N2, Toronto, Canada.
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Dranitsaris G, Shane LG, Crowther M, Feugere G, Woodruff S. Dalteparin versus vitamin K antagonists for the prevention of recurrent venous thromboembolism in patients with cancer and renal impairment: a Canadian pharmacoeconomic analysis. Clinicoecon Outcomes Res 2017; 9:65-73. [PMID: 28138260 PMCID: PMC5237592 DOI: 10.2147/ceor.s126379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Patients with cancer are at increased risk of venous thromboembolism (VTE) and the risk is further elevated after a primary VTE. To reduce the risk of recurrent events, extended prophylaxis with vitamin K antagonists (VKA) is available for use. However, in a large randomized trial (Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer [CLOT]; Lee et al), extended duration dalteparin reduced the relative risk of recurrent VTE by 52% compared to VKA (p=0.002). A recent subgroup analysis of patients with moderate-to-severe renal impairment also revealed lower absolute VTE rates with dalteparin (3% vs. 17%; p=0.011). To measure the economic value of dalteparin as an alternative to VKA, a patient-level cost utility analysis was conducted from a Canadian perspective. Methods Resource use data captured during the CLOT trial were extracted and linked to 2015 Canadian unit cost estimates. Health state utilities were then measured using the Time-Trade-Off technique in 24 randomly selected members of the general Canadian public to estimate the gains in quality-adjusted life years (QALYs). Results For the entire CLOT trial population (n=676), the dalteparin group had significantly higher mean costs compared to the VKA group ($Can5,771 vs. $Can2,569; p<0.001). However, the utility assessment revealed that 21 of 24 respondents (88%) selected dalteparin over VKA, with an associated gain of 0.14 (95% confidence interval [CI]: 0.10–0.18) QALYs. When the incremental cost of dalteparin was combined with the QALY gain, dalteparin had a cost of $Can23,100 (95% CI: $Can19,200–$Can25,800) per QALY gained. The analysis in patients with renal impairment suggested even better economic value with the cost per QALY gained being <$14,000. Conclusion Extended duration dalteparin is a cost-effective alternative to VKA for the prevention of recurrent VTE in patients with cancer, especially in those with renal impairment.
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Affiliation(s)
- George Dranitsaris
- Health Economic and Outcomes Research, Augmentium Pharma Consulting Inc, Toronto, ON, Canada
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Dranitsaris G, Molasiotis A, Clemons M, Roeland E, Schwartzberg L, Warr D, Jordan K, Dielenseger P, Aapro M. Identifying cancer patients at high risk for chemotherapy-induced nausea and vomiting (CINV): the development of a prediction tool. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw390.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Shane L, Dranitsaris G, Woodruff S, Galanaud JP, Stemer G, Debourdeau P, Valtier B, Burgers L. Dalteparin vs. vitamin K antagonist (VKA) for the prevention of recurrent venous thromboembolism (VTE) in cancer patients with renal insufficiency: A patient level pharmacoeconomic analysis in three European countries. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw377.20] [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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Dranitsaris G, Castel LD, Baladi JF, Schulman KA. Zoledronic acid versus pamidronate as palliative therapy in cancer patients: A Canadian time and motion analysis. J Oncol Pharm Pract 2016. [DOI: 10.1191/1078155201jp077oa] [Citation(s) in RCA: 10] [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: 11/05/2022]
Abstract
Pamidronate was an important advance in the palliative treatment of patients with cancer. However, pamidronate must be infused over at least 2 hours in most patients. Zoledronic acid represents the next-generation bisphosphonate with a potential for improved efficacy in the palliative care setting. One important advantage of zoledronic acid is that it can be administered over a 15-minute infusion. To measure the overall efficiency of zoledronic acid as compared with pamidronate in the outpatient setting, a USA microcosting model was adapted to Canadian inputs. Time and motion data were collected from six patients being treated with zoledronic acid or pamidronate in three USA outpatient cancer clinics. Resource use and time impact on outpatient clinical staff were reanalyzed using Canadian cost estimates. This included the evaluation of fixed, variable, and labour costs obtained from Canadian sources. The manufacturer provided drug costs. The base case analysis assumed a 5300-ft2 out-patient chemotherapy clinic with eight infusion chairs designated for bisphosphonate administration in the province of Ontario. Mean treatment times in the original USA data collected were 2 hours, 52 minutes for pamidro-nate, and 1 hour, 6 minutes for zoledronic acid (a difference of 1 hour, 46 minutes). In the Canadian version of the microcosting model, the overall treatment cost was Can$673 for pamidronate and Can$682 for zoledronic acid (2001 Canadian dollars). Findings suggest that the shorter zoledronic acid infusion time would allow an additional 27 bisphosphonate patients to be treated per day. Alternatively, approximately one additional hour of chair time could be made available with each zoledonic acid infusion. Sensitivity analyses revealed that (a) the base case results were consistent when geographic region was varied, and (b) the shorter the infusion time for zoledronic acid relative to pamidronate, the lesser the cost difference and more patients could be treated daily. In conclusion, zoledronic acid may enhance the overall efficiency of outpatient chemotherapy clinics by reducing patient waiting time for bisphosphonate administration. These benefits would be obtained at an incremental cost of Can$9 per infusion.
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Affiliation(s)
- George Dranitsaris
- Ontario Cancer Institute and Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Liana D Castel
- Duke University Medical Center, Durham, North Carolina; and Inc., Dorval, Quebec
| | | | - Kevin A Schulman
- Duke University Medical Center, Durham, North Carolina; and Inc., Dorval, Quebec
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Dranitsaris G, Johnston M, Poirier S, Schueller T, Milliken D, Green E, Zanke B. Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and meta-analysis of the literature. J Oncol Pharm Pract 2016; 11:69-78. [PMID: 16465719 DOI: 10.1191/1078155205jp155oa] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [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: 11/05/2022]
Abstract
Objective. A systematic review and meta-analysis was conducted to test the hypothesis that oncology health care workers are at an increased risk of cancer, reproductive complications and acute toxic events. Design. A structured literature search of Index Medicus/MEDLINE, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews and Healthstar was performed from 1966 to December 2004 for human epidemiological studies evaluating the risk of toxic events in health care workers exposed to cytotoxic drugs. Raw data and adjusted odds ratios (OR) reported in eligible studies were combined using a random effects model to calculate point estimates and 95% confidence intervals (CI) for each potential risk outcome. Main outcome measures. Adjusted OR for congenital malformations, stillbirths and spontaneous abortions among health care workers exposure to cytotoxic agents compared to a non-exposed control group. Results. The systematic review identified 14 studies evaluating the outcomes of interest, seven of which were suitable for statistical pooling. Due to lack of evidence, we were unable to estimate a pooled OR for the risk of cancer and acute toxic events. However, no significant association was detected between exposure to cytotoxic drugs and; congenital malformations (OR=1.64; 95% CI: 0.91-2.94) and stillbirths (OR=1.16; 95% CI: 0.73-1.82). In contrast, an association was identified between exposure to chemotherapy and spontaneous abortions (OR=1.46; 95% CI: 1.11-1.92). Conclusions. The results of this systematic review identified a small incremental risk for spontaneous abortions in female staff working with cytotoxic agents. Health policy decision makers should effectively communicate the magnitude of this risk to their staff and implement cost effective interventions for its reduction or elimination.
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Affiliation(s)
- George Dranitsaris
- Cancer Care Ontario, 429 Danforth Ave, Suite 476, Toronto, Canada, M4K 1P1.
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Dranitsaris G, Shane L, Burgers L, Woodruff S. Economic Analysis Comparing Dalteparin to Vitamin K Antagonists to Prevent Recurrent Venous Thromboembolism in Patients With Cancer Having Renal Impairment. Clin Appl Thromb Hemost 2016; 22:617-26. [PMID: 27436663 DOI: 10.1177/1076029616658118] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In a randomized trial (ie, Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer [CLOT]) that evaluated secondary prophylaxis of recurrent venous thromboembolism (VTE) in patients with cancer, dalteparin reduced the relative risk by 52% compared to oral vitamin K antagonists (VKAs; hazard ratio = 0.48, P = .002). A recent subgroup analysis in patients with moderate to severe renal impairment also revealed lower absolute VTE rates with dalteparin (3% vs 17%; P = .011). To measure the economic value of dalteparin in these populations, a pharmacoeconomic analysis was conducted from the Dutch health-care system perspective. METHODS Resource utilization data contained within the CLOT trial database were extracted and converted into direct cost estimates. Univariate analysis was then conducted to compare the total cost of therapy between patients randomized to dalteparin or VKA therapy. Health state utilities were then measured in 24 members of the general public using the time trade-off technique. RESULTS When all of the cost components were combined for the entire population (n = 676), the dalteparin group had significantly higher overall costs than the VKA control group (dalteparin = €2375 vs VKA = €1724; P < .001). However, dalteparin was associated with a gain of 0.14 (95% confidence interval [CI]: 0.10-0.18) quality-adjusted life years (QALYs) over VKA. When the incremental cost was combined with the utility gain, dalteparin had a cost of €4,697 (95% CI: €3824-€4951) per QALY gained. CONCLUSION Secondary prophylaxis with dalteparin is a cost-effective alternative to VKA for the prevention of recurrent VTE in patients with cancer.
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Affiliation(s)
| | | | - Laura Burgers
- Pfizer Netherlands, Rivium Westlaan, the Netherlands
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Abstract
Background. Cancer patients undergoing chemotherapy are at an increased risk for anemia. Hence, they are high consumers of allogenic blood transfusions. In 1997, an economic evaluation was undertaken at the Princess Margaret Hospital to estimate the cost of a transfusion in cancer patients. The analysis relied on published costing information and on an internal review of patient resource utilization. Overall, the cost of a blood transfusion was estimated at Can$599. Since 1997, there have been some major changes in the management of Canada's blood supply and within the Princess Margaret Hospital. Methods. In order to evaluate how these changes affected the cost of a transfusion in cancer patients, the original 1997 economic database was reanalyzed using updated 1999 costing information obtained from Canadian Blood Services (CBS) and from the Princess Margaret Hospital. Results. The reanalysis suggested that the cost of a blood transfusion in cancer patients increased from Can$599 in 1997 to Can$731 in 1999. The major incremental costs responsible for this increase were additional screening tests, increased opportunity costs for donors and a modest rise in distribution and administration within the hospital. Costs that were no longer relevant in 1999 were the cost of treating transfusion-related infections. Conclusions. These results support the findings of the original publication that a unit of blood is a highly resource intensive commodity which requires that each blood unit be used appropriately. Therefore, preventative strategies that would reduce the use of blood products have to be identified and implemented.
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Affiliation(s)
- George Dranitsaris
- Health Economics and Outcomes Research Unit, Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Canada
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Dranitsaris G. Review : Statistical methods in clinical research: A review for pharmacists. J Oncol Pharm Pract 2016. [DOI: 10.1177/107815529800400303] [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: 11/17/2022]
Abstract
Objective. Pharmacists have been recognized as both clinicians and researchers. As clinicians, they have to be able to critically review the results of clinical trials and to determine whether the fmdings of these studies were justified based on the methodology. As investigators, pharmacists must select the appropriate research design to answer the main study hypothesis. This paper will review basic statistical concepts that the oncology pharmacist can use to evaluate clinical trials and to design research studies. Data Sources. A variety of articles accessed from a MEDLINE search and statistical reference texts were used. Data Extraction. The information was re viewed, and statistical concepts relevant to oncology pharmacy practice were included. Data Synthesis. The concepts of descriptive and inferential statistics are presented. Detailed nu merical examples of how differences between two independent groups can be evaluated for statistical significance are provided. Similarities and differences between hypothesis testing and estimation are also highlighted.
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Affiliation(s)
- George Dranitsaris
- Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Ontario, Canada
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Dranitsaris G, Shane L, Woodruff S, Burgers L. Pharmacoeconomic analysis of dalteparin vs. vitamin k antagonists (VKA) for the prevention of recurrent venous thromboembolism (VTE) in cancer patients with renal insufficiency. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e18238] [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: 11/20/2022] Open
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Adunlin G, Dranitsaris G. Correlation between progression free survival and overall survival in patients with metastatic breast cancer receiving anthracyclines, taxanes or targeted therapies: A trial level meta-analysis. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.1066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
Affiliation(s)
- Georges Adunlin
- Virginia Commonwealth University, Department of Health Behavior and Policy, Richmond, VA
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Fraser I, Burger J, Lubbe M, Dranitsaris G, Sonderup M, Stander T. Cost-Effectiveness Modelling of Sofosbuvir-Containing Regimens for Chronic Genotype 5 Hepatitis C Virus Infection in South Africa. Pharmacoeconomics 2016; 34:403-417. [PMID: 26666639 DOI: 10.1007/s40273-015-0356-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The recently launched nucleotide polymerase inhibitor sofosbuvir represents a significant turn in the treatment paradigm of chronic hepatitis C. While effective, sofosbuvir is also associated with a considerable cost. OBJECTIVE The objective of this study was to evaluate the cost effectiveness of sofosbuvir-containing regimens in treatment-naive patients with chronic hepatitis C virus (HCV) genotype 5 (HCV-G5) mono-infection in South Africa (SA). DESIGN We constructed a lifetime horizon decision-analytic Markov model of the natural history of HCV infection to evaluate the cost effectiveness of sofosbuvir-ledipasvir (SOF/LDV) monotherapy against sofosbuvir triple therapy (SOF-TT) (sofosbuvir + pegylated interferon and ribavirin [peg-INF/RBV]) and the current standard of care (SOC) (peg-INF/RBV) for patients with chronic HCV-G5 in the South African context. The model was populated with data from published literature, expert opinion and South African private sector cost data. The price modelled for sofosbuvir was the predicted South African private sector price of 82,129.32 South African rand (R) (US$7000) for 12 weeks. The analysis was conducted from a third-party payer perspective. OUTCOME MEASURES The outcome measures were discounted and undiscounted costs (in 2015 South African rand and US dollars) and quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS Outcomes from the cost-effectiveness model show that SOF/LDV yields the most favourable future health economic outcomes compared with SOF-TT and the current SOC in SA. Findings relating to the lifetime incremental cost per QALY gained for patients infected with HCV-G5 indicate that SOF/LDV dominated both SOF-TT and SOC, i.e. SOF/LDV is less costly and more effective. CONCLUSION Outcomes from this analysis suggest that at a price of R123,190 ($US10,500) for 12 weeks of SOF/LDV might be cost effective for South African patients infected with HCV-G5.
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Affiliation(s)
- Ilanca Fraser
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University (Potchefstroom Campus), Potchefstroom, South Africa
| | - Johanita Burger
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University (Potchefstroom Campus), Potchefstroom, South Africa.
| | - Martie Lubbe
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University (Potchefstroom Campus), Potchefstroom, South Africa
| | | | - Mark Sonderup
- Department of Medicine and Division of Hepatology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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Clemons M, Bouganim N, Smith S, Mazzarello S, Vandermeer L, Segal R, Dent S, Gertler S, Song X, Wheatley-Price P, Dranitsaris G. Risk Model–Guided Antiemetic Prophylaxis vs Physician’s Choice in Patients Receiving Chemotherapy for Early-Stage Breast Cancer. JAMA Oncol 2016; 2:225-31. [DOI: 10.1001/jamaoncol.2015.3730] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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)
- Mark Clemons
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada2Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathaniel Bouganim
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephanie Smith
- Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasha Mazzarello
- Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Vandermeer
- Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Roanne Segal
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Susan Dent
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stan Gertler
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Xinni Song
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Paul Wheatley-Price
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - George Dranitsaris
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
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Ng T, Mazzarello S, Wang Z, Hutton B, Dranitsaris G, Vandermeer L, Smith S, Clemons M. Choice of study endpoint significantly impacts the results of breast cancer trials evaluating chemotherapy-induced nausea and vomiting. Breast Cancer Res Treat 2016; 155:337-44. [PMID: 26732944 DOI: 10.1007/s10549-015-3669-8] [Citation(s) in RCA: 12] [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: 10/15/2015] [Accepted: 12/25/2015] [Indexed: 10/22/2022]
Abstract
Multiple endpoints can be used to evaluate chemotherapy-induced nausea and vomiting (CINV). These endpoints reflect the various combinations of vomiting, nausea and rescue antiemetic use in the acute (0-24 h), delayed (>24-120 h) and overall (0-120 h) periods after chemotherapy. As the choice of outcome measure could potentially change the interpretation of clinical trial results, we evaluated CINV rates using different endpoints on a single dataset from a prospective cohort. Data from 177 breast cancer patients receiving anthracycline and cyclophosphamide-based chemotherapy was used to calculate CINV control rates using the 15 most commonly reported CINV endpoints. As nausea remains such a significant symptom, we explored the frequency at which pharmaceutical and non-pharmaceutical company-funded studies included measures of nausea in their primary study endpoint. CINV control rates ranged from 12.5 %, 95 % (CI 7.6-17.4 %) for total control (no vomiting, no nausea and no rescue medication) in the overall period to 77.4 %, 95 % (CI 71.2-83.6 %) for no vomiting in the overall period. Similar differences were found in the acute and delayed periods. Non-pharmaceutical company-funded trials were more likely to include a measure of nausea in the primary study outcome (9/18, 50 %) than pharmaceutical-funded trials (1/12, 8.3 %). The choice of trial endpoint has an important impact on reported CINV control rates and could significantly impact on interpretation of the results. Primary endpoints of studies, including those mandated by regulatory bodies, should account for nausea to reflect patient experience. Reporting of endpoints should be more comprehensive to allow for cross-trial comparisons.
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Affiliation(s)
- Terry Ng
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H8L6, Canada
| | | | - Zhou Wang
- Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Epidemiology, The Ottawa Hospital, Ottawa, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | | | | | | | - Mark Clemons
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H8L6, Canada. .,Ottawa Hospital Research Institute, Ottawa, Canada.
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