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Chemotherapy in combination with anti-PD-1 agents as adjuvant therapy for high-risk oral mucosal melanoma. J Cancer Res Clin Oncol 2022; 149:2293-2300. [PMID: 36088610 DOI: 10.1007/s00432-022-04090-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/24/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Adjuvant therapy plays a critical role in the treatment of oral mucosal melanoma (OMM). Anti-programmed cell death-1 (PD-1) agents are recommended as front-line therapy for metastatic melanoma, but their efficacy as adjuvant therapy for high-risk OMM remains unclear. PATIENTS AND METHODS A single-center, retrospective cohort study was conducted in 193 nodular-type oral mucosal melanoma (NOMM) patients who received chemotherapy alone or in combination with high-dose interferon-α2b (HDI) or anti-PD-1 agents as adjuvant therapy. Multivariate analysis was performed to identify significant prognostic factors for the 2-year overall survival (OS) and progression-free survival (PFS). RESULTS Tumor thickness, ulceration and invasion level were found to be independent prognostic factors for both 2-year OS and PFS, while T-stage was only associated with OS. The 2-year OS and PFS were 43.5% and 10.9% in patients who received only chemotherapy. In comparison, the 2-year OS was improved, albeit not significantly (47.4%; p > 0.05), and PFS was significantly improved (43.6%; p = 0.0028) in patients who received chemotherapy plus HDI; and both 2-year OS (71.0%; p = 0.0118) and PFS (53.6%; p = 0.0001) were significantly improved in patients received chemotherapy plus anti-PD-1. The serious adverse event (SAE) (p < 0.0001) and discontinued treatment due to SAE (p < 0.0001) were significantly lower in patients who received anti-PD-1 than in patients who received HDI. CONCLUSIONS Invasion level and tumor thickness are independent prognostic factors for NOMM. Chemotherapy plus anti-PD-1 agents seem to be the adjuvant therapy of choice for NOMM, as it is safer and more tolerable than HDI and, more importantly, it can significantly improve the OS and PFS.
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Salans M, Courtney PT, Yip A, Murphy JD. Cost-effectiveness of ipilimumab versus high-dose interferon as an adjuvant therapy in resected high-risk melanoma. Cancer Med 2021; 10:6618-6626. [PMID: 34402192 PMCID: PMC8495287 DOI: 10.1002/cam4.4194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Adjuvant ipilimumab was found to improve the overall survival and reduce toxicity compared to high-dose interferon (HDI) in patients with resected, high-risk melanoma. However, the cost of ipilimumab is substantially higher than HDI. This study evaluates the cost-effectiveness of ipilimumab as an adjuvant treatment in melanoma from a healthcare perspective. METHODS We designed a Markov model simulating resected, high-risk melanoma patients receiving either ipilimumab or HDI. Transition probabilities, including risks of survival, disease progression, and toxicity, were ascertained from clinical trial data. Costs and quality of life measurements (health utilities) were extracted from the literature. Incremental cost-effectiveness ratios (ICERs), defined as incremental costs divided by incremental quality-adjusted life-years (QALYs), assessed cost-effectiveness. ICERs <$100,000/QALY were deemed cost-effective. We measured model uncertainty with one-way and probabilistic sensitivity analyses. RESULTS In our base case model, ipilimumab increased costs by $107,100 and increased effectiveness by 0.43 QALY, yielding an ICER of $392,600/QALY. Our model was moderately sensitive to the costs of ipilimumab, though the cost of ipilimumab would need to decrease by 44% for ipilimumab to become cost-effective compared to HDI. The model was not sensitive to survival, toxicity, or other costs. Probabilistic sensitivity analysis showed that HDI would remain the cost-effective treatment option 96.2% of the time at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS Adjuvant ipilimumab increases the survival and decreases the toxicity compared to HDI in resected, high-risk melanoma patients, though this would not be considered cost-effective due to the high price of ipilimumab.
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Affiliation(s)
- Mia Salans
- University of California San Diego School of Medicine, La Jolla, California, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Patrick Travis Courtney
- University of California San Diego School of Medicine, La Jolla, California, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Anthony Yip
- University of California San Diego School of Medicine, La Jolla, California, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - James D Murphy
- University of California San Diego School of Medicine, La Jolla, California, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
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Bashraheel SS, Domling A, Goda SK. Update on targeted cancer therapies, single or in combination, and their fine tuning for precision medicine. Biomed Pharmacother 2020; 125:110009. [PMID: 32106381 DOI: 10.1016/j.biopha.2020.110009] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Until recently, patients who have the same type and stage of cancer all receive the same treatment. It has been established, however, that individuals with the same disease respond differently to the same therapy. Further, each tumor undergoes genetic changes that cause cancer to grow and metastasize. The changes that occur in one person's cancer may not occur in others with the same cancer type. These differences also lead to different responses to treatment. Precision medicine, also known as personalized medicine, is a strategy that allows the selection of a treatment based on the patient's genetic makeup. In the case of cancer, the treatment is tailored to take into account the genetic changes that may occur in an individual's tumor. Precision medicine, therefore, could be defined in terms of the targets involved in targeted therapy. METHODS A literature search in electronic data bases using keywords "cancer targeted therapy, personalized medicine and cancer combination therapies" was conducted to include papers from 2010 to June 2019. RESULTS Recent developments in strategies of targeted cancer therapy were reported. Specifically, on the two types of targeted therapy; first, immune-based therapy such as the use of immune checkpoint inhibitors (ICIs), immune cytokines, tumor-targeted superantigens (TTS) and ligand targeted therapeutics (LTTs). The second strategy deals with enzyme/small molecules-based therapies, such as the use of a proteolysis targeting chimera (PROTAC), antibody-drug conjugates (ADC) and antibody-directed enzyme prodrug therapy (ADEPT). The precise targeting of the drug to the gene or protein under attack was also investigated, in other words, how precision medicine can be used to tailor treatments. CONCLUSION The conventional therapeutic paradigm for cancer and other diseases has focused on a single type of intervention for all patients. However, a large literature in oncology supports the therapeutic benefits of a precision medicine approach to therapy as well as combination therapies.
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Affiliation(s)
- Sara S Bashraheel
- Protein Engineering Unit, Life and Science Research Department, Anti-Doping Lab-Qatar (ADLQ), Doha, Qatar; Drug Design Group, Department of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Alexander Domling
- Drug Design Group, Department of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Sayed K Goda
- Cairo University, Faculty of Science, Chemistry Department, Giza, Egypt.
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4
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Rubio-Rodríguez D, De Diego Blanco S, Pérez M, Rubio-Terrés C. Cost-Effectiveness of Drug Treatments for Advanced Melanoma: A Systematic Literature Review. PHARMACOECONOMICS 2017; 35:879-893. [PMID: 28551858 DOI: 10.1007/s40273-017-0517-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Until recently, advanced melanoma (unresectable and metastatic) has had a poor prognosis and has been treated with chemotherapy. The introduction of new treatments (BRAF and MEK inhibitors and immunotherapy) has improved overall survival and progression-free survival of some patients. OBJECTIVE The objective of this study was to review the published evidence on the cost-effectiveness of pharmacological treatments for advanced melanoma. METHODS A systematic literature search was conducted, without date or language restrictions, in PubMed, EMBASE, Scopus, the Cochrane Library, the UK National Institute for Health and Care Excellence databases and the Health Technology Assessment journal. Internet searches were also made to identify possible grey literature. Main study characteristics, methods and outcomes were extracted and critically assessed. The quality of health economic studies was assessed by the Quality Assessment of Economic Evaluation in Health Care checklist. RESULTS The search identified nine full-text pharmacoeconomic analyses of advanced melanoma treatments. According to the economic analyses published in the articles, the new treatments have been shown to be more effective (with more life-years and quality-adjusted life-years) than chemotherapy, although generally the cost per quality-adjusted life-year gained was above the commonly accepted threshold. Because of the variability of the available analyses comparing the new treatments, we cannot determine which treatment is the most cost-effective. CONCLUSIONS From the available data, it cannot be concluded that the new drugs (BRAF and MEK inhibitors and immunotherapy) are cost effective compared with chemotherapy or which is the most cost-effective new treatment.
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Affiliation(s)
| | | | - Maite Pérez
- Medical Department, AstraZeneca Farmacéutica Spain, Barcelona, Spain
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Johnston KM, McPherson E, Osenenko K, Vergidis J, Levy AR, Peacock S. Cost-effectiveness of therapies for melanoma. Expert Rev Pharmacoecon Outcomes Res 2015; 15:229-42. [PMID: 25703441 DOI: 10.1586/14737167.2015.1017563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Melanoma presents an important burden worldwide. Until recently, the prognosis for unresectable and metastatic melanoma was poor, with 10% of metastatic melanoma patients surviving for 2 years. The introduction of newer therapies including ipilimumab, vemurafenib, dabrafenib and trametinib improved progression-free survival, with additional benefits anticipated from the forthcoming class of programmed cell death 1 inhibitors. Cost of therapy and resulting cost-effectiveness is an important factor in determining patient access to specific treatments. The objective of this study was to review the published evidence regarding cost-effectiveness of melanoma therapies and provide an overview of the relative cost-effectiveness of available therapies by disease stage. For earlier-stage disease, IFN-α has been found to be cost-effective, although its clinical benefits have not been well established. For unresectable and metastatic melanoma, newer therapies provide benefits over standard-of-care chemotherapy, but comprehensive analyses will need to be conducted to determine the most cost-effective therapy.
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Malas S, Harrasser M, Lacy KE, Karagiannis SN. Antibody therapies for melanoma: new and emerging opportunities to activate immunity (Review). Oncol Rep 2014; 32:875-86. [PMID: 24969320 PMCID: PMC4121424 DOI: 10.3892/or.2014.3275] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/06/2014] [Indexed: 12/21/2022] Open
Abstract
The interface between malignant melanoma and patient immunity has long been recognised and efforts to treat this most lethal form of skin cancer by activating immune responses with cytokine, vaccine and also antibody immunotherapies have demonstrated promise in limited subsets of patients. In the present study, we discuss different antibody immunotherapy approaches evaluated in the context of melanoma, each designed to act on distinct targets and to employ different mechanisms to restrict tumour growth and spread. Monoclonal antibodies recognising melanoma-associated antigens such as CSPG4/MCSP and targeting elements of tumour-associated vasculature (VEGF) have constituted long-standing translational approaches aimed at reducing melanoma growth and metastasis. Recent insights into mechanisms of immune regulation and tumour-immune cell interactions have helped to identify checkpoint molecules on immune (CTLA4, PD-1) and tumour (PD-L1) cells as promising therapeutic targets. Checkpoint blockade with antibodies to activate immune responses and perhaps to counteract melanoma-associated immunomodulatory mechanisms led to the first clinical breakthrough in the form of an anti-CTLA4 monoclonal antibody. Novel modalities to target key mechanisms of immune suppression and to redirect potent effector cell subsets against tumours are expected to improve clinical outcomes and to provide previously unexplored avenues for therapeutic interventions.
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Affiliation(s)
- Sadek Malas
- St. John's Institute of Dermatology, Division of Genetics and Molecular Medicine and NIHR Biomedical Research Centre at Guy's and St. Thomas' Hospitals, King's College London, London SE1 9RT, UK
| | - Micaela Harrasser
- St. John's Institute of Dermatology, Division of Genetics and Molecular Medicine and NIHR Biomedical Research Centre at Guy's and St. Thomas' Hospitals, King's College London, London SE1 9RT, UK
| | - Katie E Lacy
- St. John's Institute of Dermatology, Division of Genetics and Molecular Medicine and NIHR Biomedical Research Centre at Guy's and St. Thomas' Hospitals, King's College London, London SE1 9RT, UK
| | - Sophia N Karagiannis
- St. John's Institute of Dermatology, Division of Genetics and Molecular Medicine and NIHR Biomedical Research Centre at Guy's and St. Thomas' Hospitals, King's College London, London SE1 9RT, UK
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Abstract
BACKGROUND Several studies have demonstrated an increased risk of nonmelanoma skin cancer (NMSC) in patients with inflammatory bowel disease, with the greatest risk in patients with Crohn's disease (CD). We investigated the cost-effectiveness of NMSC screening in patients with CD. METHODS A mathematical model was used to compare lifetime costs, life expectancies, and benefits of NMSC screening in a hypothetical cohort of 100,000 patients with CD. Strategies studied include: (1) Treat NMSC cases as they present and follow affected patients annually; (2) Screen patients with CD annually once they turn 50 years old, treat NMSC cases as they present and follow affected patients annually; (3) Screen patients with CD annually once they start receiving thiopurines, treat NMSC cases as they present and follow affected patients annually; (4) Screen patients with CD annually when they turn 50 years old or start receiving thiopurines, treat NMSC cases as they present, and follow affected patients annually; (5) Screen all patients with CD annually. These strategies were then studied on a biennial basis, accounting for 10 competing strategies. RESULTS Screening all patients with CD annually proved the most cost-effective strategy with an average lifetime cost of more than $333,000, a quality-adjusted life expectancy of about 26 QALYs (95% confidence interval: 22-29), ICER of $3263/QALY, and led to early detection of about 94% of incident NMSC cases. The next best strategy was screening all CD patients biennially with an average lifetime cost of more than $328,000 with 24.5 QALYs (95% confidence interval: 21-25). Only 47% of new NMSC cases were detected early with this strategy. CONCLUSION At a willingness-to-pay threshold of $50,000, screening all patients with CD annually for NMSC proved the most cost-effective strategy.
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Wilson ECF, Emery JD, Kinmonth AL, Prevost AT, Morris HC, Humphrys E, Hall PN, Burrows N, Bradshaw L, Walls J, Norris P, Johnson M, Walter FM. The cost-effectiveness of a novel SIAscopic diagnostic aid for the management of pigmented skin lesions in primary care: a decision-analytic model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:356-366. [PMID: 23538188 DOI: 10.1016/j.jval.2012.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 11/26/2012] [Accepted: 12/09/2012] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Pigmented skin lesions are commonly presented in primary care. Appropriate diagnosis and management is challenging because the vast majority are benign. The MoleMate system is a handheld SIAscopy scanner integrated with a primary care diagnostic algorithm aimed at improving the management of pigmented skin lesions in primary care. METHODS This decision-model-based economic evaluation draws on the results of a randomized controlled trial of the MoleMate system versus best practice (ISRCTN79932379) to estimate the expected long-term cost and health gain of diagnosis with the MoleMate system versus best practice in an English primary care setting. The model combines trial results with data from the wider literature to inform long-term prognosis, health state utilities, and cost. RESULTS Results are reported as mean and incremental cost and quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness ratio with probabilistic sensitivity analysis, and value of information analysis. Over a lifetime horizon, the MoleMate system is expected to cost an extra £18 over best practice alone, and yield an extra 0.01 QALYs per patient examined. The incremental cost-effectiveness ratio is £1,896 per QALY gained, with a 66.1% probability of being below £30,000 per QALY gained. The expected value of perfect information is £43.1 million. CONCLUSIONS Given typical thresholds in the United Kingdom (£20,000-£30,000 per QALY), the MoleMate system may be cost-effective compared with best practice diagnosis alone in a primary care setting. However, there is considerable decision uncertainty, driven particularly by the sensitivity and specificity of MoleMate versus best practice, and the risk of disease progression in undiagnosed melanoma; future research should focus on reducing uncertainty in these parameters.
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Kirkwood JM, Tarhini A, Sparano JA, Patel P, Schiller JH, Vergo MT, Benson Iii AB, Tawbi H. Comparative clinical benefits of systemic adjuvant therapy for paradigm solid tumors. Cancer Treat Rev 2013; 39:27-43. [PMID: 22520262 PMCID: PMC8555872 DOI: 10.1016/j.ctrv.2012.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/16/2012] [Accepted: 03/18/2012] [Indexed: 01/15/2023]
Abstract
Adjuvant therapy employing cytotoxic chemotherapy, molecularly targeted agents, immunologic, and hormonal agents has shown a significant impact upon a variety of solid tumors. The principles that guide adjuvant therapy differ among various tumor types and specific modalities, but generally indicate a greater impact of therapy in the postsurgical setting of micrometastatic disease, for which adjuvant therapy is commonly pursued, vs. the setting of gross unresectable disease. This review of adjuvant therapies in current use for five major solid tumors highlights the rationale for current effective adjuvant therapy, and draws comparisons between the adjuvant regimens that have found application in solid tumors.
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Affiliation(s)
- John M Kirkwood
- University of Pittsburgh Cancer Institute, Pittsburgh, PA 15213-1862, USA.
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10
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Controversies on the management of clinical situations with low therapeutic effectiveness in oncology. Clin Transl Oncol 2010; 12:493-8. [PMID: 20615826 DOI: 10.1007/s12094-010-0542-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Clinical scenarios associated with low therapeutic effectiveness (LTE) are especially complex and highly relevant in oncology. The objective was to test a methodological framework for creating consensual clinical recommendations for routine practice. The study was in three phases from Mars 2006 to January 2008: 1) Definition of LTE situations; 2) Preparation by 10 experts of a panel of LTE situations in cancers of breast, lung, head and neck, colon and rectum and brain; and 3) Development of a consensus on each situation and its optimal treatment by gathering agreement and disagreements (two-round Delphi method) from 68 practicing oncologists in Andalusian Community. Three major and three minor criteria were established for an LTE situation, defined when at least one major or two minor criteria were met. The expert group proposed 48 possible LTE clinical scenarios for breast (n = 7), lung (10), brain (11), head and neck (11) and colorectal cancers (9). Sixty-eight oncologists agreed to participate in the study; the response rate was 79% (from 34 medical and 17 radiation oncologists) In the first round (definition), maximum agreement was obtained with the LTE definition of 10 of the 48 scenarios; in the second round (treatment options), maximum agreement was obtained on the treatment of 3 of these 10 scenarios. Oncologists reached low levels of agreement on the definition of an LTE situation and on its treatment recommendations. This study proposes an approach to the improvement of cancer management in situations of high uncertainty.
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11
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Kirkwood JM, Tarhini AA, Moschos SJ, Panelli MC. Adjuvant therapy with high-dose interferon alpha 2b in patients with high-risk stage IIB/III melanoma. ACTA ACUST UNITED AC 2007; 5:2-3. [PMID: 18030300 DOI: 10.1038/ncponc1004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 10/03/2007] [Indexed: 11/09/2022]
Affiliation(s)
- John M Kirkwood
- Department of Medicine, University of Pittsburgh Cancer Institute, Hillman Cancer Center, Pittsburgh, PA 15213, USA.
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12
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Crott R, Ali F, Burdette-Radoux S. Cost-utility of adjuvant high-dose interferon alpha therapy in stage III cutaneous melanoma in Quebec. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2004; 7:423-432. [PMID: 15449634 DOI: 10.1111/j.1524-4733.2004.74005.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To estimate the cost-utility of adjuvant high-dose interferon in high-risk melanoma patients in Quebec compared to a watchful waiting strategy. METHOD A Markov model was developed that replicates the findings of the pivotal E1684 trial. It was then used to extrapolate survival over a period of 35 years. Costs of medical resources used during the first year were derived through a detailed analysis of a sample (n = 13) of patients treated in a leading academic hospital. Follow-up costs were assessed through a medical decision algorithm. Utilities were derived from a population-based survey (n = 104) in different locations in Quebec using the time trade-off method. RESULTS The mean incremental cost per quality-adjusted life-year of adjuvant Interferon therapy is equal to 55,090 CAN dollars over a follow-up of 7 years but drops down to 14,003 CAN dollars when extrapolated over 35 years. CONCLUSIONS Estimates of the cost-effectiveness of high-dose interferon in melanoma patients show an acceptable cost-effectiveness ratio if long-term survival is taken into account. Estimates are, however, strongly influenced by the observed trial differences in survival, the utility associated to health states, and the discount rate.
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Affiliation(s)
- R Crott
- Faculty of Pharmacy, University of Montreal, Canada.
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Wheatley K, Ives N, Hancock B, Gore M, Eggermont A, Suciu S. Does adjuvant interferon-alpha for high-risk melanoma provide a worthwhile benefit? A meta-analysis of the randomised trials. Cancer Treat Rev 2003; 29:241-52. [PMID: 12927565 DOI: 10.1016/s0305-7372(03)00074-4] [Citation(s) in RCA: 291] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several randomised trials have compared interferon-alpha with control as adjuvant therapy for high-risk malignant melanoma. The results of the individual trials have been either inconclusive or even apparently conflicting. To assess all the available evidence we performed a meta-analysis of these trials. METHODS Standard methods for quantitative meta-analysis based on published data were used. Endpoints evaluated were recurrence-free survival and overall survival. A subgroup analysis by dose of interferon-alpha was performed. FINDINGS Twelve trials, comprising 14 comparisons of interferon-alpha with control, with results available were identified. Recurrence-free survival was improved with interferon-alpha: hazard ratio 0.83, 95% confidence interval 0.77 to 0.90, p=0.000003. The benefit on overall survival was less clear (0.93, 0.85 to 1.02, p=0.1) and the confidence interval is compatible both with no benefit and with a moderate, but clinically worthwhile, benefit. There was some evidence of a dose response relationship with a significant trend for the benefit of interferon-alpha to increase with increasing dose for recurrence-free survival (test for trend: p=0.02) but not for overall survival (trend: p=0.8). INTERPRETATION This meta-analysis provides the most reliable synthesis of the data currently available. Adjuvant interferon-alpha produces clear reductions in recurrence of high-risk melanoma, with some evidence of an effect of dose of interferon-alpha, but it is unclear whether this translates into a worthwhile survival benefit or not. Additional and more mature data are needed to resolve these issues and an individual patient data meta-analysis should be performed.
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Affiliation(s)
- Keith Wheatley
- University of Birmingham Clinical Trials Unit, Park Grange, 1 Somerset Road, Edgbaston, Birmingham, B15 2RR, UK.
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14
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Samant RS, Dunscombe PB, Roberts GH. A cost-outcome analysis of long-term adjuvant goserelin in addition to radiotherapy for locally advanced prostate cancer. Urol Oncol 2003; 21:171-7. [PMID: 12810202 DOI: 10.1016/s1078-1439(02)00242-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
To quantify the incremental costs and outcomes of using long-term adjuvant goserelin in addition to radiotherapy for locally advanced prostate cancer. The cost of radiotherapy for prostate cancer has been calculated using an activity-costing model. The total cost of administering adjuvant hormonal therapy for 3 years is based on local pharmacy charges plus typical physician billing fees and additional laboratory costs. Outcome data were obtained from the published EORTC 22,863 randomized trial comparing treatment of locally advanced prostate cancer with radiotherapy alone or in combination with 3 years of adjuvant goserelin. Using this information, the cost-effectiveness of adjuvant goserelin was calculated and expressed in terms of dollars per life-years (LY) gained. The total institutional costs of radiotherapy are $9000 Cdn. and the additional costs of providing adjuvant goserelin for 3 years are approximately $19,800 CDN. The improvement in outcome with the use of adjuvant goserelin was estimated to be 1.2 LY per patient treated, giving a cost-effectiveness ratio of $16,500 Cdn ($11,000 US) per LY from an institutional perspective. Our sensitivity analysis confirms the robustness of our findings since even in our "worst case" scenario the cost-effectiveness ratio was estimated to be $21,600 Can ($14,400 US) per LY gained. This figure is still below $50,000 US per LY gained which is the quoted current standard for cost-effectiveness. This analysis demonstrates that the use of long-term adjuvant goserelin for locally advanced prostate cancer provides substantial benefit at an acceptable cost.
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Affiliation(s)
- Rajiv S Samant
- Northeastern Ontario Regional Cancer Centre, 41 Ramsey Lake Road, Sudbury, Ontario P3E 5J1, Canada.
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Garbe C, Paul A, Kohler-Späth H, Ellwanger U, Stroebel W, Schwarz M, Schlagenhauff B, Meier F, Schittek B, Blaheta HJ, Blum A, Rassner G. Prospective evaluation of a follow-up schedule in cutaneous melanoma patients: recommendations for an effective follow-up strategy. J Clin Oncol 2003; 21:520-9. [PMID: 12560444 DOI: 10.1200/jco.2003.01.091] [Citation(s) in RCA: 180] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To prospectively examine and evaluate the results of follow-up procedures in a large cohort of cutaneous melanoma patients. PATIENTS AND METHODS This was a prospective study in 2,008 consecutive patients with stage I to IV cutaneous melanoma from 1996 to 1998 on the yield of stage-appropriate follow-up examinations according to the German guidelines. Documentation of patient and follow-up data comprised patient demography, primary tumor specifics, and any clinical and technical examinations performed. The detection of metastasis was classified as early or late, and the means of their detection and the resulting overall survival probabilities were examined. RESULTS A total of 3,800 clinical examinations and 12,398 imaging techniques were documented. Sixty-two second primary melanomas in 46 patients and 233 disease recurrences in 112 patients were detected during this time. In stage I to III disease, physical examination was responsible for the discovery of 50% of all recurrences. In the primary tumor stages, 21% of all recurrences were discovered by lymph node sonography, with the majority being classified as early detection. Forty-eight percent of the recurrences were classified as early detection, and these patients had a significant benefit of overall survival probability. CONCLUSION The results of our study suggest that an elaborated follow-up schedule in cutaneous melanoma is suitable for the early detection of second primary melanomas and early recurrences. The intensity of clinical and technical examinations can be reduced during follow-up of patients in the primary tumor stages and may be intensified in locoregional disease. Recommendations for an effective follow-up strategy are outlined.
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Affiliation(s)
- Claus Garbe
- Department of Dermatology, Skin Cancer Program, Eberhard-Karls-University of Tuebingen, Germany.
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Abstract
The interferons are a group of naturally occurring biologic response modifiers that exhibit antiviral, antiproliferative, differentiating, and immune-enhancing properties. This interesting group of compounds has been found to be effective for the treatment of condylomata acuminata, skin cancers, high-risk melanoma, hepatitis C, mycosis fungoides, and keloid scars. The advantages of these agents must be weighed against their toxicities, the number of treatments, and cost.
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Affiliation(s)
- L Edwards
- Mid Charlotte Dermatology and Research, Charlotte, North Carolina, USA
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