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Bryant AK, Lewy JR, Bressler RD, Chopra Z, Gyori DJ, Bazzell BG, Moeller JA, Jacobson SI, Fendrick AM, Kerr EA, Ramnath N, Green MD, Hofer TP, Vaishnav P, Strohbehn GW. Projected environmental and public health benefits of extended-interval dosing: an analysis of pembrolizumab use in a US national health system. Lancet Oncol 2024; 25:802-810. [PMID: 38821085 DOI: 10.1016/s1470-2045(24)00200-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Health care is a major source of greenhouse gas emissions, leading to climate change and public health harms. Changes are needed to improve the environmental sustainability of health-care practices, but such changes should not sacrifice patient outcomes or financial sustainability. Alternative dosing strategies that reduce the frequency with which specialty drugs are administered, without sacrificing patient outcomes, are an attractive possibility for improving environmental sustainability. We sought to inform environmentally sustainable cancer care by estimating and comparing the environmental and financial effects of alternative, clinically equivalent strategies for pembrolizumab administration. METHODS We conducted a retrospective analysis using a cohort of patients from the Veterans Health Administration (VHA) in the USA who received one or more pembrolizumab doses between May 1, 2020, and Sept 30, 2022. Using baseline, real-world administration of pembrolizumab, we generated simulated pembrolizumab use data under three near-equivalent counterfactual pembrolizumab administration strategies defined by combinations of weight-based dosing, pharmacy-level vial sharing and dose rounding, and extended-interval dosing (ie, every 6 weeks). For each counterfactual dosing strategy, we estimated greenhouse gas emissions related to pembrolizumab use across the VHA cohort using a deterministic environmental impact model that estimated greenhouse gas emissions due to patient travel, drug manufacture, and medical waste as the primary outcome measure. FINDINGS We identified 7813 veterans who received at least one dose of pembrolizumab-containing therapy in the VHA during the study period. 59 140 pembrolizumab administrations occurred in the study period, of which 46 255 (78·2%) were dosed at 200 mg every 3 weeks, 12 885 (21·8%) at 400 mg every 6 weeks, and 14 955 (25·3%) were coadministered with infusional chemotherapies. Adoption of weight-based, extended-interval pembrolizumab dosing (4 mg/kg every 6 weeks) and pharmacy-level stewardship strategies (ie, dose rounding and vial sharing) for all pembrolizumab infusions would have resulted in 24·7% fewer administration events than baseline dosing (44 533 events vs 59 140 events) and an estimated 200 metric tons less CO2 emitted per year as a result of pembrolizumab use within the VHA (650 tons vs 850 tons of CO2, a relative reduction of 24%), largely due to reductions in distance travelled by patients to receive treatment. Similar results were observed when weight-based and extended-interval dosing were applied only to pembrolizumab monotherapy and pembrolizumab in combination with oral therapies. INTERPRETATION Alternative pembrolizumab administration strategies might have environmental advantages over the current dosing and compounding paradigms. Specialty medication dosing can be optimised for health-care spending and environmental sustainability without sacrificing clinical outcomes. FUNDING None.
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Affiliation(s)
- Alex K Bryant
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Radiation Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Jacqueline R Lewy
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - R Daniel Bressler
- School of International and Public Affairs, Columbia Climate School, and Center for Environmental Economics and Policy, Columbia University, New York, NY, USA
| | - Zoey Chopra
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Economics, University of Michigan, Ann Arbor, MI, USA
| | - Derek J Gyori
- Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Brian G Bazzell
- Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Julie A Moeller
- Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | | | - A Mark Fendrick
- Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI, USA
| | - Eve A Kerr
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Nithya Ramnath
- Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Green
- Department of Radiation Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Timothy P Hofer
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
| | - Parth Vaishnav
- School for Environment and Sustainability, University of Michigan, Ann Arbor, MI, USA
| | - Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA; Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA.
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Ito T, Kaku-Ito Y, Ohno F, Nakahara T. A real-world study on the safety profile of extended-interval dosing of immune checkpoint inhibitors for melanoma: a single-center analysis in Japan. Front Med (Lausanne) 2023; 10:1293397. [PMID: 38143437 PMCID: PMC10740208 DOI: 10.3389/fmed.2023.1293397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023] Open
Abstract
Background Anti-programmed death-1 (PD-1) antibodies are the mainstay for the treatment of unresectable or high-risk melanoma. However, real-world data on the safety profile of their extended-interval doses (EDs) are limited, particularly in Asian patients with melanoma. Materials and methods In this single-center retrospective study, we analyzed the risks of immune-related adverse events (irAEs) among 71 Japanese patients (36 males; mean age, 65.0 years) who received anti-PD-1 monotherapy for melanoma at our institute. Patients who were administered ipilimumab prior to anti-PD-1 monotherapy were excluded. Patients were divided into three groups: canonical-interval dose (CD) group (n = 50, body weight-based dosing or 240 mg Q2W for nivolumab and body weight-based dosing or 200 mg Q3W for pembrolizumab), ED group (n = 14, 480 mg Q4W for nivolumab and 400 mg Q6W for pembrolizumab), and dose-switch (DS) group (n = 7, upfront CD followed by ED). Results The CD group received nivolumab more frequently in the metastatic setting. There were no significant differences in baseline characteristics among the three groups, including in sex, age, primary tumor site, tumor subtype, and follow-up period. irAEs occurred in 36.6% (26 patients) of all patients (32.0% of the CD group, 35.7% of the ED group, and 71.4% of the DS group), while severe (grade ≥ 3) irAEs occurred in only two patients, both of whom were in the CD group. Most of the irAEs occurred during the first 6 months of anti-PD-1 therapy and, interestingly, all of the irAEs in the DS group occurred before the switch (during the CD). There was no significant difference among the three groups in the probability of irAE estimated by the Kaplan-Meier method. Conclusion These findings may highlight the safety of ED of anti-PD-1 monotherapy in the treatment of Asian patients with melanoma.
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Affiliation(s)
- Takamichi Ito
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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