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Mingge X, Jingyu W, Qi L, Zhe Z, Qing R. Promoting Access to Innovative Anticancer Medicines: A Review of Drug Price and National Reimbursement Negotiation in China. Inquiry 2023; 60:469580231170729. [PMID: 37171066 PMCID: PMC10184198 DOI: 10.1177/00469580231170729] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Providing universal access to high-cost medications like anticancer drugs is not an easy feat. Although basic medical insurance has covered over 95% of China's population since 2012, reimbursement for high-priced medicines is limited. In 2015, the Chinese government proposed establishing an open and transparent price negotiation mechanism for some patented and expensive drugs, where oncology was among the prioritized areas. In 2016, three drugs (gefitinib, icotinib, and tenofovir disoprox) underwent negotiation with the government, eventually reducing their prices by over 50% so that they could be prioritized during reimbursement processes. Focusing on anticancer medicines, this study comprehensively summarizes the progress in drug price and national reimbursement negotiation in China. Furthermore, we investigated the changes and development regarding negotiated anticancer medicines from quantity negotiated, classification, indication coverage, utilization, and procurement spending. Our findings could provide a reference for follow-up negotiations and reimbursement policies for high-value anticancer medications in other countries. From 2016 to 2021, 82 anticancer medicines were newly incorporated into the national reimbursement drug list (NRDL) via 6 rounds of negotiation. The majority of these were innovative pharmaceutics (ie, protein kinase inhibitors (28) and monoclonal antibodies (13)). Drug pricing and national reimbursement negotiation led to a marked decrease in prices and a sharp increase in the utilization of negotiated anticancer medicines. Following negotiations, the defined daily doses (DDDs) of innovative anticancer medicines experienced remarkable growth. Their proportion in total anticancer drugs DDDs also increased from 3.4% in 2014 to 20.9% in 2019. However, although drug prices decreased substantially after the negotiations, insurance spending still showed an upward trend owing to the significant increase in utilization. This calls for the government to carefully monitor the rational use of these expensive medicines and explore innovative payment models.
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Affiliation(s)
- Xia Mingge
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan
| | - Wen Jingyu
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan
| | - Liu Qi
- Institute for Hospital Management of Tsinghua University, Shenzhen, China
| | | | - Ran Qing
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan
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Uneno Y, Imura H, Makuuchi Y, Tochitani K, Watanabe N. Pre-emptive antifungal therapy versus empirical antifungal therapy for febrile neutropenia in people with cancer. Cochrane Database Syst Rev 2022; 11:CD013604. [PMID: 36440894 PMCID: PMC9703870 DOI: 10.1002/14651858.cd013604.pub2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intensive cytotoxic chemotherapy for people with cancer can cause severe and prolonged cytopenia, especially neutropenia, a critical condition that is potentially life-threatening. When manifested by fever and neutropenia, it is called febrile neutropenia (FN). Invasive fungal disease (IFD) is one of the serious aetiologies of chemotherapy-induced FN. In pre-emptive therapy, physicians only initiate antifungal therapy when an invasive fungal infection is detected by a diagnostic test. Compared to empirical antifungal therapy, pre-emptive therapy may reduce the use of antifungal agents and associated adverse effects, but may increase mortality. The benefits and harms associated with the two treatment strategies have yet to be determined. OBJECTIVES: To assess the relative efficacy, safety, and impact on antifungal agent use of pre-emptive versus empirical antifungal therapy in people with cancer who have febrile neutropenia. SEARCH METHODS We searched CENTRAL, MEDLINE Ovid, Embase Ovid, and ClinicalTrials.gov to October 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared pre-emptive antifungal therapy with empirical antifungal therapy for people with cancer. DATA COLLECTION AND ANALYSIS We identified 2257 records from the databases and handsearching. After removing duplicates, screening titles and abstracts, and reviewing full-text reports, we included seven studies in the review. We evaluated the effects on all-cause mortality, mortality ascribed to fungal infection, proportion of antifungal agent use (other than prophylactic use), duration of antifungal use (days), invasive fungal infection detection, and adverse effects for the comparison of pre-emptive versus empirical antifungal therapy. We presented the overall certainty of the evidence for each outcome according to the GRADE approach. MAIN RESULTS This review includes 1480 participants from seven randomised controlled trials. Included studies only enroled participants at high risk of FN (e.g. people with haematological malignancy); none of them included participants at low risk (e.g. people with solid tumours). Low-certainty evidence suggests there may be little to no difference between pre-emptive and empirical antifungal treatment for all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.72 to 1.30; absolute effect, reduced by 3/1000); and for mortality ascribed to fungal infection (RR 0.92, 95% CI 0.45 to 1.89; absolute effect, reduced by 2/1000). Pre-emptive therapy may decrease the proportion of antifungal agent used more than empirical therapy (other than prophylactic use; RR 0.71, 95% CI 0.47 to 1.05; absolute effect, reduced by 125/1000; very low-certainty evidence). Pre-emptive therapy may reduce the duration of antifungal use more than empirical treatment (mean difference (MD) -3.52 days, 95% CI -6.99 to -0.06, very low-certainty evidence). Pre-emptive therapy may increase invasive fungal infection detection compared to empirical treatment (RR 1.70, 95% CI 0.71 to 4.05; absolute effect, increased by 43/1000; very low-certainty evidence). Although we were unable to pool adverse events in a meta-analysis, there seemed to be no apparent difference in the frequency or severity of adverse events between groups. Due to the nature of the intervention, none of the seven RCTs could blind participants and personnel related to performance bias. We identified considerable clinical and statistical heterogeneity, which reduced the certainty of the evidence for each outcome. However, the two mortality outcomes had less statistical heterogeneity than other outcomes. AUTHORS' CONCLUSIONS For people with cancer who are at high-risk of febrile neutropenia, pre-emptive antifungal therapy may reduce the duration and rate of use of antifungal agents compared to empirical therapy, without increasing over-all and IFD-related mortality; but the evidence regarding invasive fungal infection detection and adverse events was inconsistent and uncertain.
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Affiliation(s)
- Yu Uneno
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruki Imura
- Department of Health Informatics, School of Public Health in Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Makuuchi
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kentaro Tochitani
- Department of Heathcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
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Abstract
BACKGROUND Many people with cancer experience moderate to severe pain that requires treatment with strong opioids, such as oxycodone and morphine. Strong opioids are, however, not effective for pain in all people, neither are they well tolerated by all people. The aim of this review was to assess whether oxycodone is associated with better pain relief and tolerability than other analgesic options for adults with cancer pain. This is an updated Cochrane review previously published in 2017. OBJECTIVES To assess the effectiveness and tolerability of oxycodone by any route of administration for pain in adults with cancer. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and MEDLINE In-Process (Ovid), Embase (Ovid), Science Citation Index, Conference Proceedings Citation Index - Science (ISI Web of Science), BIOSIS (ISI), and PsycINFO (Ovid) to November 2021. We also searched four trial registries, checked the bibliographic references of relevant studies, and contacted the authors of the included studies. We applied no language, date, or publication status restrictions. SELECTION CRITERIA We included randomised controlled trials (parallel-group or cross-over) comparing oxycodone (any formulation or route of administration) with placebo or an active drug (including oxycodone) for cancer background pain in adults by examining pain intensity/relief, adverse events, quality of life, and participant preference. DATA COLLECTION AND ANALYSIS Two review authors independently sifted the search, extracted data and assessed the included studies using standard Cochrane methodology. We meta-analysed pain intensity data using the generic inverse variance method, and pain relief and adverse events using the Mantel-Haenszel method, or summarised these data narratively along with the quality of life and participant preference data. We assessed the overall certainty of the evidence using GRADE. MAIN RESULTS For this update, we identified 19 new studies (1836 participants) for inclusion. In total, we included 42 studies which enrolled/randomised 4485 participants, with 3945 of these analysed for efficacy and 4176 for safety. The studies examined a number of different drug comparisons. Controlled-release (CR; typically taken every 12 hours) oxycodone versus immediate-release (IR; taken every 4-6 hours) oxycodone Pooled analysis of three of the four studies comparing CR oxycodone to IR oxycodone suggest that there is little to no difference between CR and IR oxycodone in pain intensity (standardised mean difference (SMD) 0.12, 95% confidence interval (CI) -0.1 to 0.34; n = 319; very low-certainty evidence). The evidence is very uncertain about the effect on adverse events, including constipation (RR 0.71, 95% CI 0.45 to 1.13), drowsiness/somnolence (RR 1.03, 95% CI 0.69 to 1.54), nausea (RR 0.85, 95% CI 0.56 to 1.28), and vomiting (RR 0.66, 95% CI 0.38 to 1.15) (very low-certainty evidence). There were no data available for quality of life or participant preference, however, three studies suggested that treatment acceptability may be similar between groups (low-certainty evidence). CR oxycodone versus CR morphine The majority of the 24 studies comparing CR oxycodone to CR morphine reported either pain intensity (continuous variable), pain relief (dichotomous variable), or both. Pooled analysis indicated that pain intensity may be lower (better) after treatment with CR morphine than CR oxycodone (SMD 0.14, 95% CI 0.01 to 0.27; n = 882 in 7 studies; low-certainty evidence). This SMD is equivalent to a difference of 0.27 points on the Brief Pain Inventory scale (0-10 numerical rating scale), which is not clinically significant. Pooled analyses also suggested that there may be little to no difference in the proportion of participants achieving complete or significant pain relief (RR 1.02, 95% CI 0.95 to 1.10; n = 1249 in 13 studies; low-certainty evidence). The RR for constipation (RR 0.75, 95% CI 0.66 to 0.86) may be lower after treatment with CR oxycodone than after CR morphine. Pooled analyses showed that, for most of the adverse events, the CIs were wide, including no effect as well as potential benefit and harm: drowsiness/somnolence (RR 0.88, 95% CI 0.74 to 1.05), nausea (RR 0.93, 95% CI 0.77 to 1.12), and vomiting (RR 0.81, 95% CI 0.63 to 1.04) (low or very low-certainty evidence). No data were available for quality of life. The evidence is very uncertain about the treatment effects on treatment acceptability and participant preference. Other comparisons The remaining studies either compared oxycodone in various formulations or compared oxycodone to different alternative opioids. None found any clear superiority or inferiority of oxycodone for cancer pain, neither as an analgesic agent nor in terms of adverse event rates and treatment acceptability. The certainty of this evidence base was limited by the high or unclear risk of bias of the studies and by imprecision due to low or very low event rates or participant numbers for many outcomes. AUTHORS' CONCLUSIONS The conclusions have not changed since the previous version of this review (in 2017). We found low-certainty evidence that there may be little to no difference in pain intensity, pain relief and adverse events between oxycodone and other strong opioids including morphine, commonly considered the gold standard strong opioid. Although we identified a benefit for pain relief in favour of CR morphine over CR oxycodone, this was not clinically significant and did not persist following sensitivity analysis and so we do not consider this important. However, we found that constipation and hallucinations occurred less often with CR oxycodone than with CR morphine; but the certainty of this evidence was either very low or the finding did not persist following sensitivity analysis, so these findings should be treated with utmost caution. Our conclusions are consistent with other reviews and suggest that, while the reliability of the evidence base is low, given the absence of important differences within this analysis, it seems unlikely that larger head-to-head studies of oxycodone versus morphine are justified, although well-designed trials comparing oxycodone to other strong analgesics may well be useful. For clinical purposes, oxycodone or morphine can be used as first-line oral opioids for relief of cancer pain in adults.
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Affiliation(s)
- Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Nathan Bromham
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jennifer S Hilgart
- Scientific Resource Center, VA Portland Research Foundation, Portland, Oregon, USA
| | - Andrew J Page
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Yuan Chi
- Yealth Network, Beijing Yealth Technology Co., Ltd, Beijing, China
- Cochrane Campbell Global Ageing Partnership, UK
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Ruiz-Patiño A, Arrieta O, Cardona AF, Martín C, Raez LE, Zatarain-Barrón ZL, Barrón F, Ricaurte L, Bravo-Garzón MA, Mas L, Corrales L, Rojas L, Lupinacci L, Perazzo F, Bas C, Carranza O, Puparelli C, Rizzo M, Ruiz R, Rolfo C, Archila P, Rodríguez J, Sotelo C, Vargas C, Carranza H, Otero J, Pino LE, Ortíz C, Laguado P, Rosell R. Immunotherapy at any line of treatment improves survival in patients with advanced metastatic non-small cell lung cancer (NSCLC) compared with chemotherapy (Quijote-CLICaP). Thorac Cancer 2019; 11:353-361. [PMID: 31828967 PMCID: PMC6996989 DOI: 10.1111/1759-7714.13272] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 10/02/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background To compare survival outcomes of patients with advanced or metastatic non‐small cell lung cancer (NSCLC) who received immunotherapy as first‐, second‐ or beyond line, versus matched patients receiving standard chemotherapy with special characterization of hyperprogressors. Methods A retrospective cohort study of 296 patients with unresectable/metastatic NSCLC treated with either, first‐, second‐, third‐ or fourth‐line of immunotherapy was conducted. A matched comparison with a historical cohort of first‐line chemotherapy and a random forest tree analysis to characterize hyperprogressors was conducted. Results Median age was 64 years (range 34–90), 40.2% of patients were female. A total of 91.2% of patients had an Eastern Cooperative Oncology Group (ECOG) performance score ≤ 1. Immunotherapy as first‐line was given to 39 patients (13.7%), second‐line to 140 (48.8%), and as third‐line and beyond to 108 (37.6%). Median overall survival was 12.7 months (95% CI 9.67–14 months) and progression‐free survival (PFS) of 4.27 months (95% CI 3.97–5.0). Factors associated with increased survival included treatment with immunotherapy as first‐line (P < 0.001), type of response (P < 0.001) and PD‐L1 status (P = 0.0039). Compared with the historical cohort, immunotherapy proved to be superior in terms of OS (P = 0.05) but not PFS (P = 0.2). A total of 44 hyperprogressors were documented (19.8%, [95% CI 14.5–25.1%]). Leukocyte count over 5.300 cells/dL was present in both hyperprogressors and long‐term responders. Conclusions Patients who receive immune‐checkpoint inhibitors as part of their treatment for NSCLC have better overall survival (OS) compared with matched patients treated with standard chemotherapy, regardless of the line of treatment.
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Affiliation(s)
- Alejandro Ruiz-Patiño
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia.,Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia
| | - Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Andrés F Cardona
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia.,Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia.,Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Claudio Martín
- Medical Oncology Department, Thoracic Oncology Section, Instituto Fleming, Buenos Aires, Argentina
| | - Luis E Raez
- Thoracic Oncology Program, Memorial Cancer Institute/Florida International University, Miami, Florida, USA
| | | | - Feliciano Barrón
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Luisa Ricaurte
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia
| | | | - Luis Mas
- Oncology Department, Instituto Nacional de Enfermedades Neoplásicas - IneN, Lima, Peru
| | - Luis Corrales
- Medical Oncology Department, Hospital San Juan de Dios, San José, Costa Rica
| | - Leonardo Rojas
- Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia.,Oncology Department, Clínica Colsanitas, Bogotá, Colombia
| | - Lorena Lupinacci
- Thoracic Oncology Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Carlos Bas
- Oncology Department, Hospital Alemán, Buenos Aires, Argentina
| | - Omar Carranza
- Oncology Department, Hospital Privado de la Comunidad de Mar del Plata, Mar del Plata, Argentina
| | - Carmen Puparelli
- Medical Oncology Department, Thoracic Oncology Section, Instituto Fleming, Buenos Aires, Argentina
| | - Manglio Rizzo
- Oncology Department, Hospital Austral de Buenos Aires, Buenos Aires, Argentina
| | - Rossana Ruiz
- Hematology and Oncology Department, Hospital Militar Central, Bogotá, Colombia
| | - Christian Rolfo
- Thoracic Oncology Unit, Marlene and Stewart Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Pilar Archila
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia
| | - July Rodríguez
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia
| | - Carolina Sotelo
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia
| | - Carlos Vargas
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia.,Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia.,Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Hernán Carranza
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia.,Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia.,Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Jorge Otero
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia.,Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia.,Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Luis E Pino
- Oncology Department, Institute of Oncology - ICAL, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Carlos Ortíz
- Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Paola Laguado
- Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Rafael Rosell
- Coyote Research Group, Pangaea Oncology, Laboratory of Molecular Biology, Quiron-Dexeus University Institute, Barcelona, Spain.,Institut d'Investigació en Ciències Germans Trias i Pujol, Badalona, Spain.,Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Badalona, Spain
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Abstract
Objective: To describe data with selected malignancies in people living with HIV (PLWH) and HIV in individuals affected by both conditions and to summarize drug-drug interactions (DDIs) with clinical recommendations for point-of-care review of combination therapies. Data Sources: Literature searches were performed (2005 to December 2018) in MEDLINE and EMBASE to identify studies of malignancies in PLWH in the modern era. Study Selection and Data Extraction: Article bibliographies and drug interaction databases were reviewed. Search terms included HIV, antiretroviral therapy, antineoplastic agents, malignancies, and drug interactions. Data Synthesis: In the pre-antiretroviral therapy (ART) era, malignancies in PLWH were AIDS-defining illnesses, and life expectancy was shorter. Nowadays, PLWH are living longer and developing malignancies, including lung, anal, and prostate cancers. Concurrently, the oncology landscape has evolved, with novel oral targeted agents and immunotherapies becoming routine elements of care. The increased need for and complexity with antineoplastics in PLWH has led to recommendations for multidisciplinary care of this unique population. Evaluation of DDIs requires review of metabolic pathways, absorption mechanisms, and various drug transporters associated with antineoplastics and ART. Relevance to Patient Care and Clinical Practice: This review summarizes available data of non-AIDS-defining malignancies, principles of HIV care in the patient with malignancy, and guidance for assessing DDIs between antineoplastics and ART. Summary DDI tables provide point-of-care recommendations. Conclusions: The availability of ART has transformed AIDS into a chronic medical condition, and PLWH are experiencing age-related malignancies. Pharmacists play an important role in the management of this patient population.
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Affiliation(s)
| | - Olga Klibanov
- 1 Wingate University School of Pharmacy, Wingate, NC, USA
| | - Alexandre Chan
- 2 National University of Singapore, Singapore.,3 National Cancer Center Singapore, Singapore
| | - Linda M Spooner
- 4 Massachusetts College of Pharmacy and Health Sciences University, School of Pharmacy, Worcester, MA, USA
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Abstract
BACKGROUND Platinum-based therapy, including cisplatin, carboplatin, oxaliplatin or a combination of these, is used to treat a variety of paediatric malignancies. One of the most important adverse effects is the occurrence of hearing loss or ototoxicity. In an effort to prevent this ototoxicity, different otoprotective medical interventions have been studied. This review is the second update of a previously published Cochrane review. OBJECTIVES To assess the efficacy of medical interventions to prevent hearing loss and to determine possible effects of these interventions on anti-tumour efficacy, toxicities other than hearing loss and quality of life in children with cancer treated with platinum-based therapy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 6), MEDLINE (PubMed) (1945 to 8 July 2016) and EMBASE (Ovid) (1980 to 8 July 2016). In addition, we handsearched reference lists of relevant articles and we assessed the conference proceedings of the International Society for Paediatric Oncology (2006 up to and including 2015), the American Society of Pediatric Hematology/Oncology (2007 up to and including 2016) and the International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer (2010 up to and including 2015). We scanned the International Standard Randomized Controlled Trial Number (ISRCTN) Register (www.isrctn.com) and the National Institute of Health Register (www.clinicaltrials.gov) for ongoing trials (both searched on 12 July 2016). SELECTION CRITERIA Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) evaluating platinum-based therapy together with an otoprotective medical intervention versus platinum-based therapy with placebo, no additional treatment or another protective medical intervention in children with cancer. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, data extraction, risk of bias assessment and GRADE assessment of included studies, including adverse effects. We performed analyses according to the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We identified two RCTs and one CCT (total number of participants 149) evaluating the use of amifostine versus no additional treatment in the original version of the review; the updates identified no additional studies. Two studies included children with osteosarcoma, and the other study included children with hepatoblastoma. Children received cisplatin only or a combination of cisplatin and carboplatin, either intra-arterially or intravenously. Pooling of results of the included studies was not possible. However, in the individual studies there was no significant difference in symptomatic ototoxicity only (that is, grade 2 or higher) and combined asymptomatic and symptomatic ototoxicity (that is, grade 1 or higher) between children treated with or without amifostine. Only one study, including children with osteosarcoma treated with intra-arterial cisplatin, provided information on tumour response, defined as the number of participants with a good or partial remission. The available data analysis (data were missing for one participant), best case scenario analysis and worst case scenario analysis all showed a difference in favour of amifostine, but this difference was significant only in the worst case scenario analysis (P = 0.04). There was no information on survival for any of the included studies. Only one study, including children with osteosarcoma treated with intra-arterial cisplatin, provided data on the number of participants with adverse effects other than ototoxicity grade 3 or higher. There was a significant difference in favour of the control group in the occurrence of vomiting grade 3 or 4 (risk ratio (RR) 9.04; 95% confidence interval (CI) 1.99 to 41.12; P = 0.004). There was no significant difference between treatment groups for cardiotoxicity and renal toxicity grade 3 or 4. None of the studies evaluated quality of life. The quality of evidence for the different outcomes was low. We found no eligible studies for possible otoprotective medical interventions other than amifostine and other types of malignancies. AUTHORS' CONCLUSIONS At the moment there is no evidence from individual studies in children with osteosarcoma or hepatoblastoma treated with different platinum analogues and dosage schedules that underscores the use of amifostine as an otoprotective intervention as compared to no additional treatment. Since pooling of results was not possible and all studies had serious methodological limitations, no definitive conclusions can be made. It should be noted that 'no evidence of effect', as identified in this review, is not the same as 'evidence of no effect'. Based on the currently available evidence, we are unable to give recommendations for clinical practice. We identified no eligible studies for other possible otoprotective medical interventions and other types of malignancies, so no conclusions can be made about their efficacy in preventing ototoxicity in children treated with platinum-based therapy. More high quality research is needed.
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Affiliation(s)
- Jorrit W van As
- Princess Máxima Center for Pediatric Oncologyc/o Cochrane Childhood CancerHeidelberglaan 25UtrechtNetherlands3584 CS
| | - Henk van den Berg
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
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Ho AL, Lyonel Carre A, Patel KM. Oncologic reconstruction: General principles and techniques. J Surg Oncol 2016; 113:852-64. [PMID: 26939879 DOI: 10.1002/jso.24206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 02/06/2023]
Abstract
Halsted's principle of radical mastectomy influenced cancer treatment for decades. Randomized controlled trials resulted in a paradigm shift to less radical surgery and the use of adjuvant therapies. Oncologic reconstruction performed by plastic surgeons has evolved, ranging from skin grafts and local flaps for smaller defects to pedicled flaps and free flaps for larger and more complex defects. Immediate reconstruction facilitates resection is oncologically safe and contributes to meaningful improvements in quality of life. J. Surg. Oncol. 2016;113:852-864. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Adelyn L Ho
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Antoine Lyonel Carre
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Abstract
BACKGROUND This review update has been managed by both the Childhood Cancer and Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Groups.The use of anthracycline chemotherapy is limited by the occurrence of cardiotoxicity. To prevent this cardiotoxicity, different anthracycline dosage schedules have been studied. OBJECTIVES To determine the occurrence of cardiotoxicity with the use of different anthracycline dosage schedules (that is peak doses and infusion durations) in people with cancer. SEARCH METHODS We searched the databases of the Cochrane Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 11, 2015), MEDLINE (1966 to December 2015), and EMBASE (1980 to December 2015). We also searched reference lists of relevant articles, conference proceedings, experts in the field, and ongoing trials databases. SELECTION CRITERIA Randomised controlled trials (RCTs) in which different anthracycline dosage schedules were compared in people with cancer (children and adults). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, the 'Risk of bias' assessment, and data extraction. We performed analyses according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We identified 11 studies: 7 evaluated different infusion durations (803 participants), and 4 evaluated different peak doses (5280 participants). Seven studies were RCTs addressing different anthracycline infusion durations; we identified long-term follow-up data for one of the trials in this update. The meta-analysis showed a statistically significant lower rate of clinical heart failure with an infusion duration of six hours or longer as compared to a shorter infusion duration (risk ratio (RR) 0.27; 95% confidence interval 0.09 to 0.81; 5 studies; 557 participants). The majority of participants included in these studies were adults with different solid tumours. For different anthracycline peak doses, we identified two RCTs addressing a doxorubicin peak dose of less than 60 mg/m(2) versus 60 mg/m(2) or more, one RCT addressing a liposomal doxorubicin peak dose of 25 mg/m(2) versus 50 mg/m(2), and one RCT addressing an epirubicin peak dose of 83 mg/m(2) versus 110 mg/m(2). A significant difference in the occurrence of clinical heart failure was identified in none of the studies. The participants included in these studies were adults with different solid tumours. High or unclear 'Risk of bias' issues were present in all studies. AUTHORS' CONCLUSIONS An anthracycline infusion duration of six hours or longer reduces the risk of clinical heart failure, and it seems to reduce the risk of subclinical cardiac damage. Since there is only a small amount of data for children and data obtained in adults cannot be extrapolated to children, different anthracycline infusion durations should be evaluated further in children.We identified no significant difference in the occurrence of clinical heart failure in participants treated with a doxorubicin peak dose of less than 60 mg/m(2) or 60 mg/m(2) or more. Only one RCT was available for the other identified peak doses, so we can make no definitive conclusions about the occurrence of cardiotoxicity. More high-quality research is needed, both in children and adults and in leukaemias and solid tumours.
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Affiliation(s)
- Elvira C van Dalen
- Department of Paediatric Oncology, Emma Children's Hospital/Academic Medical Center, PO Box 22660 (room TKsO-247), Amsterdam, Netherlands, 1100 DD
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9
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Phillips RS, Friend AJ, Gibson F, Houghton E, Gopaul S, Craig JV, Pizer B. Antiemetic medication for prevention and treatment of chemotherapy-induced nausea and vomiting in childhood. Cochrane Database Syst Rev 2016; 2:CD007786. [PMID: 26836199 PMCID: PMC7073407 DOI: 10.1002/14651858.cd007786.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nausea and vomiting remain a problem for children undergoing treatment for malignancies despite new antiemetic therapies. Optimising antiemetic regimens could improve quality of life by reducing nausea, vomiting, and associated clinical problems. This is an update of the original systematic review. OBJECTIVES To assess the effectiveness and adverse events of pharmacological interventions in controlling anticipatory, acute, and delayed nausea and vomiting in children and young people (aged less than 18 years) about to receive or receiving chemotherapy. SEARCH METHODS Searches included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, PsycINFO, conference proceedings of the American Society of Clinical Oncology, International Society of Paediatric Oncology, Multinational Association of Supportive Care in Cancer, and ISI Science and Technology Proceedings Index from incept to December 16, 2014, and trial registries from their earliest records to December 2014. We examined references of systematic reviews and contacted trialists for information on further studies. We also screened the reference lists of included studies. SELECTION CRITERIA Two review authors independently screened abstracts in order to identify randomised controlled trials (RCTs) that compared a pharmacological antiemetic, cannabinoid, or benzodiazepine with placebo or any alternative active intervention in children and young people (less than 18 years) with a diagnosis of cancer who were to receive chemotherapy. DATA COLLECTION AND ANALYSIS Two review authors independently extracted outcome and quality data from each RCT. When appropriate, we undertook meta-analysis. MAIN RESULTS We included 34 studies that examined a range of different antiemetics, used different doses and comparators, and reported a variety of outcomes. The quality and quantity of included studies limited the exploration of heterogeneity to narrative approaches only.The majority of quantitative data related to the complete control of acute vomiting (27 studies). Adverse events were reported in 29 studies and nausea outcomes in 16 studies.Two studies assessed the addition of dexamethasone to 5-HT3 antagonists for complete control of vomiting (pooled risk ratio (RR) 2.03; 95% confidence interval (CI) 1.35 to 3.04). Three studies compared granisetron 20 mcg/kg with 40 mcg/kg for complete control of vomiting (pooled RR 0.93; 95% CI 0.80 to 1.07). Three studies compared granisetron with ondansetron for complete control of acute nausea (pooled RR 1.05; 95% CI 0.94 to 1.17; 2 studies), acute vomiting (pooled RR 2.26; 95% CI 2.04 to 2.51; 3 studies), delayed nausea (pooled RR 1.13; 95% CI 0.93 to 1.38; 2 studies), and delayed vomiting (pooled RR 1.13; 95% CI 0.98 to 1.29; 2 studies). No other pooled analyses were possible.Narrative synthesis suggests that 5-HT3 antagonists are more effective than older antiemetic agents, even when these agents are combined with a steroid. Cannabinoids are probably effective but produce frequent side effects. AUTHORS' CONCLUSIONS Our overall knowledge of the most effective antiemetics to prevent chemotherapy-induced nausea and vomiting in childhood is incomplete. Future research should be undertaken in consultation with children, young people, and families that have experienced chemotherapy and should make use of validated, age-appropriate measures. This review suggests that 5-HT3 antagonists are effective in patients who are to receive emetogenic chemotherapy, with granisetron or palonosetron possibly better than ondansetron. Adding dexamethasone improves control of vomiting, although the risk-benefit profile of adjunctive steroid remains uncertain.
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Affiliation(s)
- Robert S Phillips
- University of YorkCentre for Reviews and DisseminationYorkUKYO10 5DD
| | - Amanda J Friend
- Leeds Community HealthcareCommunity PaediatricsStockdale House, Headingley Office Park, Victoria RoadLeedsUKLS6 1PF
| | - Faith Gibson
- London South Bank UniversityDepartment of Children's Nursing103 Borough RoadLondonUKSE1 OAA
| | - Elizabeth Houghton
- Alder Hey Children's NHS Foundation TrustPharmacyEaton RoadLiverpoolUKL12 2AP
| | - Shireen Gopaul
- Leeds Institute of Molecular Medicine/Cancer Research UK Clinical Centre/St James University HospitalSection of Experimental OncologyBeckett StreetLeedsUKLS9 &TF
| | - Jean V Craig
- School of Medicine, Health Policy and PracticeUniversity of East AngliaNorwichUKNR4 7TJ
| | - Barry Pizer
- Alder Hey Children's NHS Foundation TrustOncology UnitAlder HeyEaton RoadLiverpoolUKL12 2AP
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10
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Wojenski DJ, Barreto JN, Wolf RC, Tosh PK. Cefpodoxime for antimicrobial prophylaxis in neutropenia: a retrospective case series. Clin Ther 2014; 36:976-81. [PMID: 24832560 DOI: 10.1016/j.clinthera.2014.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 01/29/2014] [Revised: 03/18/2014] [Accepted: 04/08/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial prophylaxis in select neutropenic patients has reduced fever, infection rates, hospital length of stay, and hospitalization rates. Guidelines from the Infectious Diseases Society of America recommend the consideration of prophylaxis with a fluoroquinolone in patients at high risk for infection after chemotherapy. The use of fluoroquinolones has been associated with many adverse events, and there is limited evidence on alternative antimicrobial prophylaxis in patients intolerant of fluoroquinolones. OBJECTIVES Our study describes a single-center experience of cefpodoxime as an alternative to fluoroquinolones for antibacterial prophylaxis during neutropenia after chemotherapy and represents a retrospective evaluation of an oral cephalosporin in adult patients for this purpose. METHODS This retrospective case series analyzed data from the electronic medical records of 41 patients having hematologic malignancies and given cefpodoxime for neutropenic prophylaxis. RESULTS The rate of febrile neutropenia was 85%, with 60% culture-positive infections. Gram-positive organisms were identified in 52% of positive cultures, and gram-negative organisms represented 40% of positive cultures. Antimicrobial resistance to guideline-recommended empiric treatment regimens was not seen in breakthrough infections. CONCLUSIONS Cefpodoxime can be utilized for prophylaxis, without adversely affecting resistance to broad-spectrum agents, and maintains a high level of appropriateness of guideline-recommended empiric regimens. This study of cefpodoxime prophylaxis in adult patients intolerant to fluoroquinolones adds to the literature of potential alternative agents for prophylaxis in neutropenic patients.
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Affiliation(s)
| | | | - Robert C Wolf
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Pritish K Tosh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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11
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Mulder RL, van Dalen EC, Van den Hof M, Leclercq E, Bresters D, Koot BGP, Castellino SM, Loke Y, Post PN, Caron HN, Postma A, Kremer LCM. Hepatic late adverse effects after antineoplastic treatment for childhood cancer. Cochrane Database Syst Rev 2011; 2011:CD008205. [PMID: 21735424 PMCID: PMC6464972 DOI: 10.1002/14651858.cd008205.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [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: 12/16/2022]
Abstract
BACKGROUND Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately the improved prognosis has resulted in the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. OBJECTIVES To evaluate the existing evidence on the association between antineoplastic treatment for childhood cancer and hepatic late adverse effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). In addition, we searched reference lists of relevant articles and conference proceedings. SELECTION CRITERIA All studies except case reports, case series and studies including less than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, risk of bias assessment and data extraction. MAIN RESULTS We identified 20 cohort studies investigating hepatic late adverse effects after antineoplastic treatment for childhood cancer. All studies had methodological limitations. The prevalence of hepatic late adverse effects varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well defined as alanine aminotransferase (ALT) above the upper limit of normal resulted in five studies. In this subgroup the prevalence of hepatic late adverse effects ranged from 8.0% to 52.8%, with follow-up durations varying from one to 27 years after the end of treatment. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal resulted in three studies, with a prevalence ranging from 7.9% to 44.8%. Chronic viral hepatitis was identified as a risk factor for hepatic late adverse effects in univariate analyses. It is unclear which specific antineoplastic treatments increase the risk of hepatic late adverse effects AUTHORS' CONCLUSIONS The prevalence of hepatic late adverse effects ranged from 7.9% to 52.8% when selecting studies with an adequate outcome definition. It has not been established which childhood cancer treatments result in hepatic late adverse effects. There is a suggestion that chronic viral hepatitis increases the risk of hepatic late adverse effects. More well-designed studies are needed to reliably evaluate the prevalence of, and risk factors for, hepatic late adverse effects after antineoplastic treatment for childhood cancer.
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Affiliation(s)
- Renée L Mulder
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Malon Van den Hof
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Edith Leclercq
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Dorine Bresters
- Leiden University Medical CenterDepartment of Paediatric Immunology, Haemato‐Oncology, Bone Marrow Transplantation and Auto‐immune Diseases, Willem‐Alexander Kinder‐ en JeugdcentrumPO Box 9600LeidenNetherlands2300 RC
| | - Bart GP Koot
- Emma Children's Hospital / Academic Medical CenterDepartment of Paediatric Gastroenterology and NutritionP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Sharon M Castellino
- Wake Forest University School of MedicinePediatrics section Hematology/OncologyMedical Center blvd.Winston‐Salem, NCUSA27157
| | - Yoon Loke
- University of East AngliaSchool of MedicineNorwichUKNR4 7TJ
| | - Piet N Post
- Dutch Institute for Healthcare Improvement CBOPO Box 20064UtrechtNetherlands3502 LB
| | - Huib N Caron
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - Leontien CM Kremer
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
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12
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Colosia AD, Peltz G, Pohl G, Liu E, Copley-Merriman K, Khan S, Kaye JA. A review and characterization of the various perceptions of quality cancer care. Cancer 2011; 117:884-96. [PMID: 20939015 PMCID: PMC3073118 DOI: 10.1002/cncr.25644] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 08/12/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND It is important to maintain high-quality cancer care while reducing spending. This requires an understanding of how stakeholders define "quality." The objective of this literature review was to understand the perceptions patients, physicians, and managed care professionals have about quality cancer care, especially chemotherapy. METHODS A computerized literature search was conducted for articles concerning quality cancer care in patients who received chemotherapy. Among >1100 identified sources, 25 presented interviews/survey results from stakeholders. RESULTS Patients defined quality cancer care as being treated well by providers, having multiple treatment options, and being part of the decision-making process. Waiting to see providers, having problems with referrals, going to different locations for treatment, experiencing billing inaccuracies, and navigating managed care reimbursement negatively affected patients' quality-of-care perceptions. Providers perceived quality cancer care as making decisions based on the risks-benefits of specific chemotherapy regimens and patients' health status rather than costs. Providers objected to spending substantial time interacting with payers instead of delivering care to patients. Payers must control the costs of cancer care but do not want an adversarial relationship with providers and patients. Payers' methods of managing cancer more efficiently involved working with providers to develop assessment and decision-assist tools. CONCLUSIONS Delivering quality cancer care is increasingly difficult because of the shortage of oncologists and rising costs of chemotherapy agents, radiation therapy, and imaging tests. The definition of quality cancer care differed among stakeholders, and healthcare reform must reflect these various needs to maintain and improve quality while controlling costs.
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Affiliation(s)
- Ann D Colosia
- Market Access and Outcomes Strategy, RTI Health Solutions, Research Triangle Park, North Carolina.
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13
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Abstract
BACKGROUND Purified thymus extracts (pTE) and synthetic thymic peptides (sTP) are thought to enhance the immune system of cancer patients in order to fight the growth of tumour cells and to resist infections due to immunosuppression induced by the disease and antineoplastic therapy. OBJECTIVES To evaluate the effectiveness of pTE and sTP for the management of cancer. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE, EMBASE, AMED, BIOETHICSLINE, BIOSIS, CATLINE, CISCOM, HEALTHSTAR, HTA, SOMED and LILACS (to February 2010). SELECTION CRITERIA Randomised trials of pTE or sTP in addition to chemotherapy or radiotherapy, or both, compared to the same regimen with placebo or no additional treatment in adult cancer patients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from published trials. We derived odds ratios (OR) from overall survival (OS) and disease-free survival (DFS) rates, tumour response (TR) rates, and rates of adverse effects (AE) related to antineoplastic treatments. We used a random-effects model for meta-analysis. MAIN RESULTS We identified 26 trials (2736 patients). Twenty trials investigated pTE (thymostimulin or thymosin fraction 5) and six trials investigated sTP (thymopentin or thymosin α(1)). Twenty-one trials reported results for OS, six for DFS, 14 for TR, nine for AE and 10 for safety of pTE and sTP. Addition of pTE conferred no benefit on OS (RR 1.00, 95% CI 0.79 to 1.25); DFS (RR 0.97, 95% CI 0.82 to 1.16); or TR (RR 1.07, 95% CI 0.92 to 1.25). Heterogeneity was moderate to high for all these outcomes. For thymosin α(1) the pooled RR for OS was 1.21 (95% CI 0.94 to 1.56, P = 0.14), with low heterogeneity; and 3.37 (95% CI 0.66 to 17.30, P = 0.15) for DFS, with moderate heterogeneity. The pTE reduced the risk of severe infectious complications (RR 0.54, 95% CI 0.38 to 0.78, P = 0.0008; I² = 0%). The RR for severe neutropenia in patients treated with thymostimulin was 0.55 (95% CI 0.25 to 1.23, P = 0.15). Tolerability of pTE and sTP was good. Most of the trials had at least a moderate risk of bias. AUTHORS' CONCLUSIONS Overall, we found neither evidence that the addition of pTE to antineoplastic treatment reduced the risk of death or disease progression nor that it improved the rate of tumour responses to antineoplastic treatment. For thymosin α(1), there was a trend for a reduced risk of dying and of improved DFS. There was preliminary evidence that pTE lowered the risk of severe infectious complications in patients undergoing chemotherapy or radiotherapy.
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Affiliation(s)
- Elke Wolf
- Klinikum NordMedizinische Klinik 5‐Schwerpunkt Onkologie/HaematologieProf.‐Ernst‐Nathan‐Str. 1NuernbergGermany90340
| | - Stefania Milazzo
- Paracelsus Medical University, Klinikum NuernbergDepartment of Internal Medicine, Division of Oncology and HematologyProf.‐Ernst‐Nathan‐Str. 1NuernbergGermanyD‐90419
| | - Katja Boehm
- Klinikum NordMedizinische Klinik 5‐Schwerpunkt Onkologie/HaematologieProf.‐Ernst‐Nathan‐Str. 1NuernbergGermany90340
| | - Marcel Zwahlen
- University of BernInstitute of Social and Preventive MedicineFinkelhubelweg11BernSwitzerland3012
| | - Markus Horneber
- Paracelsus Medical University, Klinikum NurembergDepartment of Internal Medicine, Division of Oncology and HematologyProf.‐Ernst‐Nathan‐Str. 1NurembergGermanyD‐90419
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14
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Abstract
BACKGROUND Treatment of cancer is increasingly effective but associated with short and long term side effects. Oral side effects, including oral mucositis (mouth ulceration), remain a major source of illness despite the use of a variety of agents to treat them. OBJECTIVES To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy or radiotherapy or both. SEARCH STRATEGY Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 1 June 2010), CENTRAL via The Cochrane Library (to Issue 2, 2010), MEDLINE via OVID (1950 to 1 June 2010), EMBASE via OVID (1980 to 1 June 2010), CINAHL via EBSCO (1980 to 1 June 2010), CANCERLIT via PubMed (1950 to 1 June 2010), OpenSIGLE (1980 to 1 June 2010) and LILACS via the Virtual Health Library (1980 to 1 June 2010) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. SELECTION CRITERIA All randomised controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy or radiotherapy or both. Outcomes were oral mucositis, time to heal mucositis, oral pain, duration of pain control, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and quality of life. DATA COLLECTION AND ANALYSIS Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation, blindness and withdrawals. Risk of bias assessment was carried out on six domains. The Cochrane Collaboration statistical guidelines were followed and risk ratio (RR) values calculated using fixed-effect models (less than 3 trials in each meta-analysis). MAIN RESULTS Thirty-two trials involving 1505 patients satisfied the inclusion criteria. Three comparisons for mucositis treatment including two or more trials were: benzydamine HCl versus placebo, sucralfate versus placebo and low level laser versus sham procedure. Only the low level laser showed a reduction in severe mucositis when compared with the sham procedure, RR 5.28 (95% confidence interval (CI) 2.30 to 12.13).Only 3 comparisons included more than one trial for pain control: patient controlled analgesia (PCA) compared to the continuous infusion method, therapist versus control, cognitive behaviour therapy versus control. There was no evidence of a difference in mean pain score between PCA and continuous infusion, however, less opiate was used per hour for PCA, mean difference 0.65 mg/hour (95% CI 0.09 to 1.20), and the duration of pain was less 1.9 days (95% CI 0.3 to 3.5). AUTHORS' CONCLUSIONS There is weak and unreliable evidence that low level laser treatment reduces the severity of the mucositis. Less opiate is used for PCA versus continuous infusion. Further, well designed, placebo or no treatment controlled trials assessing the effectiveness of interventions investigated in this review and new interventions for treating mucositis are needed.
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Affiliation(s)
- Jan E Clarkson
- University of DundeeDental Health Services Research UnitThe Mackenzie BuildingKirsty Semple WayDundeeUKDD2 4BF
| | - Helen V Worthington
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Susan Furness
- The University of ManchesterCochrane Oral Health Group, School of DentistryCoupland III Bldg, Oxford RdManchesterUKM13 9PL
| | - Martin McCabe
- University of ManchesterSchool of Cancer and Enabling Sciences, Manchester Academic Health Science CentreAcademic Unit of Paediatric and Adolescent Oncology, Young Oncology UnitThe Christie NHS Foundation Trust, Wilmslow RoadManchesterUKM20 4BX
| | - Tasneem Khalid
- Royal Manchester Children's HospitalDepartment of Haematology/OncologyOxford RoadManchesterUKM13 9WL
| | - Stefan Meyer
- The University of ManchesterPaediatric and Adolescent Oncology, Royal Manchester Children's and Christie Hospital, School of Cancer and Enabling Sciences, Manchester Academic Health Science CentreYoung Oncology Unit, Christie HospitalWilmslow RoadManchesterUKM20 4BX
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