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Strohbehn GW, Stadler WM, Boonstra PS, Ratain MJ. Optimizing the doses of cancer drugs after usual dose finding. Clin Trials 2024; 21:340-349. [PMID: 38148731 DOI: 10.1177/17407745231213882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Since the middle of the 20th century, oncology's dose-finding paradigm has been oriented toward identifying a drug's maximum tolerated dose, which is then carried forward into phase 2 and 3 trials and clinical practice. For most modern precision medicines, however, maximum tolerated dose is far greater than the minimum dose needed to achieve maximal benefit, leading to unnecessary side effects. Regulatory change may decrease maximum tolerated dose's predominance by enforcing dose optimization of new drugs. Dozens of already approved cancer drugs require re-evaluation, however, introducing a new methodologic and ethical challenge in cancer clinical trials. In this article, we assess the history and current landscape of cancer drug dose finding. We provide a set of strategic priorities for postapproval dose optimization trials of the future. We discuss ethical considerations for postapproval dose optimization trial design and review three major design strategies for these unique trials that would both adhere to ethical standards and benefit patients and funders. We close with a discussion of financial and reporting considerations in the realm of dose optimization. Taken together, we provide a comprehensive, bird's eye view of the postapproval dose optimization trial landscape and offer our thoughts on the next steps required of methodologies and regulatory and funding regimes.
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Affiliation(s)
- Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Division of Medical Oncology, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Walter M Stadler
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Philip S Boonstra
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, USA
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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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Wesevich A, Goldstein DA, Paydary K, Peer CJ, Figg WD, Ratain MJ. Interventional pharmacoeconomics for immune checkpoint inhibitors through alternative dosing strategies. Br J Cancer 2023; 129:1389-1396. [PMID: 37542109 PMCID: PMC10628132 DOI: 10.1038/s41416-023-02367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/05/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are approved for the treatment of a variety of cancer types. The doses of these drugs, though approved by the Food and Drug Administration (FDA), have never been optimised, likely leading to significantly higher doses than required for optimal efficacy. Dose optimisation would hypothetically decrease the risk, severity, and duration of immune-related adverse events, as well as provide an opportunity to reduce costs through interventional pharmacoeconomic strategies such as off-label dose reductions or less frequent dosing. We summarise existing evidence for ICI dose optimisation to advocate for the role of interventional pharmacoeconomics.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv, Israel
- Optimal Cancer Care Alliance, Chicago, IL, USA
| | - Koosha Paydary
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William D Figg
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.
- Optimal Cancer Care Alliance, Chicago, IL, USA.
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4
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Tannock IF, Bouche G, Goldstein DA, Goto Y, Lichter AS, Prabhash K, Ranganathan P, Saltz LB, Sonke GS, Strohbehn GW, von Moos R, Ratain MJ. Patient-centred, self-funding dose optimisation trials as a route to reduce toxicity, lower cost and improve access to cancer therapy. Ann Oncol 2023:S0923-7534(23)00687-7. [PMID: 37230253 DOI: 10.1016/j.annonc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada; Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
| | - Gauthier Bouche
- Anticancer Fund, Meise, Belgium; Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasushi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | | | - Kumar Prabhash
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Leonard B Saltz
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabe S Sonke
- Department of Medical Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, & University of Amsterdam, Amsterdam, The Netherlands
| | - Garth W Strohbehn
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan; Section of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland & SAKK Competence Center, Bern
| | - Mark J Ratain
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Strohbehn GW, Lichter AS, Ratain MJ. US Government Payer-Funded Trials to Address Oncology's Drug-Dosing Conundrum: A Congressional Call to Action? J Clin Oncol 2023; 41:2488-2492. [PMID: 36780590 DOI: 10.1200/jco.22.02049] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI.,LTC Charles S Kettles VA Medical Center, Ann Arbor, MI.,University of Michigan Rogel Cancer Center, Ann Arbor, MI.,Optimal Cancer Care Alliance, Ann Arbor, MI
| | | | - Mark J Ratain
- Optimal Cancer Care Alliance, Ann Arbor, MI.,University of Chicago, Chicago, IL.,University of Chicago Medicine, Chicago, IL.,Center for Personalized Therapeutics, The University of Chicago, Chicago, IL
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