Treatment of poor-risk metastatic renal carcinoma patients with combination gemcitabine, capecitabine, and bevacizumab at a tertiary cancer center

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Background: Treatment of poor risk metastatic renal carcinoma (mRCC) is challenging, and empiric combinations may be attempted in practice once conventional therapies fail. These combinations may lead to formal clinical trials. Evaluation of mRCC patients given an empiric combination of gemcitabine (gem) capecitabine (cap), and bevacizumab (bev) at a tertiary care center was performed. Methods: After obtaining IRB approval, non investigational use of gem in combination with cap and bev in mRCC patients was identified using institutional databases. Collected data included demographics, previous therapies, number of metastatic sites, MSKCC risk stratification variables, prior nephrectomy status, drug therapy duration, and progression-free survival (PFS). Descriptive statistics were employed for data analysis. Results: Thirty-six patients were included in the analysis, with a median age of 55.5 years. Seventeen patients (47%) had previously received a tyrosine kinase inhibitor (TKI). Twenty-two patients (61%) had clear cell histology, 13 patients (36%) had sarcomatoid features, 20 patients (56%) had undergone previous nephrectomy, 20 patients (56%) had four or more sites of metastasis and 27 patients (75%) were diagnosed within 1 year of therapy. Initial treatment consisted of gem (908.61 mg/m2) every 2 weeks, cap (2.75 grams/day), and bev (828.82 mg) every 2 weeks. The median PFS for the study population was 5.83 months. The subset of TKI patients had a median PFS of 5.4 months. Therapy was relatively well tolerated with only 3 patients discontinuing one or more of the drugs due to adverse reactions. Thirteen of the patients started a TKI post discontinuation of the triple therapy. Conclusions: The triple therapy combination in this retrospective evaluation provides promising efficacy and acceptable tolerability in patients with poor prognosis mRCC. Based on these observations, a phase II is now underway assessing gemcitabine, capecitabine and becacizumab in patients with sarcomatoid RCC.

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Cost-effectiveness analysis of a randomized study with stereotactic radiosurgery (SRS) alone versus SRS plus whole brain radiation therapy (WBRT) for patients with brain metastasis

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Background: This paper illustrates the incremental cost-effectiveness ratio (ICER) and cost-utility comparison of SRS alone versus SRS plus WBRT for brain metastasis. Methods: A decision analysis model, including subsequent treatment for recurrences, was developed and populated with data from patients randomized to either SRS alone (SA) versus SRS plus WBRT (SW), using costs from the healthcare institution perspective and outcomes based on actual life years saved (LYS) and quality-adjusted-life-years (QALYs). Utilities were captured through a time-trade -off methodology, utilizing three time horizons: 10 years, 5 years, and 1 year. Tornado diagrams and one-way sensitivity analyses were conducted to determine robustness of the model. Results: Fifty-eight patients were included in the final analysis, with 31 patients in the SA arm and 27 patients in the SW arm. The average cost of the SA arm is $119,000 versus $74,000 for the SW arm. The average effectiveness for the SA arm was 1.64 LYS versus 0.60 LYS for the SW arm. The ICER for total costs per LYS and QALYs were: $43,986 per LYS; $42,136 per QALY (10year); $43, 719 per QALY (5year); $44,686 (1year) for the SA arm. The surgical cost per LYS was $7,131 for the SA arm, and the radiation cost per LYS analysis was dominated. Tornado diagrams revealed that the following variables had the highest impact on the ICER: probability of being alive with SA in recursive partitioning analysis (RPA) class 2 and no recurrence; probability of no recurrence in RPA class 2 with SA; probability of being alive with SA in RPA class 2 and being treated for recurrence; probability of no recurrence in RPA class 1 with SA; and probability of being alive with no recurrence in RPA class 1 with SA. One-way sensitivity analysis exhibited a wide range variation for the first three of the above mentioned probabilities, with the final two having less variation. Conclusions: Compared to other interventions in the $50,000 to $100,000 per QALY cost-effectiveness range from an economic perspective, the application of SA, with subsequent surgical management of recurrences, is shown to be a reasonable treatment modality for brain metastasis.

No significant financial relationships to disclose.

A retrospective study to determine the impact of medical- and lifestyle-based contraindications to a prescribed HAART regimen on clinical outcomes and adherence

OBJECTIVE

To determine whether patients who are prescribed a highly active antiretroviral therapy regimen, that minimizes medical and lifestyle contraindications, will be better able to adhere to their drug regimens and will have better clinical outcomes, than patients who do not have such a regimen.

METHODS

A retrospective chart review of patients' prescription renewals and changes in viral load and CD4(+) count and a comparison of these changes with patients' self-identified contraindications. Contraindications were identified by a questionnaire with 35 questions relating to medical history/concurrently prescribed medication and 16 questions on lifestyle. Main outcome measures are adherence assessed by prescription renewals, change in plasma HIV-1 RNA viral loads, and change in CD4(+) T-lymphocyte counts. Logistic and linear regression and student t-test were used to identify associations between outcome measurements and number of contraindications.

RESULTS

A total of 203 patients (72% male, 74% African-American, 7% Hispanic) completed the questionnaire. Seventy-four per cent of the patients had at least one medical/drug contraindication and 78% had at least one lifestyle contraindication. Increases in CD4 counts were reduced by an average of 13 cells/mm(3) (P = 0.033) for each medical/drug contraindication and viral load decreases was significant even with one medical contraindication vs. none (P = 0.042). Patients with fewer lifestyle contraindications were more likely to have at least a 1 log drop in viral load (P = 0.036). For each increase in the number of contraindications, there was a corresponding 2% decrease in the rate of adherence (P = 0.048).

CONCLUSIONS

The results suggest that using a patient administered questionnaire it is possible to identify contraindications in prescribed regimens that impact on adherence and on treatment effects on viral load and CD4 counts.

Documentation of the first steps of pediatric pharmaceutical care in a county hospital

Pediatric pharmaceutical care is still a new concept in the pharmacy profession. In our county institution with 35% of the beds reserved for pediatric patients, there existed no formal process for providing specialized pediatric pharmacy services. In an effort to rectify this situation, a study was conducted to determine the benefits of providing pharmaceutical services by having a clinical pharmacist round with physicians on a daily basis for 3 hours. All services provided were documented for 6 months and direct cost-savings were calculated. Five hundred four different interventions and services were provided, with over $7000 in savings. Because of these findings, the pharmacy and hospital administration agreed to provide a staff pharmacist to round in pediatrics on a regular basis. This approach is considered to be more cost effective than using a clinical pharmacist for daily rounds.