Access to innovative medicines for metastatic melanoma worldwide: Melanoma World Society and European Association of Dermato-oncology survey in 34 countries

According to data from recent studies from Europe, a large percentage of patients have restricted access to innovative medicines for metastatic melanoma. Melanoma World Society and European Association of Dermato-oncology conducted a Web-based survey on access to first-line recommended treatments for metastatic melanoma by current guidelines (National Comprehensive Center Network, European Society for Medical Oncology [ESMO] and European Organization for Research and Treatment of Cancer/European Association of Dermato-oncology/European dermatology Forum) among melanoma experts from 27 European countries, USA, China, Australia, Argentina, Brazil, Chile and Mexico from September 1st, 2017 to July 1st, 2018. Data on licencing and reimbursement of medicines and the number of patient treated were correlated with the data on health expenditure per capita (HEPC), Mackenbach score of health policy performance, health technology assessment (HTA), ASCO and ESMO Magnitude of clinical benefit scale (ESMO MCBS) scores of clinical benefit and market price of medicines. Regression analysis for evaluation of correlation between the parameters was carried out using SPSS software. The estimated number of patients without access in surveyed countries was 13768. The recommended BRAFi + MEKi combination and anti-PD1 immunotherapy were fully reimbursed/covered in 19 of 34 (55.8%) and 17 of 34 (50%) countries, and combination anti-CTLA4+anti-PD1 in was fully covered in 6 of 34 (17.6%) countries. Median delay in reimbursement was 991 days, and it was in significant correlation with ESMO MCBS (p = 0.02), median market price (p = 0.001), HEPC and Mackenbach scores (p < 0.01). Price negotiations or managed entry agreements (MEAs) with national authorities were necessary for reimbursement. In conclusion, great discrepancy exists in metastatic melanoma treatment globally. Access to innovative medicines is in correlation with economic parameters as well as with healthcare system performance parameters. Patient-oriented drug development, market access and reimbursement pathways must be urgently found.

Tissue factor as a novel marker for detection of circulating cancer cells

Tissue factor (TF) is a molecular marker that is up-regulated in cancer cells and aids tumoral dissemination. Our purpose was to develop a nested RT-PCR strategy against TF for detecting blood-borne tumour cells. Our method detected TF expression in a minimum of 1.5 pg total RNA from MCF7 cells. A preliminary study in blood samples from 16 advanced breast carcinoma patients showed that 80% of patients with high TF load progressed and died, while only 18% with low TF load showed the same behaviour. Kaplan-Meier analysis confirmed worse overall survival in patients with high TF load.

Small molecules and targeted therapies in distant metastatic disease

Chemotherapy, biological agents or combinations of both have had little impact on survival of patients with metastatic melanoma. Advances in understanding the genetic changes associated with the development of melanoma resulted in availability of promising new agents that inhibit specific proteins up-regulated in signal cell pathways or inhibit anti-apoptotic proteins. Sorafenib, a multikinase inhibitor of the RAF/RAS/MEK pathway, elesclomol (STA-4783) and oblimersen (G3139), an antisense oligonucleotide targeting anti-apoptotic BCl-2, are in phase III clinical studies in combination with chemotherapy. Agents targeting mutant B-Raf (RAF265 and PLX4032), MEK (PD0325901, AZD6244), heat-shock protein 90 (tanespimycin), mTOR (everolimus, deforolimus, temsirolimus) and VEGFR (axitinib) showed some promise in earlier stages of clinical development. Receptor tyrosine-kinase inhibitors (imatinib, dasatinib, sunitinib) may have a role in treatment of patients with melanoma harbouring c-Kit mutations. Although often studied as single agents with disappointing results, new targeted drugs should be more thoroughly evaluated in combination therapies. The future of rational use of new targeted agents also depends on successful application of analytical techniques enabling molecular profiling of patients and leading to selection of likely therapy responders.

Immunotherapy of distant metastatic disease

Immunotherapy of metastatic melanoma consists of various approaches leading to specific or non-specific immunomodulation. The use of FDA-approved interleukin (IL)-2 alone, in combination with interferon alpha, and/or with various chemotherapeutic agents (biochemotherapy) is associated with significant toxicity and poor efficacy that does not improve overall survival of 96% of patients. Many studies with allogeneic and autologous vaccines have demonstrated no clinical benefit, and some randomised trials even showed a detrimental effect in the vaccine arm. The ongoing effort to develop melanoma vaccines based on dendritic cells and peptides is driven by advances in understanding antigen presentation and processing, and by new techniques of vaccine preparation, stabilisation and delivery. Several agents that have shown promising activity in metastatic melanoma including IL-21 and monoclonal antibodies targeting cytotoxic T lymphocyte-associated antigen 4 (anti-CTLA-4) or CD137 are discussed. Recent advances of intratumour gene transfer technologies and adoptive immunotherapy, which represents a promising although technically challenging direction, are also discussed.

Retrospective analysis on patients with male breast cancer

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Background: Male breast cancer is uncommon, 1%(0.7 %)of all breast cancer. Nevertheless, the incidence has climbed 26% over the past 25 years. Objetive: Analyze the form of presentation and clinical evolution of patients with male breast cancer studied from 1977 to 2005. Methods: From 1977 to 2005 53 charts were analyzed: age, clinical presentation, stage (st), histological characteristics and nodal involvement. Results: Age: 33 years to 83 years (median= 59 years). Mean durations of symptoms before presentations: 11 months (m) (range 1 - 84 m.) . Forty-six (86.7%) patients (pts) had history of breast lumps, 9 (17%) were painful. Skin involvement and ulceration were present in 5 (9.43%) and 4 (7.54 %) respectively. One case of bilateralism was found. Seven (13.2%) st. I; 18 (33.96%) st. II; 20 (37.73%) st. III and 7 (13.2%) st. IV. Radical mastectomy was done in 41 pts (77.35%). Invasive ductal carcinoma was the most common histological type in 45 (84.9%). One case of lobular carcinoma was found. 60.4% of tumours expressed hormonal receptor. Adyuvant treatment: Adriamycin-based chemotherapy in 20 pts and CMF in 8 pts. Hormonotherapy was offered in 10 (19%) pts of the previous group, radiotherapy to 12 pts. twenthy pts (37.73%) presented recurrence; most common was bone in 10. The st. I and II estimated 5-year survival rate was 68% IC 95% (44–84%), st. III was 44% IC 95% (23 - 67%), st. IV (median = 24 m) with range (16 - 56 m). The 72% IC 95% (48–88%) patients st. I and II was free of disease at the 5-years, st. III was free 24% IC 95% (9–49%), st. IV (median = 7,5 m) with range (7–14 m). Conclusions: The media age at diagnosis was 59 years (10 years less than the international bibliography). (IB). Our group had longer time to presentation: 11 vs. 6 m., (IB) and most of them where in st. III. Hormonal receptore were positive in 60%.

No significant financial relationships to disclose.

Concurrent chemoradiation (CCR) for locally advanced or relapsed vulvar carcinoma (VC) treatment: An alternative to pelvic exenteration (PE)

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Background: PE is the standard treatment for locally advanced or relapsed VC that involves the anus or rectovaginal wall, with high morbidity and the consequent loss of Qol. Objective: Locoregional response, toxicity, disease free survival (DFS) and survival (SV) achieved with concurrent chemoradiation in locally advanced or relapsed VC was prospectively evaluated. Methods: From 7/93 to 05/05, 32 pts which would have required some kind of PE were treated with mitomycin C (10 mg./m2 d1) + 5-Fluoruracil (800 mg/m2 d 1–4) IV continuous infusion, plus concurrent external radiotherapy (50 Gy) to the vulva, pelvis and groin. An additional boost (15–20 Gy) was added when a less than complete clinical response (CR) was achieved. Multiple biopsies of the tumor bed were performed to confirm complete pathologic responses (CPR). Results: 30 pts (94%) completed treatment as planned. Overall, locoregional response was obtained in 25/30 (83.3%) pts: 20 (66.6%) CR, 5 (16.6%) partial response (PR). 3 (10%) pts had stable disease and 2 (6.6%) progresive disease. 14/30 (46.6%) had CPR. Radical vulvectomy or radical local excision was performed in 7 pts for residual disease after CCR (4/6 with CR and microscopic residual disease and 3/5 with PR), 2 pts with PR were lost after having completed CCR and 2 pts with CR and microscopic residual disease refused further treatment. None of the responding patients required PE. Treatment was well tolerated with mild to moderate toxicity, attributed to radiotherapy. No treatment deaths were recorded. 28 pts with a median follow-up of 25.5 months (range 6–126) showed a 5-year cumulative DFS (34%) and SV (49%). Conclusion: CCR is a safe therapeutic option with results comparable to those obtained with PE, with significant improvement of Qol. CCR has become the standard treatment for locally advanced or relapsed VC at our center.

No significant financial relationships to disclose.

Single-agent gemcitabine in pretreated patients with non-small-cell lung cancer: results of an Argentinean multicentre phase II trial

The activity and mild toxicity profile of single-agent gemcitabine therapy in untreated (chemonaive) patients with non-small-cell lung cancer (NSCLC) is well documented. This phase II trial was conducted to determine the objective tumour response rate and toxicity profile of single-agent gemcitabine in pretreated patients with NSCLC. Patients with histological evidence of advanced NCSLC stage IIIB or IV; at least one prior chemotherapy regimen including a platinum or taxane analogue; an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2; clinically measurable disease; adequate bone marrow reserve; and adequate renal function; received 1000 mg m(-2) gemcitabine administered over 30 min on days 1, 8 and 15 of a 28-day cycle defined as 3 weekly treatments followed by 1 week of rest. Twenty-nine patients were evaluated for efficacy and 32 for toxicity. One patient achieved a complete response and five patients had a partial response resulting in a total response rate of 20.6% (95% confidence interval (CI) 6-34). Median response duration was 7 months (range 4-11 months). Twelve (41%) patients reached stable disease after two cycles of therapy and 11 (38%) patients had disease progression. Median progression-free survival time was 3 months and median overall survival time was 5.5 months. Toxicity was generally mild (grades 0-2). Severe (grade 3 or 4) haematological toxicities included grade 3 anaemia in one patient and grade 3 thrombocytopenia in two patients. Severe non-haematological toxicities included one patient each with grade 3 liver transaminase elevations, nausea/vomiting and diarrhoea. This study confirms the activity and safety of single-agent gemcitabine in pretreated patients with advanced NSCLC who are refractory or sensitive to first-line therapy.