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van Boemmel-Wegmann S, Brown JD, Diaby V, Huo J, Silver N, Park H. Health Care Utilization and Costs Associated With Systemic First-Line Metastatic Melanoma Therapies in the United States. JCO Oncol Pract 2021; 18:e163-e174. [PMID: 34228489 DOI: 10.1200/op.21.00140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE US Food and Drug Administration approvals of immune checkpoint inhibitors and targeted therapies revolutionized the treatment of metastatic melanoma. Our aim was to assess health care resource utilization and costs for patients with metastatic melanoma treated with systemic therapies in first line between January 2012 and December 2017. METHODS We conducted a retrospective cohort study of patients with metastatic melanoma using MarketScan data. We included patients diagnosed with melanoma and secondary malignant neoplasm who used pembrolizumab, nivolumab, ipilimumab, ipilimumab plus nivolumab, BRAF-inhibitor (BRAF-i) plus MEK inhibitor (MEK-i), BRAF-i or MEK-i monotherapy, or chemotherapy in first line. We compared health care utilization and costs per patient per month (PPPM) using two-part and generalized linear models. RESULTS We identified 1,870 patients, including 185 pembrolizumab, 103 nivolumab, 689 ipilimumab, 185 nivolumab plus ipilimumab, 214 BRAF-i plus MEK-i, 240 BRAF-i or MEK-i monotherapy, and 254 chemotherapy users. Highest PPPM rates of hospitalizations, emergency room visits, and outpatient visits were observed in patients with ipilimumab plus nivolumab therapy (adjusted difference v pembrolizumab [aDiff], 0.18, 0.12, and 0.88, respectively; all P < .001). Ipilimumab monotherapy users (aDiff, 0.07 and 0.93; all P < .001) and chemotherapy users (aDiff, 0.10 and 2.63; all P < .001) showed higher PPPM rates of hospitalizations and outpatient visits compared with pembrolizumab users, respectively. Utilization rates in nivolumab, BRAF-i plus MEK-i, and BRAF-i or MEK-i groups were similar to the pembrolizumab group. Highest PPPM total costs and drug-related costs were observed in the ipilimumab group ($80,139 US dollars [USD] and $70,051 USD; all P < .001), followed by the ipilimumab plus nivolumab ($71,689 USD and $56,217 USD; all P < .001) and the BRAF-i plus MEK-i group ($31,184 USD and $19,648 USD; all P < .001). PPPM costs in the nivolumab group were similar to the pembrolizumab group. CONCLUSION Significant differences in health care resource utilization and costs were found across first-line metastatic melanoma regimens. Utilization rates were highest in patients using ipilimumab-containing therapies. High drug costs constituted a major fraction of total PPPM health care costs.
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Affiliation(s)
- Sascha van Boemmel-Wegmann
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Jinhai Huo
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL
| | - Natalie Silver
- Department of Otolaryngology, College of Medicine, University of Florida, Gainesville, FL
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
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Machado MADÁ, de Moura CS, Chan K, Curtis JR, Hudson M, Abrahamowicz M, Jamal R, Pilote L, Bernatsky S. Real-world analyses of therapy discontinuation of checkpoint inhibitors in metastatic melanoma patients. Sci Rep 2020; 10:14607. [PMID: 32884119 PMCID: PMC7471311 DOI: 10.1038/s41598-020-71788-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/22/2020] [Indexed: 11/21/2022] Open
Abstract
The 'real-world' patient population of metastatic melanoma is not fully represented in clinical trials investigating checkpoint inhibitors. We described therapy discontinuation in an unselected population-based cohort of adults with metastatic melanoma who started therapy with pembrolizumab, nivolumab, or nivolumab/ipilimumab from January 2015 to August 2017. Therapy discontinuation was defined as a gap between doses beyond 120 days, and/or initiation of another cancer therapy. We estimated drug-specific rate ratios for therapy discontinuation adjusted for age, sex, comorbidities, health care use, and past cancer therapies. We included 876 metastatic melanoma patients initiating pembrolizumab (44.3%), nivolumab/ipilimumab (31.2%), and nivolumab (24.5%). At 12 months of follow-up, the probabilities of therapy discontinuation were 49.9% (95% confidence interval, CI 43.6-56.5) for pembrolizumab, 58.8% (95% CI 50.5-67.3) for nivolumab, and 59.2% (95% CI 51.7-66.8) for nivolumab/ipilimumab. Stratified analyses based on prior cancer therapy, brain metastases at baseline, and sex showed similar trends. In multivariable analyses, compared with pembrolizumab, patients starting nivolumab (rate ratio 1.38, 95% CI 1.08-1.77) or nivolumab/ipilimumab (rate ratio 1.30, 95% CI 1.02-1.65) were more likely to discontinue therapy. Our findings indicate frequent discontinuations of checkpoint inhibitors at one year. The lower discontinuation associated with pembrolizumab should be confirmed in further studies.
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Affiliation(s)
| | - Cristiano Soares de Moura
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Kelvin Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jeffrey R Curtis
- Department of Medicine, University of Alabama At Birmingham, Birmingham, USA
| | - Marie Hudson
- Jewish General Hospital and Lady Davis Research Institute for Medical Research, Montreal, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Rahima Jamal
- Centre Hospitalier de L'Université de Montréal, Centre de Recherche du CHUM, Université de Montréal, Montreal, Canada
| | - Louise Pilote
- Department of Medicine, McGill University, Montreal, Canada
| | - Sasha Bernatsky
- Department of Medicine, McGill University, Montreal, Canada.
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Shah S, Raskin L, Cohan D, Freeman M, Hamid O. Treatment patterns of malignant melanoma in the United States from 2011 to 2016: a retrospective cohort study. Curr Med Res Opin 2020; 36:63-72. [PMID: 31469305 DOI: 10.1080/03007995.2019.1662688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Since 2011, the approval of several new agents has improved treatment options for malignant melanoma. We describe treatment patterns for malignant melanoma in the United States from the MarketScan database from 2011 to 2016.Methods: Treatments used for patients aged >18 years diagnosed with malignant melanoma after January 1, 2011 and enrolled in the Truven MarketScan database were analyzed. Patient data were collected for the 12-month period from the date of the first melanoma diagnosis to either death, the pre-specified study end date (August 31, 2016), or date of termination of health insurance. Treatment patterns from 2011-2013 and 2014-2016 were analyzed according to agent, year of drug administration, and line of therapy.Results: From 2011 to 2016, use of cytokines (63.8; 13.3%) and chemotherapy (19.6; 12.9%) decreased, and use of checkpoint inhibitors increased (2.0; 49.9%). Checkpoint inhibitor use also increased across all lines of therapy from 2011-2013 and 2014-2016. Use of BRAF/MEK inhibitors remained relatively stable from 2011 to 2016 (6.5-12.5%); however, the use of vemurafenib monotherapy decreased (6.5; 0.8%), and treatment with combination regimens increased (0; 10.9%) from 2011-2016. BRAF/MEK inhibitor use only increased in the first line setting from 2011-2013 (9.7%) to 2014-2016 (11.2%).Conclusion: With the approval of immune checkpoint inhibitors, BRAF/MEK inhibitors, and targeted therapies, the therapeutic landscape for the treatment of metastatic melanoma has shifted dramatically away from cytokines and chemotherapy. Treatment patterns will likely continue to evolve as scientific advances are made.
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Affiliation(s)
- Shweta Shah
- Global Health Economics, Amgen Inc., Thousand Oaks, CA, USA
| | - Leon Raskin
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - David Cohan
- Medical Affairs, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Omid Hamid
- The Angeles Clinic and Research Institute, Los Angeles, CA, USA
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Cowey CL, Liu FX, Boyd M, Aguilar KM, Krepler C. Real-world treatment patterns and clinical outcomes among patients with advanced melanoma: A retrospective, community oncology-based cohort study (A STROBE-compliant article). Medicine (Baltimore) 2019; 98:e16328. [PMID: 31305421 PMCID: PMC6641721 DOI: 10.1097/md.0000000000016328] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Recently, the effectiveness of novel immune checkpoint inhibitors and BRAF-directed therapies has been demonstrated in advanced melanoma trial populations. Limited research, however, has evaluated the impact of these therapies in a real-world setting. The aim of this study was to evaluate treatment patterns and clinical outcomes among advanced melanoma patients treated with modern therapies within community oncology clinics. Adult patients with advanced melanoma who initiated treatment within the US Oncology Network between 1/1/14 and 12/31/16 were included. Data were sourced from electronic healthcare records. Patients were followed through 12/31/17. Descriptive analyses were performed to assess patient and treatment characteristics and Kaplan-Meier methods were used for time-to-event outcomes. In total, 484 patients met eligibility criteria (32.0% with brain metastasis, 12.6% with Eastern Cooperative Oncology Group performance status ≥2). In the first-line (1L) setting during the study period, 37.0% received anti-PD1 monotherapies, 26.4% ipilimumab monotherapy, 19.8% BRAF/MEK combination therapy, 6.4% BRAF or MEK monotherapy, 4.1% ipilimumab/nivolumab combination therapy and 6.2% other regimens. Differences in baseline demographic and clinical characteristics were observed across treatment groups. For the overall study population, the median (95% confidence interval) estimates for overall survival, time to next treatment and progression-free survival were 20.7 (16.0, 26.8), 5.8 (5.3, 6.5), and 4.9 (4.2, 5.7) months, respectively. The results of this study provide real-world insight into advanced melanoma treatment trends and clinical outcomes, including high utilization of immunotherapies and BRAF/MEK combination therapy. Future research can explore underlying differences in patient subpopulations and the sequence of therapies across lines of therapy.
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Tarhini A, Atzinger C, Gupte-Singh K, Johnson C, Macahilig C, Rao S. Treatment patterns and outcomes for patients with unresectable stage III and metastatic melanoma in the USA. J Comp Eff Res 2019; 8:461-473. [PMID: 30832505 DOI: 10.2217/cer-2019-0003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe treatment patterns and outcomes of patients with unresectable stage III and metastatic/stage IV melanoma. Materials & methods: An observational retrospective chart review of patients diagnosed with advanced melanoma before 1 November 2015 who initiated a new line of therapy (LOT) from 1 January 2015 to 31 May 2016. Results: Among 487 patients, ipilimumab monotherapy (27.5%) was the most common first line of therapy (1LOT) in 2015, surpassed by nivolumab monotherapy (21.5%) in 2016. 12-month survival was ≥80.1%; proportions were highest forpatients treated with nivolumab + ipilimumab (86.6%). All treatments relatively well tolerated in real-world setting and adverse events were consistent with the previously reported safety profiles. Conclusion: This study provides important insights into real-world advanced melanoma treatment patterns and demonstrates encouraging treatment safety and patient survival data.
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Affiliation(s)
- Ahmad Tarhini
- Department of Hematology & Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH 441062, USA
| | | | | | | | | | - Sumati Rao
- Bristol-Myers Squibb, Princeton, NJ 086484, USA
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Ugurel S, Loquai C, Terheyden P, Schadendorf D, Richtig E, Utikal J, Gutzmer R, Rass K, Sunderkötter C, Stein A, Fluck M, Kaatz M, Trefzer U, Kähler K, Stadler R, Berking C, Höller C, Kerschke L, Edler L, Kopp-Schneider A, Becker JC. Chemosensitivity-directed therapy compared to dacarbazine in chemo-naive advanced metastatic melanoma: a multicenter randomized phase-3 DeCOG trial. Oncotarget 2017; 8:76029-76043. [PMID: 29100289 PMCID: PMC5652683 DOI: 10.18632/oncotarget.18635] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/10/2017] [Indexed: 01/26/2023] Open
Abstract
Chemotherapy still plays an important role in metastatic melanoma, particularly for patients who are not suitable or have no access to highly efficacious new therapies. Pre-therapeutic chemosensitivity testing might be useful to identify optimal chemotherapy regimens for individual patients. This multicenter randomized phase-3 trial was aimed to test for superiority of chemosensitivity-directed combination chemotherapy compared to standard dacarbazine monochemotherapy, and to demonstrate the chemosensitivity test result as prognostic in metastatic melanoma. Chemo-naive patients with advanced melanoma were biopsied from metastatic lesions. Tumor cells were isolated and tested ex-vivo for sensitivity to chemotherapeutic agents using an ATP-based viability assay. Patients with evaluable test results were randomly assigned to receive either chemosensitivity-directed combination chemotherapy (paclitaxel+cisplatin, treosulfan+gemcitabine, treosulfan+cytarabine), or dacarbazine. The primary study endpoint was overall survival (OS). After inclusion of 287 patients and a median follow-up of 26 months, the per-protocol population (n=244) showed no difference in OS between chemosensitivity-directed therapy and dacarbazine (median 9.2 vs 9.0 months, HR=1.08, p=0.64). The disease control rate (CR+PR+SD) tended to be higher in patients treated with chemosensitivity-directed therapy (32.8% vs 23.0%, p=0.088); objective response rates (CR+PR) showed no difference between groups (10.7% vs 12.3%, p=0.90). Patients whose tumors were tested chemosensitive showed no better OS or response rate than patients with chemoresistant tumors. Severe toxicities (CTC grade 3-4) were significantly more frequently observed with chemosensitivity-directed combination chemotherapy than with dacarbazine (40.2% vs 12.3%, p<0.0001). These results indicate, that chemosensitivity-directed combination chemotherapy is not superior to dacarbazine, but leads to significantly more severe toxicities.
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Affiliation(s)
- Selma Ugurel
- Department of Dermatology, University Hospital of Essen, Essen, Germany.,Department of Dermatology, University Hospital of Würzburg, Würzburg, Germany
| | - Carmen Loquai
- Department of Dermatology, University Hospital of Mainz, Mainz, Germany
| | - Patrick Terheyden
- Department of Dermatology, University Hospital of Lübeck, Lübeck, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital of Essen, Essen, Germany.,Translational Skin Cancer Research, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Essen, Germany
| | - Erika Richtig
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Hannover, Germany
| | - Knuth Rass
- Department of Dermatology, The Saarland University Hospital, Homburg/Saar, Germany
| | - Cord Sunderkötter
- Department of Dermatology, University Hospital of Münster, Münster, Germany
| | - Annette Stein
- Department of Dermatology, University Hospital of Dresden, Dresden, Germany
| | - Michael Fluck
- Department of Internal Medicine, Fachklinik Hornheide, Hornheide, Germany
| | - Martin Kaatz
- Department of Dermatology, University Hospital of Jena, Jena, Germany
| | - Uwe Trefzer
- Department of Dermatology, University Hospital Charite, Berlin, Germany
| | - Katharina Kähler
- Department of Dermatology, University Hospital of Kiel, Kiel, Germany
| | - Rudolf Stadler
- Department of Dermatology, Johannes Wesling Klinikum, Minden, Germany
| | - Carola Berking
- Department of Dermatology, University Hospital of Munich, Munich, Germany
| | - Christoph Höller
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Laura Kerschke
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany.,Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Lutz Edler
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | | | - Jürgen C Becker
- Department of Dermatology, University Hospital of Essen, Essen, Germany.,Department of Dermatology, University Hospital of Würzburg, Würzburg, Germany.,Translational Skin Cancer Research, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Essen, Germany.,Department of Dermatology, Medical University of Graz, Graz, Austria
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