1
|
Bharmjeet, Das A. Racial disparities in cancer care, an eyeopener for developing better global cancer management strategies. Cancer Rep (Hoboken) 2023; 6 Suppl 1:e1807. [PMID: 36971312 PMCID: PMC10440846 DOI: 10.1002/cnr2.1807] [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: 12/20/2022] [Revised: 02/05/2023] [Accepted: 03/01/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND In the last few decades, advancements in cancer research, both in the field of cancer diagnostics as well as treatment of the disease have been extensive and multidimensional. Increased availability of health care resources and growing awareness has resulted in the reduction of consumption of carcinogens such as tobacco; adopting various prophylactic measures; cancer testing on regular basis and improved targeted therapies have greatly reduced cancer mortality among populations, globally. However, this notable reduction in cancer mortality is discriminate and reflective of disparities between various ethnic populations and economic classes. Several factors contribute to this systemic inequity, at the level of diagnosis, cancer prognosis, therapeutics, and even point-of-care facilities. RECENT FINDINGS In this review, we have highlighted cancer health disparities among different populations around the globe. It encompasses social determinants such as status in society, poverty, education, diagnostic approaches including biomarkers and molecular testing, treatment as well as palliative care. Cancer treatment is an active area of constant progress and newer targeted treatments like immunotherapy, personalized treatment, and combinatorial therapies are emerging but these also show biases in their implementation in various sections of society. The involvement of populations in clinical trials and trial management is also a hotbed for racial discrimination. The immense progress in cancer management and its worldwide application needs a careful evaluation by identifying the biases in racial discrimination in healthcare facilities. CONCLUSION Our review gives a comprehensive evaluation of this global racial discrimination in cancer care and would be helpful in designing better strategies for cancer management and decreasing mortality.
Collapse
Affiliation(s)
- Bharmjeet
- Department of BiotechnologyDelhi Technological UniversityDelhi110042India
| | - Asmita Das
- Department of BiotechnologyDelhi Technological UniversityDelhi110042India
| |
Collapse
|
2
|
Kehl KL, Jaklitsch MT. Quality Surgical Care and Outcomes for Patients With Non-Small-Cell Lung Cancer. J Clin Oncol 2023:JCO2300745. [PMID: 37267584 DOI: 10.1200/jco.23.00745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/04/2023] Open
Affiliation(s)
- Kenneth L Kehl
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | |
Collapse
|
3
|
Duma N, Evans N, Mitchell E. Disparities in lung cancer. J Natl Med Assoc 2023; 115:S46-S53. [PMID: 37202003 DOI: 10.1016/j.jnma.2023.02.004] [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: 09/02/2022] [Accepted: 02/01/2023] [Indexed: 05/20/2023]
Abstract
Lung cancer is the second most common cancer and the leading cause of cancer death among men and women in the United States. Despite a substantial decline in lung cancer incidence and mortality across all races in the last few decades, medically underserved racial and ethnic minority populations continue to carry the greatest burden of disease throughout the lung cancer continuum. Black individuals experience a higher incidence of lung cancer due to lower rates of low-dose computed tomography screening, which translate into advanced disease stage at diagnosis and poorer survival outcomes compared with White individuals. With respect to treatment, Black patients are less likely to receive gold standard surgery, have access to biomarker testing or high-quality treatment compared with White patients. The reasons for those disparities are multifactorial and include socioeconomic (eg, poverty, lack of health insurance, and inadequate education), and geographic inequalities. The objective of this article is to review the sources of racial and ethnic disparities in lung cancer, and to propose recommendations to help address them.
Collapse
Affiliation(s)
| | | | - Edith Mitchell
- Sidney Kimmel Cancer Center at Jefferson Health, Philadelphia, PA, USA.
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW Despite an overall reduction in lung cancer incidence and mortality rates worldwide, Blacks still have higher mortality rates compared to Whites. There are many factors that contribute to this difference. This review seeks to highlight racial disparities in treatment and the possible reasons for these disparities. RECENT FINDINGS Factors attributing to racial disparities in lung cancer treatment include social determinants of health, differences in the administration of guideline-concordant therapy as well as molecular testing that is essential for most NSCLC patients. One way to circumvent disparities in lung cancer survivorship is to ensure equal representation of race in research at all levels that will provide insight on interventions that will address social determinants of health, differences in treatment patterns, molecular testing, and clinical trial involvement.
Collapse
Affiliation(s)
- Sharon Harrison
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA, 19111, USA
- African Caribbean Cancer Consortium, Philadelphia, PA, 19111, USA
| | - Julia Judd
- Department of Hematology/Oncology, Fox Chase Cancer Center, Temple University Hospital, 333 Cottman Ave., Philadelphia, PA, 19111, USA
| | - Sheray Chin
- African Caribbean Cancer Consortium, Philadelphia, PA, 19111, USA
- Department of Pathology (Division of Haematology & Oncology), Faculty of Medical Sciences, University of the West Indies, Mona, Jamaica
| | - Camille Ragin
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA, 19111, USA.
- African Caribbean Cancer Consortium, Philadelphia, PA, 19111, USA.
| |
Collapse
|
5
|
Huang B, Chen Q, Allison D, El Khouli R, Peh KH, Mobley J, Anderson A, Durbin EB, Goodin D, Villano JL, Miller RW, Arnold SM, Kolesar JM. Molecular Tumor Board Review and Improved Overall Survival in Non-Small-Cell Lung Cancer. JCO Precis Oncol 2021; 5:PO.21.00210. [PMID: 34622117 PMCID: PMC8492377 DOI: 10.1200/po.21.00210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/13/2021] [Accepted: 08/19/2021] [Indexed: 12/25/2022] Open
Abstract
With the introduction of precision medicine, treatment options for non-small-cell lung cancer have improved dramatically; however, underutilization, especially in disadvantaged patients, like those living in rural Appalachian regions, is associated with poorer survival. Molecular tumor boards (MTBs) represent a strategy to increase precision medicine use. UK HealthCare at the University of Kentucky (UK) implemented a statewide MTB in January 2017. We wanted to test the impact of UK MTB review on overall survival in Appalachian and other regions in Kentucky. METHODS We performed a case-control study of Kentucky patients newly diagnosed with non-small-cell lung cancer between 2017 and 2019. Cases were reviewed by the UK MTB and were compared with controls without UK MTB review. Controls were identified from the Kentucky Cancer Registry and propensity-matched to cases. The primary end point was the association between MTB review and overall patient survival. RESULTS Overall, 956 patients were included, with 343 (39%) residing in an Appalachian region. Seventy-seven (8.1%) were reviewed by the MTB and classified as cases. Cox regression analysis showed that poorer survival outcome was associated with lack of MTB review (hazard ratio [HR] = 8.61; 95% CI, 3.83 to 19.31; P < .0001) and living in an Appalachian region (hazard ratio = 1.43; 95% CI, 1.17 to 1.75; P = .004). Among individuals with MTB review, survival outcomes were similar regardless of whether they lived in Appalachia or other parts of Kentucky. CONCLUSION MTB review is an independent positive predictor of overall survival regardless of residence location. MTBs may help overcome some health disparities for disadvantaged populations.
Collapse
Affiliation(s)
- Bin Huang
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Division of Cancer Biostatistics, University of Kentucky, Lexington, KY
| | - Quan Chen
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Division of Cancer Biostatistics, University of Kentucky, Lexington, KY
| | - Derek Allison
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Radiology, University of Kentucky, Lexington, KY
| | - Riham El Khouli
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, KY
| | - Keng Hee Peh
- Department of Pharmacy, University of Kentucky, Lexington, KY
| | - James Mobley
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | | | - Eric B Durbin
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | | | - John L Villano
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Rachel W Miller
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
| | - Susanne M Arnold
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Jill M Kolesar
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY
| |
Collapse
|
6
|
Rivera MP, Charlot M, Durham DD, Throneburg A, Lane LM, Perera P, Samulski TD, Henderson LM. Molecular Biomarker and Programmed Death-Ligand 1 Expression Testing in Patients With Advanced Stage Non-small Cell Lung Cancer Across North Carolina Community Hospitals. Chest 2021; 160:1121-1130. [PMID: 33887243 DOI: 10.1016/j.chest.2021.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Precision medicine in advanced non-small cell lung cancer (NSCLC) requires molecular biomarker testing in patients with nonsquamous and select patients with squamous histologies, and programmed death-ligand 1 (PD-L1) testing in both. RESEARCH QUESTION What are rates of molecular and PD-L1 biomarker testing in patients with advanced NSCLC in community practices, and do rates vary by sociodemographic factors? What is the prevalence of molecular biomarker mutations and PD-L1 expression levels? STUDY DESIGN AND METHODS From 389 stage IV NSCLC pathology reports obtained through the University of North Carolina Lineberger Comprehensive Cancer Center's Rapid Case Ascertainment Program from 38 community hospitals across North Carolina, we abstracted demographics, histology, molecular biomarker testing and results, and PD-L1 testing and expression. We geocoded patient and hospital addresses to determine travel time, distance to care, and census block level contextual variables. We compared molecular biomarker and PD-L1 testing rates, the prevalence of molecular biomarkers, and PD-L1 expression levels by race and sex, using χ2 tests. We determined predictors of testing, using multivariable logistic regression and report adjusted ORs and 95%CI. RESULTS Among patients with nonsquamous NSCLC, 64.4% were tested for molecular biomarkers, and among all NSCLC patients 53.2% were tested for PD-L1 expression. Differences in biomarker testing rates by sociodemographic factors were not statistically significant in univariate or adjusted analyses. Adjusted analyses showed that patients living in areas with higher household internet access were more likely to undergo PD-L1 testing (adjusted OR = 1.66, 95% CI, 1.02-2.71). Sociodemographic differences in molecular biomarker prevalence and PD-L1 expression levels were not statistically significant, except for human epidermal growth factor receptor 2 (HER2) mutations, which occurred in 16.7% of males vs 0% in females, P = .05. INTERPRETATION Biomarker testing remains underused in NSCLC. Future work should include larger populations and evaluate hospital-specific testing protocols to identify and address barriers to guideline-recommended testing.
Collapse
Affiliation(s)
- M Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, NC.
| | - Marjory Charlot
- Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, NC; Division of Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, NC
| | - Danielle D Durham
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Allison Throneburg
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Lindsay M Lane
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Pasangi Perera
- Department of Radiology, The University of North Carolina, Chapel Hill, NC
| | - Teresa D Samulski
- Department of Pathology, The University of North Carolina, Chapel Hill, NC
| | - Louise M Henderson
- Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill, NC; Department of Radiology, The University of North Carolina, Chapel Hill, NC; Department of Epidemiology, The University of North Carolina, Chapel Hill, NC
| |
Collapse
|
7
|
Utilisation and Determinants of Epidermal Growth Factor Receptor Mutation Testing in Patients with Non-small Cell Lung Cancer in Routine Clinical Practice: A Global Systematic Review. Target Oncol 2021; 15:279-299. [PMID: 32445082 DOI: 10.1007/s11523-020-00718-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) mutation testing is recommended for selecting patients with non-squamous non-small cell lung cancer (NSCLC) for EGFR tyrosine kinase inhibitor drug treatment. OBJECTIVE The objective of this article was to systematically review available evidence on the utilisation and determinants of EGFR mutation testing of patients with NSCLC in routine clinical practice. PATIENTS AND METHODS Searches were made of five electronic databases (Web of Science, MEDLINE [Ovid], Science Direct, EMBASE and Scopus), bibliographies of relevant articles, studies that cited included studies and relevant cancer websites. Studies were included if they: (1) reported the rate of uptake of EGFR testing in patients with NSCLC; (2) were conducted in routine clinical practice settings; (3) were published in English prior to July 2017; and (4) had full text available. Studies were appraised using the STROBE and the National Institutes of Health (National Heart, Lung and Blood Institute) checklists. RESULTS Eighteen eligible studies were identified for this systematic review, published between 2011 and 2017, from the USA (n = 7), Canada (n = 2), Republic of Korea (n = 2), Norway (n = 1), Sweden (n = 1), Germany (n = 1), Spain (n = 1), New Zealand (n = 1), China (n = 1) and multiple countries from the Asia-Pacific region (n = 1). Overall, testing for EGFR mutations was undertaken in 16,146 of 52,257 study patients (31%), although testing rates varied widely between different studies (from 7.8% to 78.3%). Single institution retrospective audits reported higher rates of testing (median 65.7%, range 31.3-78.3%) than population-based retrospective cohort analyses (median 23%, range 11-69%) and multi-institutional cross-sectional practitioner surveys (median 19.8%, range 7.8-31.8%). Nine studies reported increasing rates of testing over the study period but maximum testing rates remained less than 75% in most studies. Factors associated with higher testing uptake rates included: female sex; younger age; former/no smoking; advanced stage of lung cancer; adenocarcinoma histology; better mobility; radiation therapy; available tissue specimen; and private insurance. Among 16,146 tested patients, EGFR mutations were detected in 4328 patients (26.8%). However, estimates of mutation prevalence were biased by incomplete and selective testing in many studies. CONCLUSIONS The uptake of EGFR mutation testing of patients with NSCLC is suboptimal in many parts of the world. Incomplete uptake of testing is fuelled by selective testing referral practices, sample limitations, and funding constraints.
Collapse
|
8
|
Palazzo LL, Sheehan DF, Tramontano AC, Kong CY. Disparities and Trends in Genetic Testing and Erlotinib Treatment among Metastatic Non-Small Cell Lung Cancer Patients. Cancer Epidemiol Biomarkers Prev 2019; 28:926-934. [PMID: 30787053 DOI: 10.1158/1055-9965.epi-18-0917] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/13/2018] [Accepted: 02/14/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite reports of socioeconomic disparities in rates of genetic testing and targeted therapy treatment for metastatic non-small cell lung cancer (NSCLC), little is known about whether such disparities are changing over time. METHODS We performed a retrospective analysis to identify disparities and trends in genetic testing and treatment with erlotinib. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified 9,900 patients with stage IV NSCLC diagnosed in 2007 to 2011 at age 65 or older. We performed logistic regression analyses to identify patient factors associated with odds of receiving a genetic test and erlotinib treatment, and to assess trends in these differences with respect to diagnosis year. RESULTS Patients were more likely to receive genetic testing if they were under age 75 at diagnosis [odds ratio (OR), 1.55] independent of comorbidity level, and this age-based gap showed a decrease over time (OR, 0.93). For untested patients, erlotinib treatment was associated with race (OR, 0.58, black vs. white; OR, 2.45, Asian vs. white), and was more likely among female patients (OR, 1.45); for tested patients, erlotinib treatment was less likely among low-income patients (OR, 0.32). Most of these associations persisted or increased in magnitude. CONCLUSIONS Race and sex are associated with rates of erlotinib treatment for patients who did not receive genetic testing, and low-income status is associated with treatment rates for those who did receive testing. The racial disparity remained stable over time, while the income-based disparity grew larger. IMPACT Attention to reducing disparities is needed as precision cancer treatments continue to be developed.
Collapse
Affiliation(s)
- Lauren L Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
9
|
Lammers A, Slatore CG, Fromme EK, Vranas KC, Sullivan DR. Association of Early Palliative Care With Chemotherapy Intensity in Patients With Advanced Stage Lung Cancer: A National Cohort Study. J Thorac Oncol 2018; 14:176-183. [PMID: 30336324 DOI: 10.1016/j.jtho.2018.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/11/2018] [Accepted: 09/26/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Patients with advanced lung cancer have a poor prognosis, but both chemotherapy and early palliative care (EPC) have been shown to improve survival and quality of life (QOL). The relationship between palliative care and receipt of chemotherapy receipt is understudied. We sought to determine if EPC is associated with chemotherapy receipt and intensity among patients with advanced stage lung cancer. METHODS Retrospective cohort study of patients in the national Veterans Health Administration (VA) with stage IIIB or IV lung cancer diagnosed between January 2007- December 2013. EPC was defined as a specialist-delivered palliative care received within 90 days of cancer diagnosis. Outcomes included any chemotherapy receipt and high-intensity chemotherapy receipt defined as: i) more than 4 cycles of a platinum-based doublet, ii) ≥3 lines of chemotherapy, iii) Bevacizumab/Cetuximab triplet therapy, iv) Erlotinib use prior to 2011, and v) chemotherapy in the last days of life. Logistic regression was used to determine the association between EPC and chemotherapy receipt after adjustment for patient and tumor characteristics. RESULTS Among the entire cohort (N=23,566), 37% received EPC and 45% received any chemotherapy. Among those with EPC, 34% received chemotherapy compared to 51% among those without EPC (Adjusted Odds Ratio (AOR=0.55, 95% CI: 0.51-0.58). Patients who received EPC had reduced receipt of high-intensity chemotherapy including >4 cycles of platinum-based doublet (AOR=0.68, 95% CI: 0.60-0.77), ≥ 3 lines of chemotherapy (AOR=0.61, 95% CI: 0.53-0.71), triplet therapy (AOR=0.68, 95% CI: 0.56-0.82) and use of erlotinib prior to 2011 (AOR=0.66, 95% CI: 0.55-0.79). Patients with EPC were more likely to receive chemotherapy in the last 14 (AOR=1.65, 95% CI: 1.44-1.87) and 30 days (AOR=1.67, 95% CI: 1.51-1.85) of life compared to those without EPC. CONCLUSIONS EPC was associated with reduced receipt of both any chemotherapy and high-intensity chemotherapy. However, receipt of chemotherapy at the very end-of-life was increased among patients with EPC compared to those without EPC. Among patients with advanced lung cancer, EPC may optimize patient selection for chemotherapy receipt leading to reduced use of high-intensity therapy by focusing on quality of life in accordance with patients' performance, preferences and goals of care.
Collapse
Affiliation(s)
- Austin Lammers
- Department of Hematology and Medical Oncology, Kaiser Permanente, Lafayette, Colorado; Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Christopher G Slatore
- VA Portland Health Care System (VAPORHCS), Health Services Research & Development, Portland, Oregon; Oregon Health and Science University, Pulmonary and Critical Care Medicine, Portland, Oregon; VAPORHCS, Section of Pulmonary and Critical Care Medicine, Portland, Oregon; Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Erik K Fromme
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kelly C Vranas
- VA Portland Health Care System (VAPORHCS), Health Services Research & Development, Portland, Oregon; Oregon Health and Science University, Pulmonary and Critical Care Medicine, Portland, Oregon; Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- VA Portland Health Care System (VAPORHCS), Health Services Research & Development, Portland, Oregon; Oregon Health and Science University, Pulmonary and Critical Care Medicine, Portland, Oregon; Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.
| |
Collapse
|
10
|
McKeage M, Elwood M, Tin Tin S, Khwaounjoo P, Aye P, Li A, Sheath K, Shepherd P, Laking G, Kingston N, Lewis C, Love D. EGFR Mutation Testing of non-squamous NSCLC: Impact and Uptake during Implementation of Testing Guidelines in a Population-Based Registry Cohort from Northern New Zealand. Target Oncol 2018; 12:663-675. [PMID: 28699084 DOI: 10.1007/s11523-017-0515-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Since 2013, clinical practice guidelines recommend EGFR mutation testing of non-squamous NSCLC to select advanced-stage patients for first-line treatment using EGFR-TKIs. OBJECTIVE We aimed to determine population-based trends in the real-world uptake and impact in routine practice of these recently updated testing guidelines. PATIENTS AND METHODS A population-based observational study was conducted of notifications to the New Zealand Cancer Registry of patients eligible for EGFR testing diagnosed in northern New Zealand between January 2010 and April 2014. The main study variable was EGFR mutation testing. Main outcome measures (overall survival and dispensing of EGFR-TKIs) were extracted from prospectively archived electronic databases until October 2015. RESULTS The population-based cohort of 1857 patients had an average age of 70 years. Most had adenocarcinoma and metastatic disease at diagnosis. EGFR testing was undertaken in 500 patients (27%) with mutations detected in 109 patients (22%). EGFR testing increased during the period of study from <5% to 67% of patients (P < 0.0001). Full uptake of testing by all eligible patients was limited by a lack of availability of specimens for testing and variable testing referral practices. The proportion of patients treated with EGFR-TKIs decreased during the same time period, both among untested patients (from 12.2% to 2.8% (P < 0.0001)) and in the population as a whole (from 13.7% to 10.6% (P < 0.05)). EGFR testing was associated with prolonged overall survival (Adjusted HR = 0.76 (95% CI, 0.65-0.89) Log-rank P < 0.0001) due at least in part to the much longer overall survival achieved by mutation-positive patients, of whom 79% received EGFR-TKIs. Compared to untested EGFR-TKI-treated patients, mutation-positive EGFR-TKI-treated patients received EGFR-TKIs for longer, and survived longer both from the start of EGFR-TKI treatment and date of their diagnosis. CONCLUSIONS In this real world setting, high uptake of EGFR testing was achieved and associated with major changes in EGFR-TKI prescribing and improved health outcomes. Modifiable factors determined testing uptake. Study registration ACTRN12615000998549.
Collapse
Affiliation(s)
- Mark McKeage
- University of Auckland, Auckland, New Zealand. .,Auckland City Hospital, Auckland, New Zealand. .,Department of Pharmacology and Clinical Pharmacology and Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road Grafton, Room 504-236A, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Mark Elwood
- University of Auckland, Auckland, New Zealand
| | | | | | - Phyu Aye
- University of Auckland, Auckland, New Zealand
| | - Angie Li
- University of Auckland, Auckland, New Zealand.,Auckland City Hospital, Auckland, New Zealand
| | - Karen Sheath
- LabPlus, Auckland City Hospital, Auckland, New Zealand
| | | | | | | | | | - Donald Love
- LabPlus, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
11
|
Vachani A, Wong YN, Israelite J, Mitra N, Hin S, Yang L, Smith-McLallen A, Armstrong K, Groeneveld PW, Epstein AJ. Validation of Molecular Pathology Codes for the Identification of Mutational Testing in Lung and Colon Cancer. Med Care 2017; 55:e131-e136. [PMID: 29135776 PMCID: PMC8011835 DOI: 10.1097/mlr.0000000000000484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Targeted therapy for patients with lung and colon cancer based on tumor molecular profiles is an important cancer treatment strategy, but the impact of gene mutation tests on cancer treatment and outcomes in large populations is not clear. In this study, we assessed the accuracy of an algorithm to identify tumor mutation testing in administrative claims data during a period before test-specific Current Procedural Terminology codes were available. MATERIALS AND METHODS We used Pennsylvania Cancer Registry data to select patients with lung or colon cancer diagnosed between 2007 and 2011 who were treated at the University of Pennsylvania Health System, and we obtained their administrative claims. A combination of Current Procedural Terminology laboratory codes (stacking codes) was used to identify potential tumor mutation testing in the claims data. Patients' electronic medical records were then searched to determine whether tumor mutation testing actually had been performed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS An algorithm using stacking codes had moderate sensitivity (86% for lung cancer and 81% for colon cancer) and high specificity (98% for lung cancer and 96% for colon cancer). Sensitivity and specificity did not vary significantly during 2007-2011. In patients with lung cancer, PPV was 98% and NPV was 92%. In patients with colon cancer, PPV was 96% and NPV was 83%. CONCLUSIONS An algorithm using stacking codes can identify tumor mutation testing in administrative claims data among patients with lung and colon cancer with a high degree of accuracy.
Collapse
Affiliation(s)
- Anil Vachani
- Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Yu-Ning Wong
- Hematology and Medical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Jennifer Israelite
- Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sakhena Hin
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lin Yang
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Peter W. Groeneveld
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Veterans Affairs’ Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Andrew J. Epstein
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Veterans Affairs’ Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
12
|
Lynch JA, Berse B, Chun D, Rivera D, Filipski KK, Kulich S, Viernes B, DuVall SL, Kelley MJ. Epidermal Growth Factor Receptor Mutational Testing and Erlotinib Treatment Among Veterans Diagnosed With Lung Cancer in the United States Department of Veterans Affairs. Clin Lung Cancer 2017; 18:401-409. [DOI: 10.1016/j.cllc.2016.11.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 12/20/2022]
|
13
|
Cheng MM, Palma JF, Scudder S, Poulios N, Liesenfeld O. The Clinical and Economic Impact of Inaccurate EGFR Mutation Tests in the Treatment of Metastatic Non-Small Cell Lung Cancer. J Pers Med 2017; 7:jpm7030005. [PMID: 28657610 PMCID: PMC5618152 DOI: 10.3390/jpm7030005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/26/2017] [Indexed: 01/17/2023] Open
Abstract
Advances in personalized medicine are supported by companion diagnostic molecular tests. Testing accuracy is critical for selecting patients for optimal therapy and reducing treatment-related toxicity. We assessed the clinical and economic impact of inaccurate test results between laboratory developed tests (LDTs) and a US Food and Drug Administration (FDA)-approved test for detection of epidermal growth factor receptor (EGFR) mutations. Using a hypothetical US cohort of newly diagnosed metastatic non-small cell lung cancer (NSCLC) patients and EURTAC (erlotinib versus standard chemotherapy as first-line treatment for European patients with advanced EGFR mutation-positive non-small-cell lung cancer) clinical trial data, we developed a decision analytic model to estimate the probability of misclassification with LDTs compared to a FDA-approved test. We estimated the clinical and economic impact of inaccurate test results by quantifying progression-free and quality-adjusted progression-free life years (PFLYs, QAPFLYs) lost, and costs due to incorrect treatment. The base-case analysis estimated 2.3% (n = 1422) of 60,502 newly diagnosed metastatic NSCLC patients would be misclassified with LDTs compared to 1% (n = 577) with a FDA-approved test. An average of 477 and 194 PFLYs were lost among the misclassified patients tested with LDTs compared to the FDA-approved test, respectively. Aggregate treatment costs for patients tested with LDTs were approximately $7.3 million more than with the FDA-approved test, due to higher drug and adverse event costs among patients incorrectly treated with targeted therapy or chemotherapy, respectively. Invalid tests contributed to greater probability of patient misclassification and incorrect therapy. In conclusion, risks associated with inaccurate EGFR mutation tests pose marked clinical and economic consequences to society. Utilization of molecular diagnostic tests with demonstrated accuracy could help to maximize the potential of personalized medicine.
Collapse
Affiliation(s)
- Mindy M Cheng
- Roche Molecular Systems, Inc., 4300 Hacienda Dr., Pleasanton, CA 94588, USA.
| | - John F Palma
- Roche Sequencing Solutions, 4300 Hacienda Dr., Pleasanton, CA 94588, USA.
| | - Sidney Scudder
- Roche Molecular Systems, Inc., 4300 Hacienda Dr., Pleasanton, CA 94588, USA.
| | - Nick Poulios
- Roche Molecular Systems, Inc., 4300 Hacienda Dr., Pleasanton, CA 94588, USA.
| | - Oliver Liesenfeld
- Roche Molecular Systems, Inc., 4300 Hacienda Dr., Pleasanton, CA 94588, USA.
| |
Collapse
|
14
|
Lynch JA, Berse B, Coomer N, Kautter J. 21-Gene recurrence score testing among Medicare beneficiaries with breast cancer in 2010–2013. Genet Med 2017; 19:1134-1143. [DOI: 10.1038/gim.2017.19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/24/2017] [Indexed: 01/15/2023] Open
|
15
|
Gray SW, Kim B, Sholl L, Cronin A, Parikh AR, Klabunde CN, Kahn KL, Haggstrom DA, Keating NL. Medical Oncologists' Experiences in Using Genomic Testing for Lung and Colorectal Cancer Care. J Oncol Pract 2017; 13:e185-e196. [PMID: 28095174 PMCID: PMC5456256 DOI: 10.1200/jop.2016.016659] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Genomic testing improves outcomes for many at-risk individuals and patients with cancer; however, little is known about how genomic testing for non-small-cell lung cancer (NSCLC) and colorectal cancer (CRC) is used in clinical practice. PATIENTS AND METHODS In 2012 to 2013, we surveyed medical oncologists who care for patients in diverse practice and health care settings across the United States about their use of guideline- and non-guideline-endorsed genetic tests. Multivariable regression models identified factors that are associated with greater test use. RESULTS Of oncologists, 337 completed the survey (participation rate, 53%). Oncologists reported higher use of guideline-endorsed tests (eg, KRAS for CRC; EGFR for NSCLC) than non-guideline-endorsed tests (eg, Onco typeDX Colon; ERCC1 for NSCLC). Many oncologists reported having no patients with CRC who had mismatch repair and/or microsatellite instability (24%) or germline Lynch syndrome (32%) testing, and no patients with NSCLC who had ALK testing (11%). Of oncologists, 32% reported that five or fewer patients had KRAS and EGFR testing for CRC and NSCLC, respectively. Oncologists, rather than pathologists or surgeons, ordered the vast majority of tests. In multivariable analyses, fewer patients in nonprofit integrated health care delivery systems underwent testing than did patients in hospital or office-based single-specialty group settings (all P < .05). High patient volume and patient requests (CRC only) were also associated with higher test use (all P < .05). CONCLUSION Genomic test use for CRC and NSCLC varies by test and practice characteristics. Research in specific clinical contexts is needed to determine whether the observed variation reflects appropriate or inappropriate care. One potential way to reduce unwanted variation would be to offer widespread reflexive testing by pathology for guideline-endorsed predictive somatic tests.
Collapse
Affiliation(s)
- Stacy W. Gray
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin Kim
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Lynette Sholl
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Angel Cronin
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Aparna R. Parikh
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Carrie N. Klabunde
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Katherine L. Kahn
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - David A. Haggstrom
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Nancy L. Keating
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
16
|
Lynch JA, Berse B, Dotson WD, Khoury MJ, Coomer N, Kautter J. Utilization of genetic tests: analysis of gene-specific billing in Medicare claims data. Genet Med 2017; 19:890-899. [PMID: 28125086 DOI: 10.1038/gim.2016.209] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
PURPOSE We examined the utilization of precision medicine tests among Medicare beneficiaries through analysis of gene-specific tier 1 and 2 billing codes developed by the American Medical Association in 2012. METHODS We conducted a retrospective cross-sectional study. The primary source of data was 2013 Medicare 100% fee-for-service claims. We identified claims billed for each laboratory test, the number of patients tested, expenditures, and the diagnostic codes indicated for testing. We analyzed variations in testing by patient demographics and region of the country. RESULTS Pharmacogenetic tests were billed most frequently, accounting for 48% of the expenditures for new codes. The most common indications for testing were breast cancer, long-term use of medications, and disorders of lipid metabolism. There was underutilization of guideline-recommended tumor mutation tests (e.g., epidermal growth factor receptor) and substantial overutilization of a test discouraged by guidelines (methylenetetrahydrofolate reductase). Methodology-based tier 2 codes represented 15% of all claims billed with the new codes. The highest rate of testing per beneficiary was in Mississippi and the lowest rate was in Alaska. CONCLUSIONS Gene-specific billing codes significantly improved our ability to conduct population-level research of precision medicine. Analysis of these data in conjunction with clinical records should be conducted to validate findings.Genet Med advance online publication 26 January 2017.
Collapse
Affiliation(s)
- Julie A Lynch
- RTI International, Waltham, Massachusetts, USA.,Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Brygida Berse
- RTI International, Waltham, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA.,Veterans Health Administration, Bedford, Massachusetts, USA
| | - W David Dotson
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Muin J Khoury
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicole Coomer
- RTI International, Research Triangle Park, North Carolina, USA
| | | |
Collapse
|
17
|
Introducing the Microbiome into Precision Medicine. Trends Pharmacol Sci 2017; 38:81-91. [DOI: 10.1016/j.tips.2016.10.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/28/2016] [Accepted: 10/03/2016] [Indexed: 12/18/2022]
|
18
|
Sharpening the attack on non-small cell lung cancer. JAAPA 2016; 29:1-5. [PMID: 27787282 DOI: 10.1097/01.jaa.0000502872.97211.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Advanced non-small cell lung cancer (NSCLC) has long been a diagnosis with few treatment options and poor outcomes. However, recent discoveries about the molecular biology of NSCLC are changing the way it is treated. Driver mutations that cause uncontrolled cancer cell proliferation have been discovered in some types of NSCLC. This has led to the discovery of therapies that can target a specific driver mutation in advanced NSCLC and halt cancer progression. This article reviews standard treatment of NSCLC and explores the targetable mutations of NSCLC, available targeted treatments, treatment obstacles, and the future of targeted therapy in NSCLC.
Collapse
|
19
|
Romine PE, Harkins SK, Gray SW. Quality in the Age of Precision Medicine: The Clinician Perspective. J Oncol Pract 2016; 12:839-843. [DOI: 10.1200/jop.2016.015321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Perrin E. Romine
- University of Washington School of Medicine, Seattle, WA; Harvard Medical School; Dana-Farber Cancer Institute; and Brigham & Women’s Hospital, Boston, MA
| | - Sophie K. Harkins
- University of Washington School of Medicine, Seattle, WA; Harvard Medical School; Dana-Farber Cancer Institute; and Brigham & Women’s Hospital, Boston, MA
| | - Stacy W. Gray
- University of Washington School of Medicine, Seattle, WA; Harvard Medical School; Dana-Farber Cancer Institute; and Brigham & Women’s Hospital, Boston, MA
| |
Collapse
|
20
|
Shinde R, Cao X, Kothari S. Biopsy Procedures and Molecular Testing Utilization and Related Costs in Patients with Metastatic Lung Cancer. J Manag Care Spec Pharm 2016; 22:1194-203. [PMID: 27668568 PMCID: PMC10397943 DOI: 10.18553/jmcp.2016.15404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) gene mutations and anaplastic lymphoma kinase (ALK) gene rearrangements are key therapeutic targets for biomarker-driven treatment with an EGFR or ALK tyrosine kinase inhibitor (TKI) in patients with metastatic non-small cell lung cancer (NSCLC). To appropriately guide treatment decisions, since 2011, the National Comprehensive Cancer Network and the American Society of Clinical Oncology therefore recommend EGFR and ALK analysis in tumor samples obtained at the time of diagnosis in patients with non-squamous NSCLC. Currently, there are limited data on utilization patterns and cost of biopsy procedures and biomarker tests in patients with metastatic NSCLC who receive an EGFR or ALK TKI. OBJECTIVES To (a) describe utilization patterns and costs associated with biopsy procedures and biomarker testing in patients with NSCLC who received erlotinib or crizotinib between 2009 and 2012 and (b) investigate the timing of these procedures relative to the erlotinib or crizotinib index date. METHODS Adult patients with metastatic lung cancer were identified by ICD-9-CM diagnostic codes within the Truven Health Analytic MarketScan database. Patients were included in the analysis if they had an index erlotinib or crizotinib claim between January 1, 2009, and September 30, 2012 (index period) and were continuously enrolled for ≥ 12 months before the index claim. Because there is no specific ICD-9-CM diagnostic code for NSCLC, patients with metastatic lung cancer who received erlotinib or crizotinib were considered to have metastatic NSCLC. Using CPT and ICD-9-CM codes, lung biopsy procedures performed during the 24 months before or 12 months after the index claim date were identified. For every patient, biomarker testing claims for EGFR and ALK were identified using the molecular pathology stacked CPT code during the 2 months before or 1 month after the index date. The frequency of claims for biopsy procedures and biomarker testing was analyzed descriptively. The overall summary measures for biomarker testing, especially frequency of EGFR testing in patients receiving erlotinib, was also described as before and after 2011, the year when biomarker testing became part of the guidelines. Per patient and overall costs for biopsy procedures and biomarker testing were calculated from payer and patient perspectives. RESULTS Of the 4,926 identified patients, 4,801 (97.5%) received erlotinib, and 125 (2.5%) received crizotinib. Biopsy procedure claims were identified for 3,579 (72.7%) patients, including 3,503 (73.0%) erlotinib recipients and 76 (60.8%) crizotinib recipients. Biomarker testing claims were identified for 675 (13.7%) patients, including 634 (13.2%) erlotinib recipients and 41 (32.8%) crizotinib recipients. Overall, most biomarker testing procedures (476 of 741) were identified in 435 (of 675) patients after year 2011. Also, among erlotinib recipients, percentage of patients receiving EGFR testing was increased over the index period. Per patient mean (SD) numbers of biopsy procedures and biomarker tests were 1.2 (1.1) and 0.2 (0.4), respectively. In the outpatient setting, per patient mean (SD) cost per biopsy procedure was $1,223 ($1,899) from the payer perspective and $60 ($147) from the patient perspective, whereas in the inpatient setting, it was $8,163 ($18,712) and $180 ($691), respectively. Among patients receiving at least 1 biomarker test, the per patient mean (SD) cost for the overall population was $891 ($1,062) and $43 ($229); for erlotinib recipients, it was $906 ($1,084) and $42 ($228); and for crizotinib recipients, it was $664 ($576) and $55 ($243) in payer and patient perspectives, respectively. CONCLUSIONS This study provides insight into the use and cost of biopsy and biomarker testing procedures in patients with metastatic NSCLC. The low frequency of biomarker testing highlights the need for more awareness of testing to guide treatment decisions in these patients. Costs associated with biopsy procedures and biomarker testing provide insight into the economic impact on metastatic NSCLC patients treated with targeted therapy. DISCLOSURES This study was sponsored by Merck & Co. Shinde is a study manager working for Merck under contract with AllSourcePPS, an Agile 1 company in Huntington Beach, California. Cao and Kothari are employees of Merck & Co., Kenilworth, New Jersey. Study concept and design were contributed primarily by Shinde and Kothari. Data analysis was performed by Cao. Data interpretation was performed by Shinde, Cao, and Kothari. Shinde wrote the manuscript with assistance from Cao and Kothari. The revision was completed primarily by Shinde and Kothari.
Collapse
|
21
|
Sabri A, Batool M, Xu Z, Bethune D, Abdolell M, Manos D. Predicting EGFR mutation status in lung cancer:Proposal for a scoring model using imaging and demographic characteristics. Eur Radiol 2016; 26:4141-4147. [PMID: 27027313 DOI: 10.1007/s00330-016-4252-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 01/16/2016] [Accepted: 01/26/2016] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine if a combination of CT and demographic features can predict EGFR mutation status in bronchogenic carcinoma. METHODS We reviewed demographic and CT features for patients with molecular profiling for resected non-small cell lung carcinoma. Using multivariate logistic regression, we identified features predictive of EGFR mutation. Prognostic factors identified from the logistic regression model were then used to build a more practical scoring system. RESULTS A scoring system awarding 5 points for no or minimal smoking history, 3 points for tumours with ground glass component, 3 points for airbronchograms, 2 points for absence of preoperative evidence of nodal enlargement or metastases and 1 point for doubling time of more than a year, resulted in an AUROC of 0.861. A total score of at least 8 yielded a specificity of 95 %. On multivariate analysis sex was not found to be predictor of EGFR status. CONCLUSIONS A weighted scoring system combining imaging and demographic data holds promise as a predictor of EGFR status. Further studies are necessary to determine reproducibility in other patient groups. A predictive score may help determine which patients would benefit from molecular profiling and may help inform treatment decisions when molecular profiling is not possible. KEY POINTS • EGFR mutation-targeted chemotherapy for bronchogenic carcinoma has a high success rate. • Mutation testing is not possible in all patients. • EGFR associations include subsolid density, slow tumour growth and minimal/no smoking history. • Demographic or imaging features alone are weak predictors of EGFR status. • A scoring system, using imaging and demographic features, is more predictive.
Collapse
Affiliation(s)
- Ali Sabri
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada. .,Halifax Infirmary, Room 3510, 1796 Summer Street, Halifax, NS, Canada.
| | - Madiha Batool
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - Zhaolin Xu
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Drew Bethune
- Department of Surgery, Dalhousie University, QEII Health Sciences center, Halifax, Nova Scotia, Canada
| | - Mohamed Abdolell
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada
| |
Collapse
|
22
|
Lynch JA, Berse B, Petkov V, Filipski K, Zhou Y, Khoury MJ, Hassett M, Freedman AN. Implementation of the 21-gene recurrence score test in the United States in 2011. Genet Med 2016; 18:982-90. [PMID: 26890451 DOI: 10.1038/gim.2015.218] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/17/2015] [Indexed: 01/17/2023] Open
Abstract
PURPOSE We examined hospital use of the 21-gene breast cancer test in the United States. We report state-level differences in utilization and propose a model for predicting implementation of guideline-recommended genomic testing. METHODS Genomic Health provided test orders for calendar year 2011.We summarized utilization at the hospital and state levels. Using logistic regression, we analyzed the association between the likelihood to order the test and the hospital's institutional and regional characteristics. RESULTS In 2011, 45% of 4,712 acute-care hospitals ordered the test, which suggests that 25% of newly diagnosed invasive female breast cancer cases were tested. Significant predictors of testing included participation in National Cancer Institute (NCI) clinical research cooperative groups (odds ratio (OR) 3.73; 95% confidence interval, 2.96-4.70), advanced imaging (OR, 2.19; CI, 1.78-2.68), high-complexity laboratory (OR, 2.15; CI, 1.24-3.70), affiliation with a medical school (OR, 1.57; CI, 1.31-1.88), and reconstructive surgery (OR, 1.23; CI, 1.01-1.50). Significant regional predictors included metropolitan county (OR, 3.77; CI, 2.83-5.03), above-mean income (OR, 1.37; CI, 1.11-1.69), and education (OR, 1.26; CI, 1.03-1.54). Negative predictors included designation as a critical-access hospital (OR, 0.10; CI, 0.07-0.14) and distance from an NCI cancer center (OR, 0.998; CI, 0.997-0.999), with a 15% decrease in likelihood for every 100 miles. CONCLUSION Despite considerable market penetration of the test, there are significant regional and site-of-care differences in implementation, particularly in rural states.Genet Med 18 10, 982-990.
Collapse
Affiliation(s)
- Julie A Lynch
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,RTI International, Research Triangle Park, Durham, North Carolina, USA
| | - Brygida Berse
- RTI International, Research Triangle Park, Durham, North Carolina, USA.,Boston University School of Medicine, Boston, Massachusetts, USA.,Veterans Health Administration, Bedford, Massachusetts, USA
| | - Valentina Petkov
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kelly Filipski
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Yingjun Zhou
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Epidemiology and Genomics Research Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael Hassett
- Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew N Freedman
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
23
|
Romanus D, Cardarella S, Cutler D, Landrum MB, Lindeman NI, Gazelle GS. Cost-effectiveness of multiplexed predictive biomarker screening in non-small-cell lung cancer. J Thorac Oncol 2015; 10:586-94. [PMID: 25590606 PMCID: PMC4395466 DOI: 10.1097/jto.0000000000000474] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Population-wide screening for epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) gene rearrangements to inform cancer therapy in non-small-cell lung cancer (NSCLC) is recommended by guidelines. We estimated cost-effectiveness of multiplexed predictive biomarker screening in metastatic NSCLC from a societal perspective in the United States. METHODS We constructed a microsimulation model to compare the life expectancy and costs of multiplexed testing and molecularly guided therapy versus treatment with cisplatin-pemetrexed (CisPem). All testing interventions included a two-step algorithm of concurrent EGFR mutation and ALK overexpression testing with immunohistochemistry followed by ALK rearrangement confirmation with a fluorescence in situ hybridization assay for immunohistochemistry-positive results. Three strategies were included: "Test-treat" approach, where molecularly guided therapy was initiated after obtainment of test results; "Empiric switch therapy," with concurrent initiation of CisPem and testing and immediate switch to test-result conditional treatment after one cycle of CisPem; and "Empiric therapy" approach in which CisPem was continued for four cycles before start of a tyrosine kinase inhibitor. RESULTS The incremental cost-effectiveness ratio for "Test-treat" compared with treatment with CisPem was $136,000 per quality-adjusted life year gained. Both empiric treatment approaches had less favorable incremental cost-effectiveness ratios. "Test-treat" and "Empiric switch therapy" yielded higher expected outcomes in terms of quality-adjusted life years and life-years than "Empiric therapy." These results were robust across plausible ranges of model inputs. CONCLUSION From a societal perspective, our cost-effectiveness results support the value of multiplexed genetic screening and molecularly guided therapy in metastatic NSCLC.
Collapse
Affiliation(s)
- Dorothy Romanus
- *Institute for Technology Assessment, Massachusetts General Hospital, Harvard University, Boston, Massachusetts; †Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts; ‡Department of Economics, Harvard University, Cambridge, Massachusetts; §Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; ‖Department of Pathology, Brigham and Women' Hospital, Harvard Medical School, Boston, Massachusetts; and ¶Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | |
Collapse
|
24
|
Lynch J, Whatley A, Uchendu US, Ibrahim SA. Race and genomics in the Veterans Health Administration. Am J Public Health 2014; 104 Suppl 4:S522-4. [PMID: 25100413 DOI: 10.2105/ajph.2014.302202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Julie Lynch
- Julie Lynch is with the Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Health Administration, and the Research Triangle Institute, Research Triangle Park, NC. Angela Whatley is with the Veterans Health Administration, Washington, DC. Uchenna S. Uchendu is with the Office of Health Equity, Department of Veterans Affairs, Washington, DC. Said A. Ibrahim is with the Center for Health Equity Research and Promotion and University of Pennsylvania Perelman School of Medicine, Philadelphia. Uchenna S. Uchendu and Said A. Ibrahim are also guest editors for this supplement issue
| | | | | | | |
Collapse
|
25
|
Krishnan VG, Ebert PJ, Ting JC, Lim E, Wong SS, Teo ASM, Yue YG, Chua HH, Ma X, Loh GSL, Lin Y, Tan JHJ, Yu K, Zhang S, Reinhard C, Tan DSW, Peters BA, Lincoln SE, Ballinger DG, Laramie JM, Nilsen GB, Barber TD, Tan P, Hillmer AM, Ng PC. Whole-genome sequencing of asian lung cancers: second-hand smoke unlikely to be responsible for higher incidence of lung cancer among Asian never-smokers. Cancer Res 2014; 74:6071-81. [PMID: 25189529 DOI: 10.1158/0008-5472.can-13-3195] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Asian nonsmoking populations have a higher incidence of lung cancer compared with their European counterparts. There is a long-standing hypothesis that the increase of lung cancer in Asian never-smokers is due to environmental factors such as second-hand smoke. We analyzed whole-genome sequencing of 30 Asian lung cancers. Unsupervised clustering of mutational signatures separated the patients into two categories of either all the never-smokers or all the smokers or ex-smokers. In addition, nearly one third of the ex-smokers and smokers classified with the never-smoker-like cluster. The somatic variant profiles of Asian lung cancers were similar to that of European origin with G.C>T.A being predominant in smokers. We found EGFR and TP53 to be the most frequently mutated genes with mutations in 50% and 27% of individuals, respectively. Among the 16 never-smokers, 69% had an EGFR mutation compared with 29% of 14 smokers/ex-smokers. Asian never-smokers had lung cancer signatures distinct from the smoker signature and their mutation profiles were similar to European never-smokers. The profiles of Asian and European smokers are also similar. Taken together, these results suggested that the same mutational mechanisms underlie the etiology for both ethnic groups. Thus, the high incidence of lung cancer in Asian never-smokers seems unlikely to be due to second-hand smoke or other carcinogens that cause oxidative DNA damage, implying that routine EGFR testing is warranted in the Asian population regardless of smoking status.
Collapse
Affiliation(s)
- Vidhya G Krishnan
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore
| | | | | | - Elaine Lim
- Medical Oncology, Mount Elizabeth Medical Centre, Mount Elizabeth, Singapore. Medical Oncology, Tan Tock Seng Hospital, Singapore, Singapore; Medical Oncology, National University Hospital, Singapore, Singapore
| | | | - Audrey S M Teo
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore
| | - Yong G Yue
- Lilly Corporate Center, Indianapolis, Indiana
| | - Hui-Hoon Chua
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore
| | - Xiwen Ma
- Lilly Corporate Center, Indianapolis, Indiana
| | - Gary S L Loh
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore
| | - Yuhao Lin
- Lilly Corporate Center, Indianapolis, Indiana
| | - Joanna H J Tan
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore.
| | - Kun Yu
- Lilly Corporate Center, Indianapolis, Indiana
| | - Shenli Zhang
- Genomic Oncology, Duke-NUS Graduate Medical School, Singapore, Singapore
| | | | - Daniel S W Tan
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | | | | | | | | | | | | | - Patrick Tan
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore. Genomic Oncology, Duke-NUS Graduate Medical School, Singapore, Singapore. Cancer Science Institute of Singapore, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore
| | - Axel M Hillmer
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore.
| | - Pauline C Ng
- Cancer Therapeutics and Stratified Oncology, Genome Institute of Singapore, Singapore, Singapore.
| |
Collapse
|
26
|
|