Economic evaluation of adjuvant therapy with osimertinib in patients with early-stage non-small cell lung cancer and mutated EGFR

PURPOSE

The ADAURA trial demonstrated the superiority of osimertinib over a placebo with regard to disease-free survival, showing it to be indicated as an adjuvant therapy for treatment of non-small cell lung cancer with mutated epidermal growth factor receptor (EGFR). The aim of the present study was to conduct a cost-utility analysis and an analysis of the budgetary impact of adjuvant therapy with osimertinib in patients with non-small cell lung cancer with mutated EGFR who had undergone resection surgery with curative intent.

METHODS

Analyses were based on the outcomes of the ADAURA clinical trial and were conducted through a Spanish National Health Service perspective. The outcome measures used were quality-adjusted life years (QALY).

RESULTS

The average overall cost of adjuvant treatment with osimertinib over a period of 100 months in the overall sample of trial patients (stages IB-IIIA) was 220,961 €, compared with 197,849 € in the placebo group. Effectiveness, estimated according to QALY, was 6.26 years in the osimertinib group and 5.96 years in the placebo group, with the incremental cost-utility ratio being 77,040 €/QALY. With regard to the budgetary impact, it was estimated that, in 2021, approximately 1130 patients would be subsidiaries to receive osimertinib. This pertains to a difference of 17,375,330 € over 100 months to fund this treatment relative to no treatment.

CONCLUSION

Taking into account a Spanish threshold of 24,000 €/QALY, the reduction in the acquisition cost of osimertinib will have to be greater than 10%, to obtain a cost-effective alternative.

Anti-tumor antibody isotype response can be modified with locally administered immunoadjuvants

In situ vaccination with immunostimulatory compounds is a demonstrated means to treat tumors preclinically. While these therapeutic effects have been attributed to the actions of T cells or innate immune activation, characterisation of the humoral immune response is seldom performed. This study aims to identify whether the injection of immunoadjuvants, Addavax (Adda) and cytosine-phosphorothioate-guanine oligodeoxynucleotide (CpG), intratumorally can influence the antibody response. Specifically, whether intratumoral injection of immunoadjuvants can alter the tumor-specific antibody target, titre and isotype. Following this, the study aimed to investigate whether serum obtained from in situ vaccinated mice could neutralise circulating tumor cells. Serum was obtained from mice bearing B16F10-OVA-Luc-GFP tumors treated with immunoadjuvants. Antibody targets' titre and isotype were assessed by indirect ELISA. The ability of serum to neutralise circulating cancer cells was evaluated in a B16F10 pseudo-metastatic model. It was observed that tumor-bearing mice mount a specific anti-tumor antibody response. Antibody titre and target were unaffected by in situ vaccination with immunoadjuvants; however, a higher amount of IgG2c was produced in mice receiving Adda plus CpG. Serum from in situ vaccinated mice was unable to neutralise circulating B16F10 cells. Thus, this study has demonstrated that anti-tumor antibody isotype may be modified using in situ vaccination; however, this alone is not sufficient to neutralise circulating cancer cells.

The production and influence of anti-Vibrio parahaemolytics IgY against experimental infection of V. parahaemolyticus in cultured Fenneropenaeus indicus

The increasing number of antibiotic-resistant bacteria emphasizes the need to find alternatives to complement antibiotics. Immunotherapy may also be used as a complementary treatment against pathogens that are difficult to treat with traditional antibiotics. Eggs are normal dietary components and there is practically no risk of toxic side effects of IgY given orally. In the present study, pathogenic Vibrio parahaemolyticus was isolated from infected shrimp and studied their virulence factors including LD₅₀ (by challenging with Fenneropenaeus indicus), proteolytic and hemolytic activities. The edible antibody IgY was raised by injecting the antigen of Extra Cellular Products (ECP) of V. parahaemolyticus to Gallus gallus domesticus during layoff period with and without the herbal immunoadjuvants, Asparagus racemosus and Glycine max (V.p wo: V. parahaemolyticus ECP without adjuvant; V.p A: V. parahaemolyticus ECP with A. racemosus and V.p G: V. parahaemolyticus ECP with G. max). Eggs were collected after five weeks of immunization and anti- V. parahaemolyticus IgY was extracted and purified. Physicochemical properties of the immunized Chickens' serum and anti- V. parahaemolyticus IgY's cross reactivity, growth inhibition assay, single radial immunodiffusion assay and bacterial agglutination were studied. The results revealed that, the serum protein parameters were significantly (P ≤ 0.001) increased in experimental groups from control group. The antibody raised with immunoadjuvants had significantly (P ≤ 0.001) higher cross reactivity, growth inhibition, single radial immunoassay and bacterial agglutination when compared with and without immunoadjuvant and control groups. Further the control and experimental anti-V. parahaemolytics IgY coated artificial diets were fed to F. indicus for 60 days. After 30 and 60 dpv (days of post vaccination), shrimps from each groups were challenged with virulent V. parahaemolyticus and studied the survival, haematological and immunological parameters. The IgY coated diets (V. p A and V.p G) fed shrimps had decreased cumulative mortality, significantly (P ≤ 0.001) improved coagulase activity, total haemocyte count and oxyhaemocyanin. The immunological parameters such as prophenoloxidase, intracellular anion production, lysozyme production and phagocytosis also improved significantly (P ≤ 0.001) in IgY treated shrimps.

Cationic Nanostructures as Adjuvants for Vaccines

Spherical or discoidal lipid polymer nanostructures bearing cationic charges successfully adsorb a variety of oppositely charged antigens (Ag) such as proteins, peptides, nucleic acids, or oligonucleotides. This report provides instructions for the preparation and physical characterization of four different cationic nanostructures able to combine and deliver antigens to the immune system: (1) dioctadecyl dimethylammonium bromide (DODAB) bilayer fragments (DODAB BF); (2) polystyrene sulfate (PSS) nanoparticles (NPs) covered with one cationic dioctadecyl dimethylammonium bromide bilayer (DODAB) named (PSS/DODAB); (3) cationic NPs of biocompatible polymer poly(methyl methacrylate) (PMMA) prepared by emulsion polymerization of the methyl methacrylate (MMA) monomer in the presence of DODAB BF (PMMA/DODAB NPs); (4) antigen NPs (NPs) where the cationic polymer poly(diallyl dimethyl ammonium chloride) (PDDA) directly combined at nontoxic and low dose with the antigen (Ag); when the oppositely charged model antigen is ovalbumin (OVA), NPs are named PDDA/OVA. These nanostructures provide adequate microenvironments for carrying and delivering antigens to the antigen-presenting cells of the immune system.

Polyphosphazene immunoadjuvants: Historical perspective and recent advances

The development of successful vaccines has been increasingly reliant on the use of immunoadjuvants - additives, which can enhance and modulate immune responses to vaccine antigens. Immunoadjuvants of the polyphosphazene family encompass synthetic biodegradable macromolecules, which attain in vivo activity via antigen delivery and immunostimulation mechanisms. Over the last decades, the technology has witnessed evolvement of next generation members, expansion to include various antigens and routes of administration, and progression to clinical phase. This was accompanied by gaining important insights into the mechanism of action and the development of a novel class of virus-mimicking nano-assemblies for antigen delivery. The present review evaluates in vitro and in vivo data generated to date in the context of latest advances in understanding the primary function and biophysical behavior of these macromolecules. It also provides an overview of relevant synthetic and characterization methods, macromolecular biodegradation pathways, and polyphosphazene-based multi-component, nanoparticulate, and microfabricated formulations.

Supramolecular assembly of Toll-like receptor 7/8 agonist into multimeric water-soluble constructs enables superior immune stimulation in vitro and in vivo

Resiquimod or R848 (RSQD) is a Toll-like receptor (TLR) 7/8 agonist which shows promise as vaccine adjuvant due to its potential to promote highly desirable cellular immunity. The development of this small molecule in the field to date has been largely impeded by its rapid in vivo clearance and lack of association with vaccine antigens. Here, we report a multimeric TLR 7/8 construct of nano-scale size, which results from a spontaneous self-assembly of RSQD with a water-soluble clinical-stage polymer - poly[di(carboxylatophenoxy)phosphazene] (PCPP). The formation of ionically paired construct (PCPP-R) and a ternary complex, which also includes Hepatitis C virus (HCV) antigen, has been demonstrated by dynamic lights scattering (DLS), turbidimetry, fluorescence spectroscopy, asymmetric flow field flow fractionation (AF4), and ¹H NMR spectroscopy methods. The resulting supramolecular assembly PCPP-R enabled superior immunostimulation in cellular assays (mouse macrophage reporter cell line) and displayed improved in vitro hemocompatibility (human erythrocytes). In vivo studies demonstrated that PCPP-R adjuvanted HCV formulation induced higher serum neutralization titers in BALB/c mice and shifted the response towards desirable cellular immunity, as evaluated by antibody isotype ratio (IgG2a/IgG1) and ex vivo analysis of cytokine secreting splenocytes (higher levels of interferon gamma (IFN-γ) single and tumor necrosis factor alpha (TNF-α)/IFN-γ double producing cells). The non-covalent multimerization approach stands in contrast to previously suggested RSQD delivery methods, which involve covalent conjugation or encapsulation, and offers a flexible methodology that can be potentially integrated with other parenterally administered drugs.

Physicochemical properties of anti Vibrio harveyi egg yolk antibody (IgY) and its immunological influence in Indian white shrimp Fenneropenaeus indicus

Edible antibodies specific to host pathogens is an attractive approach to establish protective immunity, especially against gastrointestinal pathogens both in humans and animals. The edible antibody of anti-Vibrio harveyi IgY (anti-V. h IgY) was produced by antigen mixed with immunoadjuvant Asparagus racemosus and Glycine max. Hens were immunized and eggs were collected five weeks after the immunization. Anti-V. harveyi IgY stability in different digestive enzymes such as trypsin and chymotrypsin were evaluated to determine its ability to withstand in the gastrointestinal tract of F. indicus. Specific binding activity and concentration (average 9.5% of total IgY content) of the anti-V. h IgY were determined by the ELISA using V. harveyi antigen. Further the anti-V. h IgY diets including V.h wo, V.h A, V.h G and control diets were fed to F. indicus for 60 days. After 30 and 60 of feeding, group of shrimps were challenged with virulent V. harveyi. After the respective days of feeding, haematological and immunological changes were studied. The parameters including total haemocyte count (THC), coagulase activity, oxyhaemocyanin level, prophenoloxidase, intracellular superoxide anion production, lysozyme, phagocytosis and bacterial agglutinin had significantly (P ≤ .001) increased in the experimental groups in comparission with the control diet fed shrimps. The anti-V. h IgY coated diets helped to reduce the Vibrio load and boosted the immune system in F. indicus's against V. harveyi challenge. The research work shows the potential applications of egg yolk antibodies as anti-bacterial prophylactic uses for infectious diseases and suggests an edible antibody concept as an alternative to conventional antibiotics.