Real-world treatment patterns, clinical outcomes, and health care resource utilization in advanced unresectable hepatocellular carcinoma

BACKGROUND: The incidence of advanced unresectable hepatocellular carcinoma (HCC) is increasing in developed countries and the prognosis of advanced HCC remains poor. Real-world evidence of treatment patterns and outcomes can highlight the unmet clinical need. METHODS: We conducted a retrospective population-based cohort study of patients with advanced unresectable HCC diagnosed in Alberta, Canada (2008-2018) using electronic medical records and administrative claims data. A chart review was conducted on patients treated with systemic therapy to capture additional information related to treatment. RESULTS: A total of 1,297 advanced HCC patients were included of whom 555 (42.8%) were recurrent cases and the remainder were unresectable at diagnosis. Median age at diagnosis was 64 (range 21-94) years and 82.1% were men. Only 274 patients (21.1%) received first-line systemic therapy and, of those, 32 patients (11.7%) initiated second-line therapy. Nearly all of the patients received sorafenib (>96.4%) in first-line, and these patients had considerably higher median survival (12.23 months; 95% CI 10.72-14.10) compared with patients not treated with systemic therapy (2.66 months; 95% CI 2.33-3.12; log-rank p <0.001). Among patients treated with systemic therapy, overall survival was higher for recurrent cases, patients with Child-Pugh A functional status, and patients with HCV or multiple known HCC risk factors (p <0.05). CONCLUSIONS: In a Canadian real-world setting, patients who received systemic therapy had greater survival than those who did not, but outcomes were universally poor. These results underscore the need for effective front-line therapeutic options.

Real-world treatment patterns, clinical outcomes, and health care resource utilization in advanced unresectable hepatocellular carcinoma

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Background: The incidence of advanced unresectable hepatocellular carcinoma (HCC) is increasing in several developed countries and the prognosis of advanced HCC remains poor. Real-world evidence of treatment patterns and patient outcomes can highlight the unmet clinical need within this population. Methods: We conducted a retrospective population-based cohort study of advanced unresectable HCC patients diagnosed in Alberta, Canada between 2008-2018 using electronic medical records and administrative claims data. A chart review was conducted among patients treated with systemic therapy to capture additional treatment information that is not available in the administrative data. The objectives of this study were to describe the treatment patterns, overall survival, and healthcare resource utilization of advanced HCC patients. Results: A total of 1,297 advanced HCC patients were included in this study, of which 555 (42.8%) were recurrent cases and the remainder were advanced unresectable cases at diagnosis. Median age at diagnosis was 64 (range: 21-94) and 82.1% were men. Only 274 patients (21.1%) received first-line systemic therapy and of those 32 patients (11.7%) initiated second-line therapy. Nearly all of the patients treated with systemic therapy received sorafenib (> 96.4%) in first-line and over half of these patients (55.8%) had a dose reduction during the course of treatment. Patients who received systemic therapy had considerably higher median overall survival (12.23 months; 95% CI: 10.72-14.10) compared to patients not treated with systemic therapy (2.66 months; 95% CI: 2.33-3.12; log-rank p-value < 0.001). Among patients who received first-line systemic therapy, the 2-year and 5-year survival rates were 17.9% (95% CI: 13.7-23.4) and 3.9% (95% CI: 1.8-8.6), respectively. Among patients treated with systemic therapy, overall survival was highest for recurrent cases, patients with Child-Pugh A, patients with hepatitis C virus or multiple known HCC risk factors, and for recurrent patients who received transarterial chemoembolization and ablation (separate procedures) in early stage (log-rank: p < 0.05). No significant differences in survival were observed for dose reduction in first-line therapy, age group, sex, the presence of cirrhosis, or the presence of metastatic disease (log-rank: p > 0.05). Among patients that received first-line systemic therapy, the average time spent in hospital was 9, 9, and 8 days per patient within years 1, 2, and 3, respectively. Conclusions: In a Canadian real-world setting, patients who received systemic therapy had considerably greater survival than those who did not, but the initiation rate was low and dose reductions were common. The low uptake of systemic therapy and the modest survival gains highlight the importance of earlier diagnosis and the need for novel and more effective first-line therapies.

Abstract P3-12-01: Value-based approach to treatment of HER2-positive breast cancer: Examining the evidence

Outcomes of HER2-positive breast cancer have improved significantly with use of targeted therapies. Survival in both early (EBC) and metastatic breast cancer (MBC) has improved along with gains in quality of life. With increasing costs of cancer care, it became imperative that health systems evaluate cost-effectiveness and value provided by new therapies.

Methods: We conducted a review of 'value' utilizing the ASCO 2015, ASCO 2016 (revised) and ESMO framework for all currently available HER2 targeted therapies. We performed a systematic review of cost-effectiveness analyses (CEAs) of these therapies across the neoadjuvant, adjuvant, and metastatic disease settings. We included economic evaluations from published literature and government agencies involved in drug-approval assessments from NICE (UK), pCODR (Canada), and PBAC (Australia).

Results: 22 studies evaluating 1-year of trastuzumab (H) in EBC were identified. Of these, 17 found the regimen cost-effective (CE). Three of 22 plus an additional 1 evaluated 9 weeks H, all of which found it CE. NICE and PBAC determined adjuvant H to be CE, consistent with clinical benefit (Table 1). There are currently no academic CEAs of neoadjuvant pertuzumab (P). It has been evaluated in drug-approval processes by NICE and pCODR, both finding cost-effectiveness highly uncertain. In MBC, 6 studies evaluating H for first line were identified. The combination with chemotherapy was CE in 3 of 4 studies, whereas monotherapy and combination with anastrazole were not. A total of 9 studies evaluating lapatinib for MBC were identified. While it was CE combined with capecitabine for second line, in all other combinations it was not. Two studies evaluating P for MBC did not find the regimen CE, despite significant clinical benefit. However, PBAC considers the regimen CE and pCODR recommended funding based on net clinical benefit, whereas NICE did not. No academic CEAs of trastuzumab emtansine (T-DM1) in the literature were identified however cost-effectiveness in second line has been evaluated by pCODR, NICE and PBAC. All groups found it not CE, even with very high clinical benefit (Table 1).

Table 1: ASCO Net Health Benefit (NHB), modified NHB (mNHB) and ESMO Magnitude of Clinical Benefit Score (MCBS) for landmark trials in HER2+ breast cancer compared with cost-effectivenessStudySettingRegimenNHBmNHBMCBSCost-EffectiveNeoSphereEBC (Neoadjuvant)DH+/- P-&gt;surgery-&gt;FECNA*NA*NA*-TRYPHAENA"DCH+P-&gt;surgeryNANANA-NSABP-B31/NCCTGN9831EBC (Adjuvant)AC-based chemo +/- H4828AYFinHer"FEC based chemo +/- H x 9 weeksNA*NA*NA*YHERA"Chemo +/- 1y H3226AYSlamon et alMBC (1st line)TH vs T1617.72YCLEOPATRA"DHP vs. DH32324NTanDEM"Anastrozole +/- H2213.93NJohnston et al"Letrozole +/- Lapatinib5513.61NEMILIAMBC (2nd line)T-DM1 vs. lapatinib + cape4246.45NEGF100151MBC (&gt;/=2nd line)Cape + lapatinib vs. cape alone1629.44N* = Not significant

Conclusion: While there is consistent value provided by Her2 targeted therapies, there is generally lack of support for these in MBC based on cost-effectiveness analysis. We need to work towards a model that integrates value, clinical benefit and cost to implement new therapies in cancer, including HER2 positive breast cancer.

Citation Format: Nixon NA, Hannouf M, Verma S. Value-based approach to treatment of HER2-positive breast cancer: Examining the evidence [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-12-01.

Withholding stereotactic radiotherapy in elderly patients with stage I non-small cell lung cancer and co-existing COPD is not justified: outcomes of a Markov model analysis

BACKGROUND AND PURPOSE

To model outcomes of SBRT versus best supportive care (BSC) in elderly COPD patients with stage I NSCLC.

MATERIAL AND METHODS

A Markov model was constructed to simulate the quality-adjusted and overall survival (OS) in patients ⩾75years undergoing either SBRT or BSC for a five-year timeframe. SBRT rates of local, regional and distant recurrences were obtained from 247 patients treated at the VUMC, Amsterdam. Recurrence rates were converted into transition probabilities and stratified into four groups according to T stage (1, 2) and COPD GOLD score (I-II, III-IV). Data for untreated patients were obtained from the California Cancer Registry. Tumor stage and GOLD score utilities were adapted from the literature.

RESULTS

Our model correlated closely with the source OS data for SBRT treated and untreated patients. After SBRT, our model predicted for 6.8-47.2% five-year OS and 14.9-27.4 quality adjusted life months (QALMs). The model predicted for 9.0% and 2.8% five-year OS, and 10.1 and 6.1 QALMs for untreated T1 and T2 patients, respectively. The benefit of SBRT was the least for T2, GOLD III-IV patients.

CONCLUSION

Our model indicates that SBRT should be considered in elderly stage I NSCLC patients with COPD.