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Facchinetti F, Camerini A, Bennati C, Bordi P, Carlo ED, Mazzoni F, Metro G, Bertolini F, Longo L, Ricciardi S, Pilotto S, Giardina D, Passiglia F, Scotti V, Piacentini P, Frega S, Calabrò L, Guida A, Grosso MA, Longobardi J, Merlini A, Cosso F, Leonetti A, Gariazzo E, Guaitoli G, Belluomini L, Bearz A, Tognetto M, Bria E, Cortinovis DL, Novello S, Maio MD, Tiseo M. A prospective study on clinicians' attitudes and survival outcomes for patients with advanced NSCLC and poor performance status in the immunotherapy era: PICASO (GOIRC-04-2020). Lung Cancer 2025; 204:108580. [PMID: 40382877 DOI: 10.1016/j.lungcan.2025.108580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2025] [Revised: 05/05/2025] [Accepted: 05/07/2025] [Indexed: 05/20/2025]
Abstract
BACKGROUND Therapeutic strategies for patients with advanced NSCLC and an ECOG performance status (PS) 2 at diagnosis are supported by limited evidence. PATIENTS AND METHODS We led a prospective, observational study in 20 Italian centers on patients with advanced NSCLC and ECOG PS 2. Patients with EGFR mutations, ALK fusions or receiving first-line targeted treatments were excluded. We recorded physicians' attitudes in addressing first-line treatments and clinical outcomes. The primary endpoint was progression-free rate at six months. RESULTS From March 2022 to October 2023, 198 consecutive patients were included. Median age was 73 years (range 43-91). Forty-four patients (22%) were candidate to best supportive care, 49 (25%) to single agent chemotherapy, 14 (7%) to platinum doublet, 40 (20%) to mono-immunotherapy, 52 (26%) to chemo-immunotherapy. At a median follow-up of 9.4 months (95 % CI 7.2 - 11.7), 6-month progression-free rate was 15.3%, with a median progression-free survival of 1.6 months (95 % CI 1.3 - 1.9). Six-months overall survival (OS) rate was 27.7%, with a median OS of 2.8 months (95 % CI 2.0 - 3.6). Patients receiving chemo-immunotherapy (PD-L1 < 50%) had 6-month progression-free and OS rates of 22.9% and 29.1% respectively, with median PFS 1.9 months and median OS 3.7 months; mono-immunotherapy for patients with PD-L1 ≥ 50% led to slightly better outcomes. Among 155 patients receiving active treatment, no clinical-pathological characteristic harbored a prognostic role. One third of patients receiving immunotherapy-containing regimens encountered early clinical progression or death before the first radiological evaluation. No relevant safety signals emerged across treatments. CONCLUSIONS Less than half of patients with NSCLC and ECOG PS 2 were candidates to the regimens recommended for fit pts, i.e. mono-immunotherapy or chemo-immunotherapy according to PD-L1. Even with immunotherapy, most of these patients have dismal outcomes, suggesting that trials dedicating to PS 2 perform an intrinsic patient selection.
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Affiliation(s)
- Francesco Facchinetti
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA; Gruppo Oncologico di Ricerca Clinica (GOIRC), Parma, Italy.
| | - Andrea Camerini
- Medical Oncology, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Chiara Bennati
- Department of Onco-Hematology, AUSL della Romagna, Ravenna, Italy
| | - Paola Bordi
- Medical Oncology Unit, University Hospital of Parma, Italy
| | - Elisa De Carlo
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Francesca Mazzoni
- Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Giulio Metro
- Medical Oncology, Santa Maria della Misericordia Hospital, University of Perugia, Italy
| | - Federica Bertolini
- Division of Medical Oncology, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Lucia Longo
- Medical Oncology Unit, Sassuolo Hospital, AUSL Modena, Italy
| | | | - Sara Pilotto
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Italy
| | - Donatella Giardina
- UOC Oncologia di Prossimità, Ospedale B. Ramazzini di Carpi, AUSL Modena, Italy
| | - Francesco Passiglia
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Vieri Scotti
- Radiation Oncology Unit, Oncology Department, AOU Careggi Firenze, Italy
| | - Paolo Piacentini
- Department of Medical Oncology, AULSS 9 Scaligera, Verona, Italy
| | - Stefano Frega
- Oncologia 2, Istituto Oncologico Veneto (IOV) IRCCS, Padua, Italy
| | - Luana Calabrò
- Oncology Unit, University Hospital of Ferrara, Italy
| | - Annalisa Guida
- Dipartimento di Oncologia, Azienda Ospedaliera Santa Maria of Terni, Italy
| | - Maria Antonietta Grosso
- Medical Oncology, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Jenny Longobardi
- Department of Onco-Hematology, AUSL della Romagna, Ravenna, Italy
| | - Alessandra Merlini
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Federica Cosso
- Department of Oncology, Careggi University Hospital, Florence, Italy
| | | | - Eleonora Gariazzo
- Medical Oncology, Santa Maria della Misericordia Hospital, University of Perugia, Italy
| | - Giorgia Guaitoli
- Division of Medical Oncology, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Lorenzo Belluomini
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Italy
| | - Alessandra Bearz
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | | | - Emilio Bria
- UOSD Oncologia Toraco-Polmonare, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Diego Luigi Cortinovis
- Department of Medicine and Surgery, Oncology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marcello Tiseo
- Gruppo Oncologico di Ricerca Clinica (GOIRC), Parma, Italy; Medical Oncology Unit, University Hospital of Parma, Italy; Department of Medicine and Surgery, University Hospital of Parma, Italy
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Zuellig JA, Adam R, Udry F, Tibau A, Šeruga B, Ocaña A, Amir E, Templeton AJ. The Effect of Staging Intervals on Progression-Free Survival in Registration Studies of Oncologic Drugs: A Meta-Analysis. Cancers (Basel) 2025; 17:1359. [PMID: 40282533 PMCID: PMC12025954 DOI: 10.3390/cancers17081359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Revised: 04/14/2025] [Accepted: 04/16/2025] [Indexed: 04/29/2025] Open
Abstract
BACKGROUND/OBJECTIVES To study whether shorter restaging intervals are associated with lower hazard ratios (HRs) for progression-free survival (PFS), as suggested in breast cancer. METHODS Studies supporting the registration of oncologic drugs in Switzerland from 2010 to 2022 were analyzed. HRs and 95% confidence intervals (CIs) for PFS were pooled in a meta-analysis using the generic inverse-variance method and a random-effects model in RevMan v5.4. The HRs were stratified by restaging intervals ( RESULTS A total of 112 studies comprising 69,579 patients were included. The median restaging interval was 8 weeks, with a range of 4 to 18 weeks. Longer restaging intervals (≥8 weeks) were associated with lower HRs compared to shorter intervals (<8 weeks), with pooled HRs of 0.48 (95% CI: 0.44-0.52) and 0.58 (95% CI: 0.53-0.63), respectively. The difference between the groups was statistically significant (p = 0.005), with a substantial heterogeneity (Cochran's Q p < 0.001; I2 = 90%). Subgroup analyses based on treatment type, including immunotherapy, monoclonal antibodies, and tyrosine kinase inhibitors, did not show any statistically significant differences in HRs. Studies of melanoma with shorter staging intervals were associated with lower HRs (0.44 vs. 0.58, p = 0.02), whereas shorter interval studies of kidney cancer had higher HRs (0.67 vs. 0.44, p = 0.01). Sensitivity analyses with other cut-offs and a meta-regression yielded similar results. CONCLUSIONS Studies leading to the authorization of drugs to treat incurable solid tumors applying restaging intervals ≥ 8 weeks were associated with lower HRs for PFS. The potential impact of restaging intervals on the results for PFS warrants further investigation.
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Affiliation(s)
- Jonas A. Zuellig
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland; (J.A.Z.); (R.A.); (F.U.)
| | - Roman Adam
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland; (J.A.Z.); (R.A.); (F.U.)
| | - Filomena Udry
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland; (J.A.Z.); (R.A.); (F.U.)
| | - Ariadna Tibau
- Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, 08041 Barcelona, Spain;
- Departament de Medicina, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain
| | - Bostjan Šeruga
- Department of Medical Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Alberto Ocaña
- Experimental Therapeutics Unit, Medical Oncology Department, Hospital Clínico Universitario San Carlos IdISSC, 28040 Madrid, Spain;
- Instituto de Investiagción Sanitaria del Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center, Toronto, ON M5S 1A1, Canada;
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Arnoud J. Templeton
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland; (J.A.Z.); (R.A.); (F.U.)
- Department of Medical Oncology, St. Claraspital, 4058 Basel, Switzerland
- St. Clara Research, 4058 Basel, Switzerland
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Amin P, Malik A, Mcinnes MDF, Brown MJ, Szava-Kovats A. Environmental Sustainability and Cancer Imaging. Can Assoc Radiol J 2025:8465371251323107. [PMID: 40016862 DOI: 10.1177/08465371251323107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2025] Open
Abstract
The rising global burden of cancer drives increased demands for medical imaging, which is essential throughout cancer care. However, delivering medical imaging presents significant environmental challenges including high energy use, reliance on single-use supplies, and the production of environmental pollutants. Environmental factors, such as ultraviolet radiation, wildfire smoke, and carcinogenic pollutants contribute to rising cancer rates, while extreme weather events driven by climate change disrupt cancer care delivery-highlighting the close connection between patient and planetary health. This review explores opportunities to improve the environmental sustainability of oncologic imaging, emphasizing the importance of patient-relevant outcomes-such as quality of life and overall survival-as a guiding principle in cancer care. Key strategies include optimizing imaging schedules to reduce low-value imaging, selecting modalities with lower environmental impact where clinically appropriate, minimizing waste streams, and adopting energy-efficient practices. Artificial intelligence offers the potential to personalize imaging schedules and improve efficiency, though its benefits must be weighed against energy use. Mobile imaging programs and integrated scheduling reduce patient travel-related emissions while promoting health equity, particularly in underserved communities. Future research should focus on optimizing imaging intervals to address patient-relevant outcomes better, expanding the use of abbreviated imaging protocols, and the judicious deployment of artificial intelligence, ensuring its benefits justify energy use.
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Affiliation(s)
- Parthiv Amin
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Aleena Malik
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Matthew D F Mcinnes
- OHRI Methodology and Implementation Research Program, School of Epidemiology and Public Health, Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - Maura J Brown
- Department of Diagnostic Imaging BC Cancer, University of British Columbia, Vancouver, BC, Canada
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de Boissieu P, Chevret S. Misleading Reporting of a Negative Randomized Clinical Trial May Affect Clinical Practice. J Clin Oncol 2025; 43:354-355. [PMID: 39383491 DOI: 10.1200/jco.24.01104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 07/01/2024] [Indexed: 10/11/2024] Open
Affiliation(s)
- Paul de Boissieu
- Paul de Boissieu, PhD, Drug Assessment Division, Haute Autorité de Santé, Saint-Denis La Plaine, France; and Sylvie Chevret, MD, PhD, Membre titulaire de la Commission de la Transparence, Haute Autorité de Santé, Saint-Denis La Plaine, France, ECSTRRA team, UMR1153, Inserm, Paris Cité Université, Paris, France
| | - Sylvie Chevret
- Paul de Boissieu, PhD, Drug Assessment Division, Haute Autorité de Santé, Saint-Denis La Plaine, France; and Sylvie Chevret, MD, PhD, Membre titulaire de la Commission de la Transparence, Haute Autorité de Santé, Saint-Denis La Plaine, France, ECSTRRA team, UMR1153, Inserm, Paris Cité Université, Paris, France
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Martínez-Barros H, Pousada-Fonseca Á, Pedreira-Bouzas J, Clopés-Estela A. [Translated article] Characteristics, clinical benefit, and reimbursement of new authorisations for oncohaematology drugs in Spain between 2017 and 2020. FARMACIA HOSPITALARIA 2024; 48:T272-T277. [PMID: 39069449 DOI: 10.1016/j.farma.2024.07.006] [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] [Received: 12/13/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 07/30/2024] Open
Abstract
OBJECTIVE To describe the authorisations and funding resolutions for new onco-haematological drugs in Spain between 2017 and 2020, as well as the results of their main trials. METHODS Observational, cross-sectional, descriptive study conducted between October and December 2022. Onco-haematology drugs approved by the European Medicines Agency between 2017 and 2020 were included, according to EFPIA patients W.A.I.T Indicator 2021 Survey. Authorisation information was obtained from the main study of the European Public Assessment Report. Data were collected on medicines, their authorisation and main study, benefit shown, cost, and status and time to reimbursement. RESULTS Forty-one new drugs authorised for 49 indications were identified. More than half (58.5%) were targeted therapies, and 61.2% were for the treatment of solid tumours (61.2%). Most had palliative intent (71.4%) and were indicated in relapsed or refractory disease (55.1%). Of the clinical trials, 57.1% were phase III and 63.3% were randomised. The primary endpoint was overall survival in 16.3%, increasing to 25.8% among randomised clinical trials. Regarding licensed drugs based on response rate, the median response rate was 56.4% [IQI 40-66.3]. In those authorised on the basis of surrogate time-to-event endpoints, the median hazard ratio was 0.54 [IQI 0.38-0.57], and among those using overall survival was 0.71 [IQI 0.59-0.77]. Globally, 22.4% had shown benefit in overall survival, with a median gain of 4 months [IQI 3.6-16.7]. One-third (33.3%) of the indications evaluable according to the European Society for Medical Oncology Magnitude of Clinical Benefit Scale showed substantial clinical benefit. Of the indications, 75.5% were funded, half (48.6%; 36.7% of the total) with restrictions. The median time to funding was 19.5 months [IQI 11.4-29.3]. CONCLUSIONS Most main clinical trials of new onco-haematology drugs approved in Spain used surrogate primary endpoint and, at the time of authorisation, few had shown to prolong overall survival. More than a third were uncontrolled clinical trials.
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Affiliation(s)
| | | | | | - Ana Clopés-Estela
- Servicio de Farmacia, Instituto Catalán de Oncología (ICO) t, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Universidad Ramon Llull, Barcelona, Spain
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Martínez-Barros H, Pousada-Fonseca Á, Pedreira-Bouzas J, Clopés-Estela A. Characteristics, clinical benefit and reimbursement of new authorisations for oncohaematology drugs in Spain between 2017 and 2020. FARMACIA HOSPITALARIA 2024; 48:272-277. [PMID: 38797624 DOI: 10.1016/j.farma.2024.04.022] [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] [Received: 12/13/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE To describe the authorisations and funding resolutions for new onco-hematological drugs in Spain between 2017 and 2020, as well as the results of their main trials. METHODS Observational, cross-sectional, descriptive study conducted between October and December 2022. Onco-hematology drugs approved by the European Medicines Agency between 2017 and 2020 were included, according to EFPIA patients W.A.I.T Indicator 2021 Survey. Authorisation information was obtained from the main study of the European Public Assessment Report (EPAR). Data were collected on medicines, their authorisation and main study, benefit shown, cost, and status and time to reimbursement. RESULTS Forty-one new drugs authorised for 49 indications were identified. More than half (58.5%) were targeted therapies, and 61.2% were for the treatment of solid tumors (61.2%). Most had palliative intent (71.4%) and were indicated in relapsed or refractory disease (55.1%). Of the clinical trials, 57.1% were phase III and 63.3% were randomised. The primary endpoint was overall survival in 16.3%, increasing to 25.8% among randomised clinical trials. Regarding licensed drugs based on response rate, the median response rate was 56.4% (IQI 40.0-66.3). In those authorised on the basis of surrogate time-to-event endpoints, the median Hazard Ratio was 0.54 (IQI 0.38-0.57), and among those using overall survival was 0.71 (IQI 0.59-0.77). Globally, 22.4% had shown benefit in overall survival, with a median gain of 4 months (IQI 3.6-16.7). One third (33.3%) of the indications evaluable according to the European Society for Medical Oncology Magnitude of Clinical Benefit Scale showed substantial clinical benefit. Of the indications, 75.5% were funded, half (48.6%; 36.7% of the total) with restrictions. The median time to funding was 19.5 months (IQI 11.4-29.3). CONCLUSIONS Most main clinical trials of new onco-haematology drugs approved in Spain used surrogate primary endpoint and, at the time of authorisation, few had shown to prolong overall survival. More than a third were uncontrolled clinical trials.
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Affiliation(s)
| | | | | | - Ana Clopés-Estela
- Servicio de Farmacia, Instituto Catalán de Oncología (ICO), Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Universidad Ramon Llull, Barcelona, España
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Xander NSH, Leeneman B, Dingemans AMC, Fiets WE, de Jong WK, Uyl NEM, Wymenga ANM, Reyners AKL, Uyl-de Groot CA. Using non-randomized trials to assess the clinical benefit of systemic anti-cancer treatments: Viable or not? Eur J Cancer 2024; 209:114262. [PMID: 39111205 DOI: 10.1016/j.ejca.2024.114262] [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] [Received: 05/07/2024] [Revised: 07/25/2024] [Accepted: 07/25/2024] [Indexed: 08/25/2024]
Abstract
BACKGROUND The Dutch Committee for the Evaluation of Oncological Agents (cieBOM) assesses the clinical benefit of systemic anti-cancer treatments (SACTs). For SACTs tested in non-randomized trials (NRTs), cieBOM primarily utilizes response-related thresholds as assessment criteria. As sufficiency of NRT-based evidence for benefit assessments is questionable, this study investigated whether and how NRTs can be used to assess the clinical benefit of new SACTs initially appraised by cieBOM based on randomized controlled trials (RCTs). METHODS Using the RCTs underpinning cieBOM recommendations issued between 2015 and 2017, we searched for matching NRTs and applied the NRT-related assessment criteria by cieBOM to them. We then compared the assessment outcomes to the respective RCT-based cieBOM recommendations. Further, we investigated how the assessments would change when applying different response-related thresholds and adding a progression-free survival (PFS) threshold. RESULTS For 13 of the 37 eligible recommendations, a matching NRT was found. Two treatments were assessed positively and six negatively; five treatments were non-assessable. Two positive recommendations matched a positive NRT-based assessment; one matching negative assessment was found, and one treatment could not be assessed based on either trial results. Adding a > 6 months PFS threshold decreased the number of non-assessable NRTs (five to two). CONCLUSIONS Limited publications and inconsistent data reporting hampered the viability of NRTs for clinical benefit assessments of SACTs beyond the scope of rare indications. Further, response-related assessment criteria alone might not fully grasp the clinical benefit of novel SACTs. NRT-based assessments should be considered with caution due to uncertainty of the trial results.
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Affiliation(s)
- N S H Xander
- Department of Health Technology Assessment, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands.
| | - B Leeneman
- Department of Health Technology Assessment, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands
| | - A-M C Dingemans
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - W E Fiets
- Department of Medical Oncology, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD Leeuwarden, the Netherlands
| | - W K de Jong
- Department of Pulmonology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - N E M Uyl
- Department of Health Technology Assessment, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands
| | - A N M Wymenga
- Department of Medical Oncology, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ Enschede, the Netherlands
| | - A K L Reyners
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - C A Uyl-de Groot
- Department of Health Technology Assessment, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands
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Gupta M, Akhtar OS, Bahl B, Mier-Hicks A, Attwood K, Catalfamo K, Gyawali B, Torka P. Health-related quality of life outcomes reporting associated with FDA approvals in haematology and oncology. BMJ ONCOLOGY 2024; 3:e000369. [PMID: 39886148 PMCID: PMC11256025 DOI: 10.1136/bmjonc-2024-000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/21/2024] [Indexed: 02/01/2025]
Abstract
Objective Health-related quality of life (HRQoL) outcomes are important in making clinical and policy decisions. This study aimed to examine the HRQoL reporting in cancer drug trials leading to Food and Drug Administration (FDA) approvals. Methods and analysis This retrospective cohort study analysed HRQoL data for trials leading to FDA approvals between July 2015 and May 2020. Proportion of included trials that reported HRQoL, latency between FDA approval and first report of HRQoL data, HRQoL outcomes, and their correlation with OS (overall survival) and PFS (progression-free survival) were analysed. Results Of the 233 trials associated with 207 FDA approvals, HRQoL was reported in 50% of trials, of which only 42% had the data reported by the time of FDA approval. There were no changes in frequency of HRQoL reporting between 2015 and 2020. HRQoL data were first reported in the primary publication in only 30% trials. Of the 115 trials with HRQoL data available, HRQoL improved in 43%, remained stable in 53% and worsened in 4% of trials. Among the trials that led to FDA approvals based on surrogate endpoints (79%), HRQoL was reported in 45% and improved only in 18% trials. There was no association between OS and PFS benefit and HRQoL outcomes. Conclusion Rates of HRQoL reporting were suboptimal in trials that led to FDA approvals with no improvements seen between 2015 and 2020. HRQoL reporting was often delayed and not presented in the primary publication. HRQoL reporting was further sparse in trials with approvals based on surrogate endpoints and HRQoL improved in only a minority of them.
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Affiliation(s)
- Medhavi Gupta
- Program in Women's Oncology, Brown University, Providence, Rhode Island, USA
| | | | - Bhavyaa Bahl
- University of Colorado System, Denver, Colorado, USA
| | | | | | - Kayla Catalfamo
- Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Pallawi Torka
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Lengliné E, Baba J, de Boissieu P, Beaufils A, Desbiolles A, Diatta T, Cochat P, Chevret S. Composite event-free-survival as an endpoint in oncology drug evaluation: Review and guidance perspectives from the Haute Autorité de Santé (HAS). Eur J Cancer 2024; 204:114047. [PMID: 38653034 DOI: 10.1016/j.ejca.2024.114047] [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] [Received: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The use of right-censored composite endpoints, such as progression-free survival, has been questioned in haemato-oncology trials due to potential bias in estimated treatment effect. This may impact the accuracy of health technology evaluations. We hypothesized that there is heterogeneity and potential sources of bias in the reporting of composite endpoints to health technology assessment (HTA) bodies. METHODS We reviewed the submissions for reimbursement of oncology drugs in 2021 and 2022 that used a composite endpoint in the pivotal trial, after appraisal by the French HTA body. The retrieved information included the clinical study report, protocol, and statistical analysis plan submitted by the industry. All events of the composite endpoint and all causes of censored observations were measured. The design characteristics and treatment effect estimates were recorded. FINDINGS Seventy-six submissions were selected, including seven without a right-censored endpoint and four evaluating associations, resulting in 65 analysed records: 17 for haematological and 48 for solid tumours. Out these 65 submissions, 47 (72·3%) used a randomized controlled design, and 18 (27·7%) a non-comparative design. The most frequently used composite endpoint was progression-free survival, used in 54 (83·1%) of the submissions. Censoring was possibly informative in 51 (92·7%) cases, mostly due to the onset of new treatment (44/51, 86·3%) and/or discontinuation of follow-up (33/51, 64·7%). In contrast, 38 (58·5%) trials reported a quantification of censored observations, with only 12/51 (23·5%) quantifying the informative ones. The estimated treatment effect on the composite outcome increased with the amount of censoring, suggesting a higher benefit of the drug, but remained below that on survival with poor evidence of surrogacy (R-squared=0·23). INTERPRETATION Clinical study reports should be improved in terms of reporting censoring, while stakeholders should be aware of this potential source of bias. At a minimum, sensitivity analysis that ignores intercurrent events should be requested.
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Affiliation(s)
- Etienne Lengliné
- Hematology department, Hôpital Saint-Louis AP-HP, Paris, France.
| | - Joachim Baba
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Paul de Boissieu
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Alexandre Beaufils
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Alice Desbiolles
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Thierno Diatta
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Pierre Cochat
- Drug evaluation department, Haute Autorité de Santé, Saint Denis Paris France
| | - Sylvie Chevret
- ECSTRRA Team, Université Paris Cité, UMR1153, INSERM, Paris, France
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10
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Tibau A, Kesselheim AS. Global cooperation and early access-clinical outcomes matter. Lancet Oncol 2024; 25:687-688. [PMID: 38754452 DOI: 10.1016/s1470-2045(24)00210-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Ariadna Tibau
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA; Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
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11
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Osipenko L, Potey P, Perez B, Angelov F, Parvanova I, Ul-Hasan S, Mossialos E. The Origin of First-in-Class Drugs: Innovation Versus Clinical Benefit. Clin Pharmacol Ther 2024; 115:342-348. [PMID: 37983965 DOI: 10.1002/cpt.3110] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
First-in-class (FIC) designation became a hallmark of innovation, however, even at the marketing authorization stage, little is known about the clinical benefits these products deliver. We identified the provenance of the FIC drugs that entered the French market from 2008 to 2018 and matched these medicines to the clinical benefit grading by Haute Autorité de Santé (HAS) and Prescrire. Analyses were performed using descriptive statistics to present our findings by drug origin and therapeutic area and to establish the degree of concordance between HAS and Prescrire. Of the 135 FIC drugs identified, 71.1% (n = 96) originated from the industry, 16.3% (n = 22) from academia, and 12.6% (n = 17) from joint partnerships. Three therapeutic areas accounted for most FIC medications: antineoplastic (25.9%, N = 35), anti-infective (14.1%, N = 19), and metabolic (11.1%, N = 15) agents. HAS and Prescrire agreed on 60.74% of clinical benefit gradings. According to HAS, only 5% of all FIC drugs had substantial added benefit, and only 3%, according to Prescrire. HAS and Prescrire graded 45.9% and 68.2%, respectively, of FIC drugs as no clinical benefit and 48.9% and 28.9%, respectively, as some clinical benefit. FIC-designated drugs are primarily of industry (> 70%) rather than academic origin. We found that 55% of FIC medicines that entered the French market over the 10-year period deliver no additional clinical benefit. Whereas FIC medicines may represent important scientific advancements in drug development, in > 50% of cases, the new mode of action does not translate into additional clinical benefits for patients.
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Affiliation(s)
- Leeza Osipenko
- Department of Health Policy, LSE, London, UK
- Consilium Scientific, London, UK
| | - Philippe Potey
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Bernardo Perez
- Department of Health Policy, LSE, London, UK
- Cleveland Clinic, Cleveland, Ohio, USA
| | - Filip Angelov
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | | | - Saba Ul-Hasan
- Department of Health Policy, LSE, London, UK
- Consilium Scientific, London, UK
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12
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Nadler MB, Wilson BE, Desnoyers A, Valiente CM, Saleh RR, Amir E. Magnitude of effect and sample size justification in trials supporting anti-cancer drug approval by the US Food and Drug Administration. Sci Rep 2024; 14:459. [PMID: 38172190 PMCID: PMC10764749 DOI: 10.1038/s41598-023-50694-0] [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: 03/28/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
Approval of drugs is based on randomized trials observing statistically significant superiority of an experimental agent over a standard. Statistical significance results from a combination of effect size and sampling, with larger effect size more likely to translate to population effectiveness. We assess sample size justification in trials supporting cancer drug approvals. We identified US FDA anti-cancer drug approvals for solid tumors from 2015 to 2019. We extracted data on study characteristics, statistical plan, accrual, and outcomes. Observed power (Pobs) was calculated based on completed study characteristics and observed hazard ratio (HRobs). Studies were considered over-sampled if Pobs > expected with HRobs similar or worse than expected or if Pobs was similar to expected with HRobs worse than expected. We explored associations with over-sampling using logistic regression. Of 75 drug approvals (reporting 94 endpoints), 21% (20/94) were over-sampled. Over-sampling was associated with immunotherapy (OR: 5.5; p = 0.04) and associated quantitatively but not statistically with targeted therapy (OR: 3.0), open-label trials (OR: 2.5), and melanoma (OR: 4.6) and lung cancer (OR: 2.17) relative to breast cancer. Most cancer drug approvals are supported by trials with justified sample sizes. Approximately 1 in 5 endpoints are over-sampled; benefit observed may not translate to clinically meaningful real-world outcomes.
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Affiliation(s)
- Michelle B Nadler
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, The University of Toronto, Toronto, ON, Canada.
| | - Brooke E Wilson
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, The University of Toronto, Toronto, ON, Canada
- Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Alexandra Desnoyers
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, The University of Toronto, Toronto, ON, Canada
- Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Consolacion Molto Valiente
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, The University of Toronto, Toronto, ON, Canada
| | - Ramy R Saleh
- Division of Medical Division of Medical Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Department of Medicine, The University of Toronto, Toronto, ON, Canada
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13
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Thakur S. Real-World Evidence Studies in Oncology Therapeutics: Hope or Hype? Indian J Surg Oncol 2023; 14:829-835. [PMID: 38187834 PMCID: PMC10767035 DOI: 10.1007/s13193-023-01784-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 06/12/2023] [Indexed: 01/09/2024] Open
Abstract
Randomized controlled trial (RCT) remains a gold standard in evidence-based medicine for assessing the efficacy and safety of cancer therapies. However, due to some inherent methodological limitations of RCT, such as stringent inclusion criteria, highly specific treatment, ethical and scientific compromise in rare cancer, and inability to adequately assess safety, real-world evidence (RWE) has been adjudged as a suitable option to complement data obtained from RCT. Moreover, in the context of cancer therapeutics, few notable merits pertain to developing a novel product for rare cancer subtypes, establishing new indications for already approved drugs, optimization of treatment regimen and sequence, a better description of long-term safety, and supporting the reimbursement-related decision. However, the implementation of RWE for the aforementioned purposes will be limited by various challenges, especially in the context of developing economies such as India. Special attention should be given to the availability of data, maintaining the quality standard, and establishing stringent regulations for privacy and security along with active regulatory engagement with relevant stakeholders. Such activities will be key to facilitating the use of RWE in cancer therapeutics.
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Affiliation(s)
- Sayanta Thakur
- Department of Pharmacology, MJNMC&H, Vivekananda Street, Pilkhana, Cooch Behar 736101 India
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14
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Zhang S, Zhang J, Liu S, Pang H, Stinchcombe TE, Wang X. Enrollment Success, Factors, and Prediction Models in Cancer Trials (2008-2019). JCO Oncol Pract 2023; 19:1058-1068. [PMID: 37793091 PMCID: PMC10667018 DOI: 10.1200/op.23.00147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/15/2023] [Accepted: 08/15/2023] [Indexed: 10/06/2023] Open
Abstract
PURPOSE To investigate the enrollment success rate of cancer clinical trials conducted in 2008-2019 and various factors lowering the enrollment success rate. METHODS This is a cross-sectional study with clinical trial information from the largest registration database ClinicalTrials.gov. Enrollment success rate was defined as actual enrollment greater or equal to 85% of the estimated enrollment goal. The association between trial characteristics and enrollment success was evaluated using the multivariable logistic regression. RESULTS A total of 4,004 trials in breast, lung, and colorectal cancers were included. The overall enrollment success rate was 49.1%. Compared with 2008-2010 (51.5%) and 2011-2013 (52.1%), the enrollment success rate is lower in 2014-2016 (46.5%) and 2017-2019 (36.4%). Regression analyses found trial activation year, phase I, phase I/phase II, and phase II (v phase III), sponsor agency of government (v industry), not requiring healthy volunteers, and estimated enrollment of 50-100, 100-200, 200, and >500 (v 0-50) were associated with a lower enrollment success rate (P < .05). However, trials with placebo comparator, ≥5 locations (v 1 location), and a higher number of secondary end points (eg, ≥5 v 0) were associated with a higher enrollment success rate (P < .05). The AUC for prediction of the final logistic regression models for all trials and specific trial groups ranged from 0.69 to 0.76. CONCLUSION This large-scale study supports a lower enrollment success rate over years in cancer clinical trials. Identified factors for enrollment success can be used to develop and improve recruitment strategies for future cancer trials.
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Affiliation(s)
- Siqi Zhang
- Duke Cancer Institute, Duke University, Durham, NC
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jianrong Zhang
- Centre for Cancer Research & Department of General Practice and Primary Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Sida Liu
- Department of Statistics, Florida State University, Tallahassee, FL
| | - Herbert Pang
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Thomas E. Stinchcombe
- Duke Cancer Institute, Duke University, Durham, NC
- Duke University Medical Center, Durham, NC
| | - Xiaofei Wang
- Duke Cancer Institute, Duke University, Durham, NC
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
- Alliance Statistics and Data Management Center, Duke University, Durham, NC
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15
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Ardin C, Humez S, Leroy V, Ampere A, Bordier S, Escande F, Turlotte A, Stoven L, Nunes D, Cortot A, Gauvain C. Pursuit or discontinuation of anti-PD1 after 2 years of treatment in long-term responder patients with non-small cell lung cancer. Ther Adv Med Oncol 2023; 15:17588359231195600. [PMID: 37720494 PMCID: PMC10501064 DOI: 10.1177/17588359231195600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023] Open
Abstract
Background The optimal duration of immune checkpoint inhibitor (ICI) treatment for patients with advanced non-small cell lung cancer (NSCLC) remains to be determined. Treatment durations in cornerstone phase 3 clinical trials vary between a fixed 2-year duration and pursuit until disease progression. Clinical practices may thus differ according to the attending physician. Objectives Here we provide real-world data about treatment decisions at 2 years, with subsequent clinical outcomes. Design and Methods This multicentric observational study included patients with advanced NSCLC whose disease was controlled after 2 years of pembrolizumab or nivolumab. The primary outcome was the decision to discontinue ICI treatment or not, along with factors motivating this decision. Secondary outcomes included progression-free survival (PFS) (according to treatment continuation or not) and adverse events. Results A total of 91 patients were included, of which 60 (66%) had been pre-treated. The programmed death-ligand 1 expression level was ⩾50% in 43 patients (47%). In 61 patients (67%), ICI was continued after 2 years of treatment. This decision was significantly associated with the care center (p < 0.001) but neither with the tumor response at 2 years, as evaluated by CT scan or PET scan, nor with clinical status, immune-related adverse events, or previous locally treated oligo-progressive disease under ICI. Two years after the 2-year decision, PFS was 68.5%, [95% confidence interval (CI) (53.3-88.0)] in the 'ICI discontinuation' group and 64.1% [95% CI (51.9-79.2)] in the 'ICI pursuit' group; hazard ratio for relapse was 1.14 [95% CI (0.54-2.30), p = 0.77]. The overall survival rate at 24 months after discontinuation was 89.2% [95% CI (78.4-100)] for the 'discontinuation' group and 93.1% [95% CI (85.8-100)] for the 'pursuit' group. Given insufficient power, overall survival could not be compared. Conclusion The decision to continue ICI or not after 2 years of treatment depends mainly on the care center and does not seem to impact survival. Larger, randomized data sets are required to confirm this result.
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Affiliation(s)
- Camille Ardin
- Service de Pneumologie-Oncologie Thoracique, Institut Cœur Poumon, Lille University Hospital, Boulevard du Professeur Jules Leclercq, Lille 59037, France
| | - Sarah Humez
- Service d’anatomo-pathologie, Lille University Hospital, Lille, France
| | - Vincent Leroy
- Service de Pneumologie, Clinique Tessier, Valenciennes, France
| | - Alexandre Ampere
- Service de Pneumologie, Centre Hospitalier de Béthune, Beuvry, France
| | - Soraya Bordier
- Service de Pneumologie, Centre Hospitalier de Dunkerque, Dunkerque, France
| | - Fabienne Escande
- Service de Biochimie -Biologie Moléculaire, Lille University Hospital, Lille, France
| | - Amélie Turlotte
- Service de Pneumologie, Centre Hospitalier d’Arras, Arras, France
| | - Luc Stoven
- Service de Pneumologie, Centre Hospitalier de Boulogne, Boulogne-sur-mer, France
| | - David Nunes
- Service de Pneumologie-Oncologie Thoracique, Institut Cœur Poumon, Lille University Hospital, Lille, France
- Service de Pneumologie, Centre hospitalier Victor Provo, Roubaix, France
| | - Alexis Cortot
- Service de Pneumologie-Oncologie Thoracique, Institut Cœur Poumon, Lille University Hospital, Lille, France
- University of Lille, CHU Lille, CNRS, Inserm, Institut Pasteur de Lille, UMR9020 – UMR-S 1277 - Canther, Lille, France
| | - Clément Gauvain
- Service de Pneumologie-Oncologie Thoracique, Institut Cœur Poumon, Lille University Hospital, Lille, France
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16
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Wanjarkhedkar P, Kulkarni P, Hingmire S, Deshmukh C, Pawar S, Melinkeri S, Prabhakaran A, Baheti A, Pingley S, Shende S, Kelkar D. Integrative Cancer Care Unit: An institutional experiment towards Integrative Oncology. J Ayurveda Integr Med 2023; 14:100714. [PMID: 37202298 PMCID: PMC10692370 DOI: 10.1016/j.jaim.2023.100714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 05/20/2023] Open
Affiliation(s)
- Pankaj Wanjarkhedkar
- Ayurveda & Integrative Cancer Care, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India.
| | - Padmaj Kulkarni
- Medical Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Sachin Hingmire
- Medical Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Chetan Deshmukh
- Medical Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Satyajit Pawar
- Medical Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Sameer Melinkeri
- Clinical Hematology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Anushree Prabhakaran
- Clinical Hematology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Abhijit Baheti
- Clinical Hematology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Sonali Pingley
- Radiation Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Shaileshkumar Shende
- Radiation Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
| | - Dhananjay Kelkar
- Surgical Oncology, VLM Cancer Center, Deenanath Mangeshkar Hospital & Research Center, Pune, MH, India
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17
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Pandiella A, Calvo E, Moreno V, Amir E, Templeton A, Ocana A. Considerations for the clinical development of immuno-oncology agents in cancer. Front Immunol 2023; 14:1229575. [PMID: 37638048 PMCID: PMC10451075 DOI: 10.3389/fimmu.2023.1229575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Targeting of the immune system has shown to be a successful therapeutic approach in cancer, with the development of check point inhibitors (ICI) or T-cell engagers (TCE). As immuno-oncology agents modulate the immune system to attack cancer cells and do not act directly on oncogenic vulnerabilities, specific characteristics of these compounds should be taken in consideration during clinical development. In this review we will discuss relevant concepts including limitations of preclinical models, special pharmacologic boundaries, clinical development strategies such as the selection of clinical indication, line of treatment and backbone partner, as well as the endpoints and expected magnitude of benefit required at different stages of the drug development. In addition, future directions for early and late trial designs will be reviewed. Examples from approved drugs or those currently in clinical development will be discussed and options to overcome these limitations will be provided.
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Affiliation(s)
- Atanasio Pandiella
- Centro de Investigación del Cáncer, CIC-CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red en Oncología (CIBERONC), Madrid, Spain
| | - Emiliano Calvo
- START Madrid-HM Centro Integral Oncológico Clara Campal (CIOCC), Early Phase Program, HM Sanchinarro University Hospital, Madrid, Spain
| | - Victor Moreno
- START Madrid-Fundación Jiménez Díaz (FJD) Early Phase Program, Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Arnoud Templeton
- Department of Medical Oncology, St. Claraspital, Basel, Switzerland
| | - Alberto Ocana
- Centro de Investigación Biomédica en Red en Oncología (CIBERONC), Madrid, Spain
- START Madrid-Fundación Jiménez Díaz (FJD) Early Phase Program, Fundación Jiménez Díaz Hospital, Madrid, Spain
- Experimental Therapeutics Unit, Medical Oncology Department, Hospital Clínico San Carlos (HCSC), Instituto de Investigación Sanitaria (IdISSC), Madrid, Spain
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18
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Booth CM, Sengar M, Goodman A, Wilson B, Aggarwal A, Berry S, Collingridge D, Denburg A, Eisenhauer EA, Ginsburg O, Goldstein D, Gunasekera S, Hammad N, Honda K, Jackson C, Karikios D, Knopf K, Koven R, Marini BL, Maskens D, Moraes FY, Mohyuddin GR, Poudyal BS, Pramesh CS, Roitberg F, Rubagumya F, Schott S, Sirohi B, Soto-Perez-de-Celis E, Sullivan R, Tannock IF, Trapani D, Tregear M, van der Graaf W, Vanderpuye V, Gyawali B. Common Sense Oncology: outcomes that matter. Lancet Oncol 2023; 24:833-835. [PMID: 37467768 DOI: 10.1016/s1470-2045(23)00319-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/21/2023]
Affiliation(s)
| | | | - Aaron Goodman
- University of California San Diego, San Diego, CA, USA
| | | | | | - Scott Berry
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | | | | | | | - Nazik Hammad
- Queen's University, Kingston, ON, K7L 3N6, Canada
| | | | | | | | - Kevin Knopf
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian F Tannock
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | | | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology, and Nuclear Medicine, Accra, Ghana
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19
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Servetto A, Di Maio M, Salomone F, Napolitano F, Paratore C, Di Costanzo F, Viscardi G, Santaniello A, Formisano L, Bianco R. Analysis of phase III clinical trials in metastatic NSCLC to assess the correlation between QoL results and survival outcomes. BMC Med 2023; 21:234. [PMID: 37400832 DOI: 10.1186/s12916-023-02953-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND In addition to improving survival outcomes, new oncology treatments should lead to amelioration of patients' quality of life (QoL). Herein, we examined whether QoL results correlated with PFS and OS outcomes in phase III randomized controlled trials (RCTs) investigating new systemic treatments in metastatic non-small cell lung cancer (NSCLC). METHODS The systematic search of PubMed was conducted in October 2022. We identified 81 RCTs testing novel drugs in metastatic NSCLC and published in the English language in a PubMed-indexed journal between 2012 and 2021. Only trials reporting QoL results and at least one survival outcome between OS and PFS were selected. For each RCT, we assessed whether global QoL was "superior," "inferior," or with "non-statistically significant difference" in the experimental arm compared to the control arm. RESULTS Experimental treatments led to superior QoL in 30 (37.0%) RCTs and inferior QoL in 3 (3.7%) RCTs. In the remaining 48 (59.3%) RCTs, a statistically significant difference between the experimental and control arms was not found. Of note, we found a statistically significant association between QoL and PFS improvements (X2 = 3.93, p = 0.0473). In more detail, this association was not significant in trials testing immunotherapy or chemotherapy. On the contrary, in RCTs testing target therapies, QoL results positively correlated with PFS outcomes (p = 0.0196). This association was even stronger in the 32 trials testing EGFR or ALK inhibitors (p = 0.0077). On the other hand, QoL results did not positively correlate with OS outcomes (X2 = 0.81, p = 0.368). Furthermore, we found that experimental treatments led to superior QoL in 27/57 (47.4%) trials with positive results and in 3/24 (12.5%) RCTs with negative results (p = 0.0028). Finally, we analyzed how QoL data were described in publications of RCTs in which QoL outcomes were not improved (n = 51). We found that a favorable description of QoL results was associated with sponsorship by industries (p = 0.0232). CONCLUSIONS Our study reveals a positive association of QoL results with PFS outcomes in RCTs testing novel treatments in metastatic NSCLC. This association is particularly evident for target therapies. These findings further emphasize the relevance of an accurate assessment of QoL in RCTs in NSCLC.
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Affiliation(s)
- Alberto Servetto
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Fabio Salomone
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Fabiana Napolitano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Chiara Paratore
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
- Department of Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Fabrizio Di Costanzo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Giuseppe Viscardi
- Department of Pneumology and Oncology, AORN Ospedali Dei Colli-Monaldi, Naples, Italy
| | - Antonio Santaniello
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy.
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20
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Sidali S, Sritharan N, Campani C, Gregory J, Durand F, Ganne-Carrié N, Ronot M, Lévy V, Nault JC. Fragility index of positive phase II and III randomised clinical trials of treatments for hepatocellular carcinoma (2002-2022). JHEP Rep 2023; 5:100755. [PMID: 37425214 PMCID: PMC10326696 DOI: 10.1016/j.jhepr.2023.100755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 07/11/2023] Open
Abstract
Background & Aims The fragility index (FI), i.e., theminimum number of best survivors reassigned to the control group required to revert the statistically significant result of a clinical trial to non-significant, is a metric to evaluate the robustness of randomized controlled trials (RCTs). We aimed to assess the FI in the field of HCC. Methods This is a retrospective analysis of phase 2 and 3 RCTs for the treatment of HCC published between 2002 and 2022. We included two-arm studies with 1:1 randomization and significant positive results for a primary time-to-event endpoint for the FI calculation, which involves the iterative addition of a best survivor from the experimental group to the control group, until positive significance (p <0,05, Log-rank test) is lost. Results We identified 51 phase 2 and 3 positive RCTs, of which 29 (57%) were eligible for fragility index calculation. After reconstruction of the Kaplan-Meier curves, 25/29 studies remained significant, among which the analysis was performed. The median (interquartile range (IQR)) FI was 5 (2-10) and Fragility Quotient (FQ) was 3% (1%-6%). Ten trials (40%) had a FI of 2 or less. FI was positively correlated to the blind assessment of the primary endpoint (median FI 9 with blind assessment versus 2 without, p = 0.01), the number of reported events in the control arm (RS = 0.45, p = 0.02) and to impact factor (RS = 0.58, p = 0.003). Conclusions Several phases 2 and 3 RCTs in HCC have a low fragility index, underlying the limited robustness on the conclusion of their superiority over control treatments. The fragility index might provide an additional tool to assess the robustness of clinical trial data in HCC. Impact and implications The fragility index is a method to assess robustness of a clinical trial and is defined the minimum number of best survivors reassigned to the control group required to revert the statistically significant result of a clinical trial to non-significant. Among 25 randomised controlled trials in HCC, the median fragility index was 5, and 10 trials among 25 (40%) had a fragility index of 2 or less, indicating an important fragility.
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Affiliation(s)
- Sabrina Sidali
- Université de Paris, Service d’Hépatologie, DMU DIGEST, Hôpital Beaujon, APHP Nord, Clichy, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Team ‘Functional Genomics of Solid Tumors’, Equipe Labellisée Ligue Nationale Contre le Cancer, Labex OncoImmunology, Paris, France
| | - Nanthara Sritharan
- Department of Clinical Research, Paris Seine Saint Denis Hospital, Sorbonne Paris University, APHP, Bobigny, France
| | - Claudia Campani
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Team ‘Functional Genomics of Solid Tumors’, Equipe Labellisée Ligue Nationale Contre le Cancer, Labex OncoImmunology, Paris, France
| | - Jules Gregory
- Department of Radiology, FHU MOSAIC, Hôpital Beaujon APHP Nord, Clichy, France
- Université de Paris, INSERM, UMR1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), METHODS Team, Paris, France
| | - François Durand
- Université de Paris, Service d’Hépatologie, DMU DIGEST, Hôpital Beaujon, APHP Nord, Clichy, France
| | - Nathalie Ganne-Carrié
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Team ‘Functional Genomics of Solid Tumors’, Equipe Labellisée Ligue Nationale Contre le Cancer, Labex OncoImmunology, Paris, France
- Liver Unit, Hôpital Avicenne, Hôpitaux Universitaires Paris-Seine-Saint-Denis, Assistance-Publique Hôpitaux de Paris, Bobigny, France
- Unité de Formation et de Recherche Santé Médecine et Biologie Humaine, Université Sorbonne Paris Nord, Bobigny, France
| | - Maxime Ronot
- Department of Radiology, FHU MOSAIC, Hôpital Beaujon APHP Nord, Clichy, France
- Université de Paris, INSERM U1149 ‘Centre de Recherche sur L'inflammation’, CRI, Paris, France
| | - Vincent Lévy
- Department of Clinical Research, Paris Seine Saint Denis Hospital, Sorbonne Paris University, APHP, Bobigny, France
- ECSTRRA Team, CRESS UMR 1153, Hôpital Saint-Louis, APHP, Paris, France
| | - Jean-Charles Nault
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université de Paris, Team ‘Functional Genomics of Solid Tumors’, Equipe Labellisée Ligue Nationale Contre le Cancer, Labex OncoImmunology, Paris, France
- Liver Unit, Hôpital Avicenne, Hôpitaux Universitaires Paris-Seine-Saint-Denis, Assistance-Publique Hôpitaux de Paris, Bobigny, France
- Unité de Formation et de Recherche Santé Médecine et Biologie Humaine, Université Sorbonne Paris Nord, Bobigny, France
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21
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Sengar M, Hopman WM, Mohyuddin GR, Goodman AM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Sullivan R, Booth CM. Randomised controlled trials evaluating anticancer therapies in haematological cancers: an overview of global research activity. Ecancermedicalscience 2023; 17:1558. [PMID: 37396096 PMCID: PMC10310333 DOI: 10.3332/ecancer.2023.1558] [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: 12/18/2022] [Indexed: 07/04/2023] Open
Abstract
Background Design, results, and interpretation of oncology randomised controlled trials (RCTs) have changed substantially over the past decade. In this study, we describe all RCTs evaluating anticancer therapies in haematological cancers published globally during 2014-2017 with comparisons with solid tumours RCTs. Methods A PubMed literature search identified all phase 3 RCTs of anticancer therapy for haematological cancers and solid tumours published globally during 2014-2017. Descriptive statistics, chi-square tests and the Kruskal-Wallis test were used to compare RCT design results, and output between haematological cancers and solid tumours as well as for different haematological cancer subtypes. Results 694 RCTs were identified; 124 in haematological cancers and 570 in solid tumours. Overall survival (OS) was the primary endpoint in only 12% (15/124) of haematological cancer trials compared to 35% (200/570) in solid tumours (p < 0.001). Haematological cancer RCTs evaluated the systemic novel therapy more often than the solid tumour RCT (98% versus 84%, p = 0.002). Use of surrogate endpoints like progression-free survival (PFS) and time to treatment failure (TTF) were more common in haematological cancers than solid tumours (47% versus 31%, p < 0.001). Within haematological cancers, the use of PFS and TTF was more prevalent in chronic lymphocytic leukaemia and multiple myeloma as compared to others (80%-81% versus 0%-41%, p < 0.001). Seventy-eight percent of haematologic trials were funded by industry as compared to 70% of solid tumour trials. Only 4% (5/124) of haematologicalcancer trials were led by investigators in upper-middle and lower-middle-income countries as compared to the 9% of solid tumour trials. Conclusion The fact that only 12% of haematological cancer RCTs are designed to show improvements in OS is of grave concern for the field and the care of future patients. This is further compounded by the highly prevalent use of alternative primary endpoints that are rarely valid surrogates for OS in haematological cancers.
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Affiliation(s)
- Manju Sengar
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 400012, India
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Haematological Malignancies, University of Utah, Salt Lake City, UT 84112, USA
| | - Aaron M Goodman
- Division of Blood and Marrow Transplantation, University of California, San Diego, CA 92093, USA
| | - Bishal Gyawali
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
| | - Deborah Mukherji
- American University of Beirut Medical Center, Beirut 11-0236, Lebanon
| | - Nazik Hammad
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada
| | - CS Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 400012, India
| | - Ajay Aggarwal
- Institute of Cancer Policy, King’s College London, WC2R 2LS London, UK
- London School of Hygiene and Tropical Medicine, WC1E 7HT London, UK
| | - Richard Sullivan
- Institute of Cancer Policy, King’s College London, WC2R 2LS London, UK
| | - Christopher M Booth
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
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22
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Gnanasakthy A, Levy C, Norcross L, Doward L, Winnette R. A Review of Labeling Based on Patient-Reported Outcome Endpoints for New Oncology Drugs Approved by the European Medicines Agency (2017-2021). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:893-901. [PMID: 36746305 DOI: 10.1016/j.jval.2023.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE A review of new oncology indications approved by the European Medicines Agency (EMA) for 2012-2016 showed that 33% of new drugs had labeling based on patient-reported outcomes (PROs). We reviewed labeling text based on PRO endpoints for new oncology indications approved during 2017-2021. METHODS New oncology drugs approved by EMA to treat indications of cancers during 2017-2021 were identified from the EMA website. PRO-related language reported in EMA summaries of product characteristics (SmPCs) were summarized and compared with similar findings reported for oncology indications approved during 2012-2016. RESULTS Review documents by the EMA during 2017-2021 were available for 49 new oncology drugs for 70 cancer indications. Submissions for 52 (74.3%) of the 70 indications included PRO data for EMA review. Of all submissions, 14 (20.0%) approvals contained PRO-related language in the SmPC. Broad concepts such as health-related quality of life were most common and found in 8 of 14 (57.1%) PRO-related labels. CONCLUSION PRO-related language appeared in SmPCs for 20% of all indications of new oncology drugs approved by EMA during 2017-2021 compared with approximately 33% of EMA approvals during 2012-2016. PRO-related labeling during the same periods showed a greater decline (from 47% to 27%) for indications of new oncology drugs that also included PRO data. One possible reason for this decline may be the increase in open-label studies from 62% between 2012 and 2016 to approximately 79% between 2017 and 2021.
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23
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Tang M, Pearson SA, Simes RJ, Chua BH. Harnessing Real-World Evidence to Advance Cancer Research. Curr Oncol 2023; 30:1844-1859. [PMID: 36826104 PMCID: PMC9955401 DOI: 10.3390/curroncol30020143] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Randomized controlled trials (RCTs) form a cornerstone of oncology research by generating evidence about the efficacy of therapies in selected patient populations. However, their implementation is often resource- and cost-intensive, and their generalisability to patients treated in routine practice may be limited. Real-world evidence leverages data collected about patients receiving clinical care in routine practice outside of clinical trial settings and provides opportunities to identify and address gaps in clinical trial evidence. This review outlines the strengths and limitations of real-world and RCT evidence and proposes a framework for the complementary use of the two bodies of evidence to advance cancer research. There are challenges to the implementation of real-world research in oncology, including heterogeneity of data sources, timely access to high-quality data, and concerns about the quality of methods leveraging real-world data, particularly causal inference. Improved understanding of the strengths and limitations of real-world data and ongoing efforts to optimise the conduct of real-world evidence research will improve its reliability, understanding and acceptance, and enable the full potential of real-world evidence to be realised in oncology practice.
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Affiliation(s)
- Monica Tang
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick 2031, Australia
- Correspondence:
| | | | - Robert J. Simes
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown 2050, Australia
| | - Boon H. Chua
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick 2031, Australia
- Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia
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24
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van Stein RM, Sikorska K, van der Aa MA, Sonke GS, van Driel WJ, van Gent MDJM, van Ham MAPC, Hermans RHM, de Hingh IHJT, Schreuder HWR, The Dutch OVHIPEC‐1 trial group. Evaluation of external validity of the OVHIPEC-1 trial in a real-world population. Int J Gynaecol Obstet 2022; 161:640-648. [PMID: 36495280 DOI: 10.1002/ijgo.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/31/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The OVHIPEC-1 trial (Phase III randomised clinical trial for stage III ovarian carcinoma randomising between interval cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy) showed improved survival when interval cytoreductive surgery (CRS) was combined with hyperthermic intraperitoneal chemotherapy in patients with stage III epithelial ovarian cancer (EOC). The authors compared the control arm of the trial with a real-world population treated in the Netherlands during the same period to explore generalizability of the trial results. METHODS For this nationwide comparative cohort study, all patients with EOC undergoing interval CRS between 2007 and 2016 were identified from the Netherlands Cancer Registry if they fulfilled the eligibility criteria of OVHIPEC-1 (n = 1376). Patient and treatment characteristics, and overall survival (OS) were compared between trial and real-world populations. RESULTS Age, comorbidity, BRCA status, histologic subtype, and residual disease were similar in trial and real-world patients. Trial patients had a better performance status, higher socioeconomic status, and underwent bowel surgery more often. In a real-world setting, patients more often received more than six cycles. The difference in OS between the trial and the real-world populations was not statistically significant (unadjusted hazard ratio, 1.09 [95% confidence interval, 0.87-1.37]; P = 0.44). CONCLUSION Despite differences in patient characteristics, OS of patients treated in the control arm of OVHIPEC-1 was similar to patients treated outside the trial. The trial population accurately represents real-world patients with stage III EOC undergoing interval CRS in terms of outcome.
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Affiliation(s)
- Ruby M van Stein
- Department of Gynecologic Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Karolina Sikorska
- Department of Biometrics, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Maaike A van der Aa
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Willemien J van Driel
- Department of Gynecologic Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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25
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Association between control group therapy and magnitude of clinical benefit of cancer drugs. Sci Rep 2022; 12:21342. [PMID: 36494465 PMCID: PMC9734169 DOI: 10.1038/s41598-022-25983-9] [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: 07/28/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Little is known about the impact of control group therapy on clinical benefit scales such as American Society of Clinical Oncology Value Framework (ASCO-VF), European Society for Medical Oncology Magnitude Clinical Benefit Scale (ESMO-MCBS), National Comprehensive Cancer Network (NCCN) Evidence Blocks and ASCO Cancer Research Committee (ASCO-CRC). We searched Drugs@FDA to identify cancer drugs approved between January 2012 and December 2021 based on randomized trials (RCTs). Definition of substantial clinical benefit was based on recommendations for each scale. Associations between characteristics of control group therapy and clinical benefit were explored using logistic regression. RCTs with a control group of active treatment plus placebo were associated with significantly lower odds of substantial benefit with ESMO-MCBS (OR 0.27, P = 0.003) and ASCO-VF (OR 0.30, P = 0.008) but not with NCCN Evidence Blocks or ASCO-CRC. This effect was attenuated and lost statistical significance without adjustment for quality of life (QoL) and/or toxicity (ESMO-MCBS OR 0.50, P = 0.17; ASCO-VF OR 0.49, P = 0.11). Clinical benefit scales can be sensitive to control group therapy. RCTs with substantial overlap between experimental and control therapy showed lower magnitude of clinical benefit using ESMO-MCBS and ASCO-VF scales; possibly due to differences in the weighting of QoL and toxicity between different frameworks.
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26
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Implications of Oncology Trial Design and Uncertainties in Efficacy-Safety Data on Health Technology Assessments. Curr Oncol 2022; 29:5774-5791. [PMID: 36005193 PMCID: PMC9406873 DOI: 10.3390/curroncol29080455] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Advances in cancer medicines have resulted in tangible health impacts, but the magnitude of benefits of approved cancer medicines could vary greatly. Health Technology Assessment (HTA) is a multidisciplinary process used to inform resource allocation through a systematic value assessment of health technology. This paper reviews the challenges in conducting HTA for cancer medicines arising from oncology trial designs and uncertainties of safety-efficacy data. Methods: Multiple databases (PubMed, Scopus and Google Scholar) and grey literature (public health agencies and governmental reports) were searched to inform this policy narrative review. Results: A lack of robust efficacy-safety data from clinical trials and other relevant sources of evidence has made HTA for cancer medicines challenging. The approval of cancer medicines through expedited pathways has increased in recent years, in which surrogate endpoints or biomarkers for patient selection have been widely used. Using these surrogate endpoints has created uncertainties in translating surrogate measures into patient-centric clinically (survival and quality of life) and economically (cost-effectiveness and budget impact) meaningful outcomes, with potential effects on diverting scarce health resources to low-value or detrimental interventions. Potential solutions include policy harmonization between regulatory and HTA authorities, commitment to generating robust post-marketing efficacy-safety data, managing uncertainties through risk-sharing agreements, and using value frameworks. Conclusion: A lack of robust efficacy-safety data is a central problem for conducting HTA of cancer medicines, potentially resulting in misinformed resource allocation.
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27
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Vener C, Rossi S, Minicozzi P, Marcos-Gragera R, Poirel HA, Maynadié M, Troussard X, Pravettoni G, De Angelis R, Sant M. Clear Improvement in Real-World Chronic Myeloid Leukemia Survival: A Comparison With Randomized Controlled Trials. Front Oncol 2022; 12:892684. [PMID: 35912208 PMCID: PMC9333088 DOI: 10.3389/fonc.2022.892684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) have been improving the prognosis of patients with chronic myeloid leukemia (CML), but there are still large differences in survival among European countries. This raises questions on the added value of results from population-based studies, which use real-world data, compared to results of randomized controlled trials (RCTs) involving patients with CML. There are also questions about the extent of the findings on RCTs effectiveness for patients in the general population. We compare survival data extracted from our previous systematic review and meta-analysis of CML RCTs with the latest updated population-based survival data of EUROCARE-6, the widest collaborative study on cancer survival in Europe. The EUROCARE-6 CML survival estimated in patients (15–64 years) diagnosed in 2000–2006 vs. 2007–2013 revealed that the prognostic improvement highlighted by RCTs was confirmed in real-world settings, too. The study shows, evaluating for the first time all European regions, that the optimal outcome figures obtained in controlled settings for CML are also achievable (and indeed achieved) in real-world settings with prompt introduction of TKIs in daily clinical practice. However, some differences still persist, particularly in Eastern European countries, where overall survival values are lower than elsewhere, probably due to a delayed introduction of TKIs. Our results suggest an insufficient adoption of adequate protocols in daily clinical practice in those countries where CML survival values remain lower in real life than the values obtained in RCTs. New high-resolution population-based studies may help to identify failures in the clinical pathways followed there.
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Affiliation(s)
- Claudia Vener
- Analytical Epidemiology and Health Impact Unit, Department of Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Silvia Rossi
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Pamela Minicozzi
- Analytical Epidemiology and Health Impact Unit, Department of Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy.,Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rafael Marcos-Gragera
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Autonomous Government of Catalonia, Catalan Institute of Oncology, Girona Biomedical Research Institute (IdiBGi), Universitat de Girona, Girona, Spain.,Biomedical Network Research Centers of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Group of Descriptive and Analytical Epidemiology of Cancer, Josep Carreras Leukemia Research Institute, Girona, Spain
| | | | - Marc Maynadié
- Côte d'Or Hematological Malignancies Registry, Dijon, France
| | - Xavier Troussard
- Basse Normandie Cancer Registry, Centre Hospitalier Universitaire (CHU) de Caen, Normandie, Caen, France
| | | | - Roberta De Angelis
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Department of Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
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28
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Santorsola M, Di Lauro V, Nasti G, Caraglia M, Capuozzo M, Perri F, Cascella M, Misso G, Ottaiano A. Tumour Burden Reporting in Phase III Clinical Trials of Metastatic Lung, Breast, and Colorectal Cancers: A Systematic Review. Cancers (Basel) 2022; 14:3262. [PMID: 35805034 PMCID: PMC9264965 DOI: 10.3390/cancers14133262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Randomised phase III clinical trials represent a methodological milestone to select effective drugs against metastatic cancers. In this context, and particularly in the efficacy assessment of biologic drugs, the initial metastatic tumour burden is a strong prognostic factor. METHODS A systematic literature review of randomised, phase III, first-line, clinical trials in metastatic breast, colorectal, and lung cancers, published from 2016 to 2021, was performed. Three groups of variables were collected: identity-, method- (including tumour burden assessment) and outcome-related. RESULTS Seventy trials were selected. A large portion of studies (41.4%) focused on the effects of biologic agents (signal inhibitors and immuno-therapies). A definition of low-burden disease based predominantly on the number of involved organs was reported in 28.6% of studies. No explicit reference to oligo-metastatic disease was found either in inclusion/exclusion criteria or in final descriptive data analyses. Disease extent, heterogeneously defined, was a stratification factor for randomisation in only 25.7% of studies. In two studies, a significant imbalance between arms in patients with low-burden disease was revealed. CONCLUSIONS Attention to initial tumour burden in designing future clinical trials (including the harmonisation of definitions and the reporting of eventual oligo-metastatic disease, complete estimates of tumour volume, and its consideration as a stratification factor) should be increased.
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Affiliation(s)
- Mariachiara Santorsola
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Vincenzo Di Lauro
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Guglielmo Nasti
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Michele Caraglia
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (G.M.)
| | | | - Francesco Perri
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Marco Cascella
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Gabriella Misso
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (G.M.)
| | - Alessandro Ottaiano
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
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29
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Kartolo A, Yeung C, Hopman W, Fung AS, Baetz T, Vera Badillo FE. Complete response and survival outcomes in patients with advanced cancer on immune checkpoint inhibitors. Immunotherapy 2022; 14:777-787. [PMID: 35678046 DOI: 10.2217/imt-2021-0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate overall survival in advanced cancer patients who achieved complete response (CR) with immune checkpoint inhibitor (ICI) therapy. Methods: This retrospective study included patients with advanced unresectable or metastatic cancer who received at least one cycle of palliative-intent ICI. Best overall response was used to define response groups. Results: 21 (7%) of 322 patients achieved CR. Multivariate analysis demonstrated that CR was independently associated with better overall survival compared with disease progression (hazard ratio: 0.012; 95% CI: 0.002-0.090) and stable disease (hazard ratio: 0.063; 95% CI: 0.009-0.464) as well as a nonsignificant trend toward better overall survival compared with partial response (hazard ratio: 0.169; 95% CI: 0.023-1.252) regardless of cancer type, ICI regimen or ICI line. Conclusion: Patients who achieved CR had longer survival compared with patients who did not achieve CR.
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Affiliation(s)
- Adi Kartolo
- Department of Oncology, Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Cynthia Yeung
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Wilma Hopman
- Department of Public Health Sciences, Kingston Health Sciences Centre, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Andrea S Fung
- Department of Oncology, Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Tara Baetz
- Department of Oncology, Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Francisco E Vera Badillo
- Department of Oncology, Cancer Center of Southeastern Ontario, Queen's University, Kingston, ON, K7L 3N6, Canada
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Azoulay L. Rationale, Strengths, and Limitations of Real-World Evidence in Oncology: A Canadian Review and Perspective. Oncologist 2022; 27:e731-e738. [PMID: 35762676 PMCID: PMC9438907 DOI: 10.1093/oncolo/oyac114] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/26/2022] [Indexed: 11/14/2022] Open
Abstract
Randomized controlled trials (RCTs) continue to be the basis for essential evidence regarding the efficacy of interventions such as cancer therapies. Limitations associated with RCT designs, including selective study populations, strict treatment regimens, and being time-limited, mean they do not provide complete information about an intervention’s safety or the applicability of the trial’s results to a wider range of patients seen in real-world clinical practice. For example, recent data from Alberta showed that almost 40% of patients in the province’s cancer registry would be trial-ineligible per common exclusion criteria. Real-world evidence (RWE) offers an opportunity to complement the RCT evidence base with this kind of information about safety and about use in wider patient populations. It is also increasingly recognized for being able to provide information about an intervention’s effectiveness and is considered by regulators as an important component of the evidence base in drug approvals. Here, we examine the limitations of RCTs in oncology research, review the different types of RWE available in this area, and discuss the strengths and limitations of RWE for complementing RCT oncology data.
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Affiliation(s)
- Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montréal, Québec, Canada
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Randomized Controlled Trials in Lung, Gastrointestinal, and Breast Cancers: An Overview of Global Research Activity. Curr Oncol 2022; 29:2530-2538. [PMID: 35448181 PMCID: PMC9026406 DOI: 10.3390/curroncol29040207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/25/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background: In this study, we compared and contrasted design characteristics, results, and publications of randomized controlled trials (RCTs) in gastrointestinal (GI), lung, and breast cancer. Methods: A PUBMED search identified phase III RCTs of anticancer therapy in GI, lung, and breast cancer published globally during the period 2014−2017. Descriptive statistics, chi-square tests, and the Kruskal−Wallis test were used to compare RCT design, results, and output across the cancer sites. Results: A total of 352 RCTs were conducted on GI (36%), lung (29%), and breast (35%) cancer. Surrogate endpoints were used in 55% of trials; this was most common in breast trials (72%) compared to GI (47%) and lung trials (43%, p < 0.001). Breast trials more often met their primary endpoint (54%) than GI (41%) and lung trials (41%) (p = 0.024). When graded with the ESMO-MCBS, lung cancer trials (50%, 15/30) were more likely to meet the threshold for substantial benefit. GI trials were published in journals with a substantially lower impact factor (IF; median IF 13) than lung (median IF 21) and breast cancer trials (median IF 21) (p = 0.038). Conclusions: Important differences in RCT design and output exist between the three major cancer sites. Use of surrogate endpoints and the magnitude of benefit associated with new treatments vary substantially across cancer sites.
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Ottaiano A, Santorsola M, Caracò F, Caraglia M, Nasti G. Initial tumour burden and hidden oligometastatic disease in phase 3 clinical trials. Lancet Oncol 2022; 23:452-454. [DOI: 10.1016/s1470-2045(22)00034-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 12/28/2022]
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Han HS, Lee KE, Suh YJ, Jee HJ, Kim BJ, Kim HS, Lee KW, Ryu MH, Baek SK, Park IH, Ahn HK, Jeong JH, Kim MH, Lee DH, Kim S, Moon H, Son S, Byun JH, Kim DS, An H, Park YH, Zang DY. Data collection framework for electronic medical record-based real-world data to evaluate the effectiveness and safety of cancer drugs: a nationwide real-world study of the Korean Cancer Study Group. Ther Adv Med Oncol 2022; 14:17588359221132628. [PMID: 36339930 PMCID: PMC9634188 DOI: 10.1177/17588359221132628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Electronic medical records (EMRs) have the highest value among real-world
data (RWD). The aim of the present study was to propose a data collection
framework of EMR-based RWD to evaluate the effectiveness and safety of
cancer drugs by conducting a nationwide real-world study based on the Korean
Cancer Study Group. Methods: We considered all patients who received ramucirumab plus paclitaxel (RAM/PTX)
for gastric cancer and trastuzumab emtansine (T-DM1) for breast cancer at
relevant institutions in South Korea. Standard operating procedures for
systematic data collection were prospectively developed. Investigator
reliability was evaluated using the concordance rate between the recommended
input value for representative fictional cases and the input value of each
investigator. Reliability of collected data was evaluated twice during the
study period at three institutions randomly selected using the concordance
rate between the previously collected data and data collected by an
independent investigator. The reliability results of the investigators and
collected data were used for revision of the electronic data capture system
and site training. Results: Between the starting date of medical insurance coverage and December 2018, a
total of 1063 patients at 56 institutions in the RAM/PTX cohort and 824
patients at 60 institutions in the T-DM1 cohort were included. Mean
investigator reliability in the RAM/PTX and T-DM1 cohorts was 73.5% and
71.9%, respectively. Mean reliability of collected data in the RAM/PTX and
T-DM1 cohort was 90.0% for both cohorts in the first analysis and 89.0% and
84.0% in the second analysis, respectively. Mean missing values of the
RAM/PTX and T-DM1 cohorts at the time of simulation of fictional cases and
final data analysis decreased from 20.7% to 0.46% and from 18.5% to 0.76%,
respectively. Conclusion: This real-world study provides a framework that ensures relevance and
reliability of EMR-based RWD for evaluating the effectiveness and safety of
cancer drugs.
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Affiliation(s)
- Hye Sook Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Kyoung Eun Lee
- Department of Hematology and Oncology, Ewha Womans University Hospital, Seoul, Republic of Korea
| | - Young Ju Suh
- Department of Biomedical Sciences, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Hee-Jung Jee
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Bum Jun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea
| | - Hyeong Su Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Keun-Wook Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Min-Hee Ryu
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun Kyung Baek
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - In Hae Park
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hee Kyung Ahn
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Hwan Kim
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul
| | - Dae Hyung Lee
- Inha University Hospital, Incheon, Republic of Korea
| | - Siheon Kim
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hyemi Moon
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Serim Son
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Ji-Hye Byun
- Innovation Research Department, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Dong Sook Kim
- Review & Assessment Research Department, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Hyonggin An
- Department of Biostatistics, College of Medicine, Korea University, Anam-dong 5-ga, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Yeon Hee Park
- Department of Medicine, Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Dae Young Zang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro 170 beon-gil Dongan-gu, Anyang-si, Gyeonggi-do 14068, Republic of Korea
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Fu M, Naci H, Booth CM, Gyawali B, Cosgrove A, Toh S, Xu Z, Guan X, Ross-Degnan D, Wagner AK. Real-world Use of and Spending on New Oral Targeted Cancer Drugs in the US, 2011-2018. JAMA Intern Med 2021; 181:1596-1604. [PMID: 34661604 PMCID: PMC8524355 DOI: 10.1001/jamainternmed.2021.5983] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/20/2021] [Indexed: 01/23/2023]
Abstract
Importance Launch prices of new cancer drugs in the US have substantially increased in recent years despite growing concerns about the quantity and quality of evidence supporting their approval by the US Food and Drug Administration (FDA). Objective To assess the use of and spending on new oral targeted cancer drugs among US residents with employer-sponsored insurance between 2011 and 2018, stratified by the strength of available evidence of benefit. Design, Setting, and Participants In this cross-sectional study, dispensing claims for oral targeted cancer drugs first approved by the FDA between January 1, 2011, and December 31, 2018, were analyzed. The number of patients with drugs dispensed and the total payment for all claims were aggregated by calendar year, and these outcomes were arrayed according to evidence underlying FDA approvals, including pivotal study design (availability of randomized clinical trials) and overall survival (OS) benefit, as documented in drug labels. This study was conducted from July 17, 2019, to July 23, 2021. Main Outcomes and Measures Annual and cumulative numbers of patients who had dispensing events, and annual and cumulative sums of payment for eligible drugs. Results Of 37 348 patients who had at least 1 of the 44 new oral targeted drugs dispensed between 2011 and 2018, 21 324 were men (57.1%); mean (SD) age was 64.1 (13.1) years. Most individuals (36 246 [97.0%]) received drugs for which evidence from randomized clinical trials existed; however, a growing share of patients received drugs without documented OS benefit during the study period: from 12.7% in 2011 to 58.8% in 2018. Cumulative spending on all sample drugs totaled $3.5 billion by the end of 2018, of which 96.8% was spent on drugs that were approved based on a pivotal randomized clinical trial. Cumulative spending on drugs without documented OS benefit ($1.8 billion [51.6%]) surpassed that on drugs with documented OS benefit ($1.7 billion [48.4%]) by the end of 2018. Conclusions and Relevance The findings of this cross-sectional study suggest that drugs used for treatment of cancer without documented OS benefits are adopted in the health system and account for substantial spending.
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Affiliation(s)
- Mengyuan Fu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Departments of Oncology and Public Health Sciences, Queen’s University Cancer Research Institute, Kingston, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Departments of Oncology and Public Health Sciences, Queen’s University Cancer Research Institute, Kingston, Canada
| | - Austin Cosgrove
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Ziyue Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Anita K. Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Schnog JJB, Samson MJ, Gans ROB, Duits AJ. An urgent call to raise the bar in oncology. Br J Cancer 2021; 125:1477-1485. [PMID: 34400802 PMCID: PMC8365561 DOI: 10.1038/s41416-021-01495-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/09/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023] Open
Abstract
Important breakthroughs in medical treatments have improved outcomes for patients suffering from several types of cancer. However, many oncological treatments approved by regulatory agencies are of low value and do not contribute significantly to cancer mortality reduction, but lead to unrealistic patient expectations and push even affluent societies to unsustainable health care costs. Several factors that contribute to approvals of low-value oncology treatments are addressed, including issues with clinical trials, bias in reporting, regulatory agency shortcomings and drug pricing. With the COVID-19 pandemic enforcing the elimination of low-value interventions in all fields of medicine, efforts should urgently be made by all involved in cancer care to select only high-value and sustainable interventions. Transformation of medical education, improvement in clinical trial design, quality, conduct and reporting, strict adherence to scientific norms by regulatory agencies and use of value-based scales can all contribute to raising the bar for oncology drug approvals and influence drug pricing and availability.
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Affiliation(s)
- John-John B. Schnog
- Department of Hematology-Medical Oncology, Curaçao Medical Center, Willemstad, Curaçao ,Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao
| | - Michael J. Samson
- Department of Radiation Oncology, Curaçao Medical Center, Willemstad, Curaçao
| | - Rijk O. B. Gans
- grid.4494.d0000 0000 9558 4598Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ashley J. Duits
- Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao ,grid.4494.d0000 0000 9558 4598Institute for Medical Education, University Medical Center Groningen, Groningen, The Netherlands ,Red Cross Blood Bank Foundation, Willemstad, Curaçao
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36
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Duetz C, Cucchi DGJ, Polak TB, Janssen JJWM, Ossenkoppele GJ, Estey EH, van de Loosdrecht AA. The wider perspective: twenty years of clinical trials in myelodysplastic syndromes. Br J Haematol 2021; 196:329-335. [PMID: 34632583 DOI: 10.1111/bjh.17892] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/23/2021] [Accepted: 09/29/2021] [Indexed: 12/21/2022]
Abstract
Most patients with myelodysplastic syndromes (MDS) require therapeutic intervention. However, there are few approved treatments for MDS. To explore reasons, we searched clinicaltrials.gov and clinicaltrialsregister.eu for MDS trials from 2000 to 2020. We assessed which agents were under investigation and analysed clinical trial characteristics and continuation rates from phase I to II to III to approval. As such, we identified 384 unique agents in 426 phase I, 430 phase II and 48 phase III trials. Success rates for phase III trials and agents were low, and MDS trials took markedly longer to complete than the average clinical trial. Although success rates were higher when MDS-specific phase I trials were conducted, 52% of the agents had not been evaluated in a phase I trial for MDS. MDS trials often failed to include quality of life, an especially important outcome for older MDS patients. Our work identifies factors potentially contributing to the paucity of available agents for MDS. We suggest a framework to improve clinical research in MDS that might ultimately augment the number of available agents.
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Affiliation(s)
- Carolien Duetz
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - David G J Cucchi
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tobias B Polak
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Elihu H Estey
- Department of Hematology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Bevacizumab Combined with Platinum-Taxane Chemotherapy as First-Line Treatment for Advanced Ovarian Cancer: Results of the NOGGO Non-Interventional Study (OTILIA) in 824 Patients. Cancers (Basel) 2021; 13:cancers13194739. [PMID: 34638225 PMCID: PMC8507543 DOI: 10.3390/cancers13194739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/30/2022] Open
Abstract
Simple Summary The OTILIA non-interventional study aimed to assess the safety and effectiveness of a standard treatment regimen for advanced ovarian cancer in Germany. All of the women participating in the study received chemotherapy combined with a targeted treatment called bevacizumab. Among the 824 women who received treatment in this study, the median duration of progression-free survival (time alive without their disease returning) was 19.4 months. This is similar to the results in previous randomized phase 3 trials in more restricted populations of women. The safety and effectiveness of treatment seemed to be similar in older (at least 70 years) and younger (less than 70 years) women. Quality of life improved over time. Abstract In the single-arm non-interventional OTILIA study, patients with newly diagnosed International Federation of Gynecology and Obstetrics (FIGO) stage IIIB–IV ovarian cancer received bevacizumab (15 mg/kg every 3 weeks for up to 15 months) and standard carboplatin–paclitaxel. The primary aim was to assess safety and progression-free survival (PFS). Subgroup analyses according to age were prespecified. The analysis population included 824 patients (453 aged <70 years, 371 aged ≥70 years). At data cutoff, the median bevacizumab duration was 13.8 months. Grade ≥3 adverse events (AEs), serious AEs, and AEs leading to bevacizumab discontinuation were more common in older than younger patients, whereas treatment-related AEs were less common. Median PFS was 19.4 months, with no clear difference according to age (20.0 vs. 19.3 months in patients <70 vs. ≥70 years, respectively). One-year OS rates were 92% and 90%, respectively. Mean change from baseline in global health status/quality of life showed a clinically meaningful increase over time. In German routine oncology practice, PFS and safety were similar to reported randomized phase 3 bevacizumab trials in more selected populations. There was no notable reduction in effectiveness and tolerability in patients aged ≥70 years; age alone should not preclude use of bevacizumab-containing therapy. ClinicalTrials.gov: NCT01697488.
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38
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Dabush DR, Shepshelovich D, Shochat T, Tibau A, Amir E, Goldvaser H. The impact of radiological assessment schedules on progression-free survival in metastatic breast cancer: A systemic review and meta-analysis. Cancer Treat Rev 2021; 100:102293. [PMID: 34543860 DOI: 10.1016/j.ctrv.2021.102293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of interval of restaging on the observed magnitude of benefit of progression-free survival (PFS) is undefined. MATERIALS AND METHODS Phase 3 randomized controlled trials (RCTs) investigating anti-neoplastic drugs for metastatic breast cancer which reported the restaging interval and hazard ratio (HR) for PFS were included. Data on study design and study population were collected. HRs and 95% confidence intervals for PFS and OS (overall survival) were pooled in a meta-analysis. Studies were categorized according to short (<9 weeks) or long (≥9 weeks) restaging interval. The differences in PFS and OS effect between trials employing short and long restaging intervals were assessed as subgroup analyses. Analyses were repeated for pre-specified subgroups. RESULTS Eighty-nine studies comprising 95 comparisons and 44,901 patients were included. The magnitude of PFS benefit was larger in trials which employed short compared to long restaging intervals, but this difference did not reach the pre-defined threshold for statistical significance (HR = 0.79 vs. 0.86, P = 0.15). Short restaging interval was associated with significantly higher magnitude of effect on PFS in pre-specified subgroups including non-first line trials (HR = 0.78 vs. 0.92, P = 0.04), trials with drugs replacing standard treatment (HR = 0.86 vs. 1.04, P = 0.02) and studies performed in exclusively human epidermal growth factor receptor 2 (HER2) positive disease (HR = 0.72 vs. 0.90, P = 0.02). The magnitude of OS benefit was similar with short and long restaging intervals. CONCLUSIONS Shorter restaging intervals are associated with a higher magnitude of effect on PFS, but not OS. Awareness of the impact of the restaging interval on quantification of PFS is important for the design and interpretation of RCTs.
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Affiliation(s)
| | - Daniel Shepshelovich
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Internal Medicine "D", Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center, Petah Tikva, Israel
| | - Ariadna Tibau
- Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
| | - Hadar Goldvaser
- Oncology Institute, Shaare Zedek Medical Center, and the Hebrew University Faculty of Medicine, Jerusalem, Israel.
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Farina A, Moro F, Fasslrinner F, Sedghi A, Bromley M, Siepmann T. Strength of clinical evidence leading to approval of novel cancer medicines in Europe: A systematic review and data synthesis. Pharmacol Res Perspect 2021; 9:e00816. [PMID: 34232554 PMCID: PMC8262606 DOI: 10.1002/prp2.816] [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: 02/27/2021] [Accepted: 04/27/2021] [Indexed: 11/06/2022] Open
Abstract
We aimed to evaluate the quality of clinical evidence that substantiated approval of cancer medicines by the European Medicines Agency (EMA) in the last decade. We performed a systematic review and data synthesis of EMA documents in agreement with PRISMA guidelines. We included the European Public Assessment Reports, Summaries of Product Characteristics, and published randomized controlled trials (RCTs) on anti-cancer drugs approved by EMA from 2010 to 2019, and excluded drugs not indicated for targeting solid or hematological tumors and non-innovative treatments. We synthesized frequencies of approvals differentiating between unblinded and blinded RCTs with and without overall survival (OS) as a predefined primary outcome measure. We assessed the frequency of post-approval RCTs for indications without at least one RCT at the time of approval. Of 199 approvals, 159 (80%) were supported by at least one RCT, 63 (32%) by at least one RCT having OS as the primary or co-primary endpoint, 74 (37%) by at least one blinded RCT, and 30 (15%) by at least one blinded RCT having OS as the primary or co-primary endpoint. Whereas 40 approvals (20%) were not supported by any RCT and, of those, 9 (22%) were followed by a post-approval RCT. While the majority of approvals of cancer medicines approved by EMA was supported by at least one RCT, we noted substantial methodological heterogeneity of the studies. Clinical trial registration: PROSPERO registration number CRD42020206669.
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Affiliation(s)
- Alberto Farina
- Division of Healthcare Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany.,Medical Affairs Department, Celltrion Healthcare Italy srl, Milan, Italy
| | - Federico Moro
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Frederick Fasslrinner
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annahita Sedghi
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Miluska Bromley
- Division of Healthcare Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany.,Universidad Cientifica del Sur, Lima, Peru
| | - Timo Siepmann
- Division of Healthcare Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany.,Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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40
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Sharma S, Wells JC, Hopman WM, Del Paggio JC, Gyawali B, Hammad N, Hay AE, Booth CM. Cancer, Clinical Trials, and Canada: Our Contribution to Worldwide Randomized Controlled Trials. ACTA ACUST UNITED AC 2021; 28:1518-1527. [PMID: 33924380 PMCID: PMC8167552 DOI: 10.3390/curroncol28020143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 12/23/2022]
Abstract
Canada has a long tradition of leading practice-changing clinical trials in oncology. Here, we describe methodology, results, and interpretation of oncology RCTs with Canadian involvement compared to RCTs from other high-income countries (HICs). A literature search identified all RCTs evaluating anti-cancer therapies published 2014–2017. RCTs were classified based on the country affiliation of first authors. The study cohort included 636 HIC-led RCTs; 155 (24%) had Canadian authors. Three-quarters (112/155, 72%) of Canadian RCTs were conducted in the palliative setting, compared to two thirds (299/481, 62%) of RCTs from other HICs (p = 0.022). Canadian RCTs were more likely than those from other HICs to be supported by industry (85% vs. 69%, p < 0.001). The proportion of positive Canadian trials that met the ESMO-MCBS threshold for substantial clinical benefit was comparable to RCTs without Canadian authors (29% vs. 32%, p = 0.137). Thirteen percent (20/155) of all Canadian trials were affiliated with the Canadian Cancer Trials Group (CCTG). Canada plays a meaningful role in the global cancer research ecosystem but is overly reliant on industry support. The very low proportion of trials that identify a new treatment with substantial clinical benefit is worrisome. A renewed investment in cancer clinical trials is needed in Canada.
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Affiliation(s)
- Shubham Sharma
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
| | - J. Connor Wells
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
| | - Wilma M. Hopman
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
| | - Joseph C. Del Paggio
- Department of Oncology, Northern Ontario School of Medicine, Thunder Bay, ON P3E 2C6, Canada;
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
| | - Nazik Hammad
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
| | - Annette E. Hay
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada;
- Canadian Cancer Trials Group, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
- Correspondence:
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Basket trials: From tumour gnostic to tumour agnostic drug development. Cancer Treat Rev 2020; 90:102082. [DOI: 10.1016/j.ctrv.2020.102082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/14/2022]
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Luyendijk M, Vernooij RWM, Blommestein HM, Siesling S, Uyl-de Groot CA. Assessment of Studies Evaluating Incremental Costs, Effectiveness, or Cost-Effectiveness of Systemic Therapies in Breast Cancer Based on Claims Data: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1497-1508. [PMID: 33127021 DOI: 10.1016/j.jval.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/10/2020] [Accepted: 05/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Large secondary databases, such as those containing insurance claims data, are increasingly being used to compare the effects and costs of treatments in routine clinical practice. Despite their appeal, however, caution must be exercised when using these data. In this study, we aimed to identify and assess the methodological quality of studies that used claims data to compare the effectiveness, costs, or cost-effectiveness of systemic therapies for breast cancer. METHODS We searched Embase, the Cochrane Library, Medline, Web of Science, and Google Scholar for English-language publications and assessed the methodological quality using the Good Research for Comparative Effectiveness principles. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42018103992. RESULTS We identified 1251 articles, of which 106 met the inclusion criteria. Most studies were conducted in the United States (74%) and Taiwan (9%) and were based on claims data sets (35%) or claims data linked to cancer registries (58%). Furthermore, most included large samples (mean 17 130 patients) and elderly patients, and they covered various outcomes (eg, survival, adverse events, resource use, and costs). Key methodological shortcomings were the lack of information on relevant confounders, the risk of immortal time bias, and the lack of information on the validity of outcomes. Only a few studies performed sensitivity analyses. CONCLUSIONS Many comparative studies of cost, effectiveness, and cost-effectiveness have been published in recent decades based on claims data, and the number of publications has increased over time. Despite the availability of guidelines to improve quality, methodological issues persist and are often inappropriately addressed or reported.
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Affiliation(s)
- Marianne Luyendijk
- Department of Research and Development, Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands; Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
| | - Robin W M Vernooij
- Department of Research and Development, Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands
| | - Hedwig M Blommestein
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands; Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Carin A Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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Saleh RR, Meti N, Ribnikar D, Goldvaser H, Ocana A, Templeton AJ, Seruga B, Amir E. Associations between safety, tolerability, and toxicity and the reporting of health-related quality of life in phase III randomized trials in common solid tumors. Cancer Med 2020; 9:7888-7895. [PMID: 32886422 PMCID: PMC7643655 DOI: 10.1002/cam4.3390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 01/09/2023] Open
Abstract
Background Anti‐cancer drugs are approved typically on the basis of efficacy and safety as evaluated in phase III randomized trials (RCTs). Health‐related quality of life (HRQoL) is a direct measure of patient benefit, but is under‐reported. Here we explore associations with reporting of HRQoL data in phase III RCTs in common solid tumors. Methods We searched ClinicalTrials.gov to identify phase III RCTs evaluating new drugs in adults with advanced cancers that completed accrual between January 2005 and October 2016. Data on HRQoL, safety, and tolerability comprising treatment‐related death, treatment discontinuation and commonly reported grade 3 or 4 adverse events (AEs) were extracted. Associations between these measures and reporting of HRQoL data were explored using logistic regression. Results Of 377 phase III RCTs identified initially, 143 studies were analysed and comprised 55% positive trials and 90% industry sponsored trials. HRQoL was listed as an endpoint in 59% trials; and of these, only 65% reported HRQoL data. There were higher odds of reporting HRQoL data for positive trials (OR 2.05, P = .04) and trials published in journals with higher impact factor (OR 1.35, P = .01). Reporting of HRQoL was not associated with treatment‐related death (OR 1.25, P = .40) or treatment discontinuation (OR 1.12, P = .61), but was positively associated with dyspnea and dermatological adverse events. Conclusions HRQoL is reported in only two‐thirds of RCTs that describe collecting such data. Reporting of HRQoL is associated with positive trial outcome and higher journal impact factor, but not associated with overall safety and tolerability of anti‐cancer drugs.
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Affiliation(s)
- Ramy R Saleh
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Nicholas Meti
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Domen Ribnikar
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Hadar Goldvaser
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alberto Ocana
- Experimental Therapeutics Unit, Medical Oncology Department, Hospital Clínico San Carlos, and IdISSC, Madrid, Spain.,Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain.,Centro Regional de Investigaciones Biomédicas, Castilla-La Mancha University, Ciudad Real, Spain
| | - Arnoud J Templeton
- Department of Oncology, St. Claraspital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Bostjan Seruga
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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Madariaga A, Bonilla L, McMullen M, Oza AM, Lheureux S. Efficacy and safety updates of poly ADP-ribose polymerase (PARP) inhibitor maintenance in ovarian cancer from ASCO 2020. Int J Gynecol Cancer 2020; 30:1256-1257. [PMID: 32646863 DOI: 10.1136/ijgc-2020-001723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ainhoa Madariaga
- Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Luisa Bonilla
- Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Michelle McMullen
- Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Amit M Oza
- Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Schirrmacher V, Sprenger T, Stuecker W, Van Gool SW. Evidence-Based Medicine in Oncology: Commercial Versus Patient Benefit. Biomedicines 2020; 8:biomedicines8080237. [PMID: 32717895 PMCID: PMC7460025 DOI: 10.3390/biomedicines8080237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022] Open
Abstract
At times of personalized and individualized medicine the concept of randomized- controlled clinical trials (RCTs) is being questioned. This review article explains principles of evidence-based medicine in oncology and shows an example of how evidence can be generated independently from RCTs. Personalized medicine involves molecular analysis of tumor properties and targeted therapy with small molecule inhibitors. Individualized medicine involves the whole patient (tumor and host) in the context of immunotherapy. The example is called Individualized Multimodal Immunotherapy (IMI). It is based on the individuality of immunological tumor-host interactions and on the concept of immunogenic tumor cell death (ICD) induced by an oncolytic virus. The evidence is generated by systematic data collection and analysis. The outcome is then shared with the scientific and medical community. The priority of big pharma studies is commercial benefit. Methods used to achieve this are described and have damaged the image of RCT studies in general. A critical discussion is recommended between all partners of the medical health system with regard to the conduct of RCTs by big pharma companies. Several clinics and institutions in Europe try to become more independent from pharma industry and to develop their own modern cancer therapeutics. Medical associations should include references to such studies from personalized and individualized medicine in their guidelines.
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Sprenger T, Schirrmacher V, Stücker W, van Gool SW. Position paper: new insights into the immunobiology and dynamics of tumor-host interactions require adaptations of clinical studies. Expert Rev Anticancer Ther 2020; 20:639-646. [PMID: 32600076 DOI: 10.1080/14737140.2020.1785874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Prospective double-blind placebo-controlled randomized clinical trials (RCTs) are considered standard for the proof of the efficacy of oncologic therapies. Molecular methods have provided new insights into tumor biology and led to the development of targeted therapies. Due to the increasing complexity of molecular tumor characteristics and of the individuality of specific anti-tumor immune reactivity, RCTs are unfortunately only of limited use. AREAS COVERED The historical methods of drug research and approval and the related practices of reimbursement by statutory and private health insurance companies are being questioned. New, innovative methods for the documentation of evidence in personalized medicine will be addressed. Possible perspectives and new approaches are discussed, in particular with regard to glioblastoma. EXPERT OPINION Highly specialized translational oncology groups like the IOZK can contribute to medical progress and quick transfer 'from bench to bedside.' Their contribution should be acknowledged and taken into account more strongly in the development of guidelines and the reimbursement of therapy costs. Methodological plurality should be encouraged.
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Endpoint surrogacy in oncology Phase 3 randomised controlled trials. Br J Cancer 2020; 123:333-334. [PMID: 32451466 PMCID: PMC7403397 DOI: 10.1038/s41416-020-0896-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/01/2020] [Indexed: 12/17/2022] Open
Abstract
Endpoint surrogacy is an important concept in oncology trials. Using a surrogate endpoint like progression-free survival as the primary endpoint-instead of overall survival-would lead to a potential faster drug approval and therefore more cancer patients with an earlier opportunity to receive the newly approved drugs.
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Amitai I, Raanani P, Shepshelovich D. Changes in primary outcome and sample size measures after initiation of accrual among trials supporting approval of drugs for hematological malignancies by the US food and drug administration. Leuk Lymphoma 2020; 61:2216-2220. [DOI: 10.1080/10428194.2020.1765234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Irina Amitai
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Canada
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel Shepshelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Medicine I, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Woolmore A, Arnold D, Blay JY, Buske C, Carrato A, Gerritsen W, Peeters M, Garcia-Foncillas J, Kerr D. The Oncology Data Network (ODN): Methodology, Challenges, and Achievements. Oncologist 2020; 25:e1428-e1432. [PMID: 32333623 DOI: 10.1634/theoncologist.2019-0855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Dirk Arnold
- Asklepios Tumorzentrum Hamburg, AK Altona, Hamburg, Germany
| | | | - Christian Buske
- Comprehensive Cancer Center, University Hospital Ulm, Ulm, Germany
| | - Alfredo Carrato
- Ramón y Cajal University Hospital, Alcala University, IRYCIS, CIBERONC, Madrid, Spain
| | | | - Marc Peeters
- Center for Oncological Research, University of Antwerp, and Antwerp University Hospital, Edegem, Belgium
| | - Jesus Garcia-Foncillas
- University Cancer Institute and the Department of Oncology, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - David Kerr
- John Radcliffe Hospital, Nuffield Division of Clinical Laboratory Sciences, Oxford, United Kingdom
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Schirrmacher V. Cancer Vaccines and Oncolytic Viruses Exert Profoundly Lower Side Effects in Cancer Patients than Other Systemic Therapies: A Comparative Analysis. Biomedicines 2020; 8:biomedicines8030061. [PMID: 32188078 PMCID: PMC7148513 DOI: 10.3390/biomedicines8030061] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 12/29/2022] Open
Abstract
This review compares cytotoxic drugs, targeted therapies, and immunotherapies with regard to mechanisms and side effects. Targeted therapies relate to small molecule inhibitors. Immunotherapies include checkpoint inhibitory antibodies, chimeric antigen receptor (CAR) T-cells, cancer vaccines, and oncolytic viruses. All these therapeutic approaches fight systemic disease, be it micro-metastatic or metastatic. The analysis includes only studies with a proven therapeutic effect. A clear-cut difference is observed with regard to major adverse events (WHO grades 3-4). Such severe side effects are not observed with cancer vaccines/oncolytic viruses while they are seen with all the other systemic therapies. Reasons for this difference are discussed.
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