Identifying the target NSCLC patient for maintenance therapy: an analysis from a placebo-controlled, phase III trial of maintenance pemetrexed (H3E-MC-JMEN)

Cost-effectiveness analysis of capecitabine maintenance therapy plus best supportive care vs. best supportive care alone as first-line treatment of newly diagnosed metastatic nasopharyngeal carcinoma

Objectives

Maintenance therapy with capecitabine after induction chemotherapy for patients with newly diagnosed metastatic nasopharyngeal carcinoma (mNPC) has been confirmed to be effective. This study aimed to evaluate the cost-effectiveness of capecitabine as maintenance therapy for patients with mNPC from the Chinese payers' perspective.

Methods

Markov model was conducted to simulate the disease progress and evaluated the economic and health outcomes of capecitabine maintenance plus best-supported care (CBSC) or best-supported care (BSC) alone for patients with mNPC. Survival data were derived from the NCT02460419 clinical trial. Costs and utilities were obtained from the standard fee database and published literature. Measured outcomes were total costs, quality-adjusted life-years (QALYs), life-years (LYs), incremental cost-utility ratios (ICURs), incremental cost-effectiveness ratios (ICERs), incremental net monetary benefit (INMB), and incremental net-health benefit (INHB). Sensitivity analyses were performed to assess model robustness. Additional subgroup cost-effectiveness analyses were accomplished.

Results

Throughout the course of the disease, the CBSC group provide an incremental cost of $9 734 and additional 1.16 QALYs (1.56 LYs) compared with the BSC group, resulting in an ICUR of $8 391/QALY and ICER of $6 240/LY. Moreover, the INHB was 0.89 QALYs, and the INMB was $32 034 at the willingness-to-pay threshold of $36 007/QALY. Subgroup analyses revealed that CBSC presented a positive trend of gaining an INHB in all subgroups compared with the BSC group. The results of sensitivity analyses supported the robustness of our model.

Conclusion

Compared with BSC, after induction chemotherapy, CBSC as a first-line treatment was cost-effective for newly diagnosed mNPC. These results suggest capecitabine maintenance therapy after induction chemotherapy as a new option for patients with newly diagnosed mNPC.

Efficacy of immune checkpoint inhibitor as maintenance therapy for advanced or metastatic cancers: A meta-analysis of randomized controlled trials

BACKGROUND

This study aimed to evaluate the efficacy of immune checkpoint inhibitors (ICIs) as maintenance therapy for advanced or metastatic cancers.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for eligible randomized controlled trials. A meta-analysis of eligible studies investigating the outcomes including progression-free survival (PFS), overall survival (OS), and objective response rate (ORR) with a significance level set to 0.05 was performed.

RESULTS

Five RCTs (n = 2828) were identified in this analysis. The pooled hazard ratios (HRs) of PFS and OS for ICI maintenance therapy were 0.88 (95% CI: 0.68-1.13, P = .31) and 0.82 (95% confidence interval [CI]: 0.74-0.92, P = .0005), respectively; the pooled odds ratio (OR) of ORR was 2.24 (95% CI: 1.23-4.09, P = .0008). Subgroup analysis indicated that anti-PD-L1 antibody significantly improved the OS (P = .0008), while anti-PD-1 and anti-PD-1 plus anti-cytotoxic T lymphocyte antigen 4 antibodies significantly prolonged the PFS of patients.

CONCLUSION

ICI maintenance therapy enhanced the survival of patients with advanced or metastatic cancers.

Association of baseline symptom burden with efficacy outcomes: Exploratory analysis from the randomized phase III REVEL study in advanced non-small-cell lung cancer

OBJECTIVES

The REVEL study demonstrated improved efficacy with ramucirumab plus docetaxel versus placebo plus docetaxel for previously treated advanced/metastatic non-small-cell lung cancer (NSCLC) without further detriment to patient quality of life, symptoms, or functioning. This post hoc analysis explored the association between baseline Lung Cancer Symptom Scale (LCSS) Average Symptom Burden Index (ASBI) and efficacy.

MATERIALS AND METHODS

Baseline ASBI scores were the average of the 6 LCSS symptom components. Low and high symptom burden (LSB ≤ median, HSB > median) were analyzed across and by treatment arms for effects on overall survival (OS), progression-free survival (PFS), and objective response rate (ORR) using the Kaplan-Meier method and Cox proportional hazards model.

RESULTS

Baseline LCSS compliance was approximately 78% in both REVEL treatment arms. Patients with LSB versus HSB had fewer poor prognostic factors. The HSB patient population significantly overlapped with previously identified aggressive disease subgroups (rapidly progressing disease or refractory to first-line treatment). Patients with LSB versus HSB had significantly improved OS (P < 0.0001), PFS (P < 0.0001), and ORR (P = 0.0003) regardless of treatment, with superior ORR and PFS but not OS in the ramucirumab plus docetaxel arm. Patients with HSB treated with ramucirumab plus docetaxel versus docetaxel had improved OS (median, 7.39 vs. 5.95 months; HR 0.749 [95% CI 0.610-0.920]; P = 0.0308), PFS (median, 4.01 vs. 2.63 months; HR 0.749 [0.619-0.907]; P = 0.0202), and ORR (18% vs. 11%; P = 0.0458). Of patients with rapidly progressing disease, 57% (92/162) also had HSB.

CONCLUSIONS

Baseline ASBI may be an independent prognostic factor in this large second-line cohort of patients with advanced NSCLC. The preservation of improved PFS and OS in the HSB cohort suggests that the addition of ramucirumab to docetaxel provides benefit in patients with greater symptom burden, consistent with previous data on REVEL patients with aggressive disease.

Efficacy of renin-angiotensin system inhibitors for patients with heart failure with preserved ejection fraction and mild to moderate chronic kidney disease

Background Renin-angiotensin system (RAS) inhibitors are first-line treatments for chronic kidney disease, but it is not known if these agents can improve outcome in patients with heart failure with preserved ejection fraction (HFpEF) and chronic kidney disease. Design This was a post-hoc analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial. Methods The primary outcome was a composite endpoint of all-cause death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure. We analyzed hazard ratios in patients taking RAS inhibitors compared with those not taking RAS inhibitors using Cox proportional hazard models. Results A total of 1465 HFpEF patients with mild to moderate chronic kidney disease was included. The mean follow-up period was 2.8 years; 502 patients experienced at least one confirmed primary outcome event. The primary outcome event rates in patients not taking and taking RAS inhibitors were 175.4 and 112.8 per 1000 person-years, respectively. The risks of primary outcome events and all-cause death were significantly lower in patients taking RAS inhibitors than in those not taking RAS inhibitors (adjusted hazard ratio (95% confidence interval) for primary outcome events: 0.75 (0.60-0.95), p = 0.01; adjusted hazard ratio for all-cause death: 0.69 (0.52-0.93), p = 0.01). Among propensity score-matched patients, these risks were also significantly lower in those taking RAS inhibitors than in those not taking RAS inhibitors (hazard ratio: 0.67 (0.50-0.90), p = 0.008; hazard ratio: 0.60 (0.41-0.88), p = 0.01). Conclusion Use of RAS inhibitors was associated with reduced risks of adverse cardiovascular outcomes in HFpEF patients with mild to moderate chronic kidney disease.

Favorable effects of statins in the treatment of heart failure with preserved ejection fraction in patients without ischemic heart disease

BACKGROUND

The effects of statins in patients with heart failure with preserved ejection fraction (HFpEF) remain unclear. This study aimed to assess whether statin therapy is associated with a decreased risk of mortality in patients with HFpEF.

METHODS

We used data from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. The primary outcome was all-cause mortality. We analyzed hazard ratios (HRs) for outcomes with 95% confidence intervals (95% CIs) in patients taking statins compared with those not taking statins using multivariable Cox proportional hazard models.

RESULTS

This study included 3378 patients with HFpEF. The mean follow-up period was 3.3years; 497 patients died during the study period. Among all patients, the adjusted HR for all-cause death was significantly lower in those taking statins compared with those not taking statins (HR 0.79, 95% CI 0.63-0.99, P=0.04). The risks of all-cause and cardiovascular mortality in patients without ischemic heart disease (IHD) were significantly lower in those taking statins compared with those not taking statins (HR 0.63, 95% CI 0.44-0.91, P=0.01 and HR 0.59, 95% CI 0.37-0.94, P=0.02, respectively), whereas the risks in patients with IHD did not differ significantly between those taking and not taking statins (HR 0.97, 95% CI 0.72-1.31, P=0.83 and HR 0.95, 95% CI 0.66-1.36, P=0.77, respectively). Among propensity score-matched patients without IHD, the risks of all-cause and cardiovascular death were significantly lower in those taking statins compared with those not taking statins.

CONCLUSIONS

Statin therapy was associated with improved outcomes in HFpEF patients, particularly those without IHD.

Favourable changes in mortality in people with diabetes: US NHANES 1999-2010

AIMS

Diabetes-related complications have declined during the past two decades. We aimed to examine whether mortality in people with diabetes improved over time in the 1999 to 2010 National Health and Nutrition Examination Survey (NHANES).

METHODS

We conducted a prospective cohort study using 1999 to 2004 and 2005 to 2010 data from the NHANES. For primary analyses, we compared the unadjusted, age-adjusted and multivariable-adjusted hazard ratios (HR) for mortality outcomes (total, cardiovascular, cardiac and cancer deaths) of the participants with diabetes with those without diabetes using Cox proportional hazard models.

RESULTS

For each mortality outcome, HR (95% confidence interval) in diabetic participants during the period 2005 to 2010 was lower than that during the period 1999 to 2004 (all-cause death, 2.76 [1.87-4.08] vs 4.23 [2.57-6.98]; cardiovascular death, 2.70 [1.20-6.04] vs 8.82 [3.28-23.70]; cardiac death, 2.45 [0.98-6.09] vs 15.55 [7.01-34.50]; cancer death, 2.33 [0.87-6.23] vs 3.03 [1.20-7.65]). Compared with mortality outcome during the period 1999 to 2004, greater declines in mortality during the period 2005 to 2010 were observed for cardiovascular (-54.0%) and cardiac deaths (-64.8%). In age-adjusted and multivariable-adjusted models, the cumulative event rates for total, cardiovascular and cardiac deaths were not significantly different between participants with and without diabetes during the period 2005-2010; this was not the case during the period 1999-2004. The leading cause of death was malignant neoplasm during the period 2005-2010.

CONCLUSION

Considerably improved outcomes for total, cardiovascular and cardiac deaths were observed in people with diabetes during the 2005 to 2010 NHANES compared to the 1999 to 2004 NHANES.

Phase II evaluation of LY2603618, a first-generation CHK1 inhibitor, in combination with pemetrexed in patients with advanced or metastatic non-small cell lung cancer

Introduction LY2603618 is a selective inhibitor of checkpoint kinase 1 (CHK1) protein kinase, a key regulator of the DNA damage checkpoint, and is predicted to enhance the effects of antimetabolites, such as pemetrexed. This phase II trial assessed the overall response rate, safety, and pharmacokinetics (PK) of LY2603618 and pemetrexed in patients with non-small cell lung cancer (NSCLC). Methods In this open-label, single-arm trial, patients with advanced or metastatic NSCLC progressing after a prior first-line treatment regimen (not containing pemetrexed) and Eastern Cooperative Oncology Group performance status ≤2 received pemetrexed (500 mg/m(2), day 1) and LY2603618 (150 mg/m(2), day 2) every 21 days until disease progression. Safety was assessed using Common Terminology Criteria for Adverse Events v3.0. Serial blood samples were collected for PK analysis after LY2603618 and pemetrexed administration. Expression of p53, as measured by immunohistochemistry and genetic variant analysis, was assessed as a predictive biomarker of response. Results Fifty-five patients were enrolled in the study. No patients experienced a complete response; a partial response was observed in 5 patients (9.1 %; 90 % CI, 3.7-18.2) and stable disease in 20 patients (36.4 %). The median progression-free survival was 2.3 months (range, 0-27.1). Safety and PK of LY2603618 in combination with pemetrexed were favorable. No association between p53 status and response was observed. Conclusions There was no significant clinical activity of LY2603618 and pemetrexed combination therapy in patients with advanced NSCLC. The results were comparable with historical pemetrexed single-agent data, with similar safety and PK profiles being observed.

Cost-effectiveness of Prophylaxis Against Pneumocystis jiroveci Pneumonia in Patients with Crohn's Disease

BACKGROUND

Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids.

AIMS

We sought to address this debate using insights from simulation modeling.

METHODS

We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy.

RESULTS

At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy.

CONCLUSION

Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.

Bayesian network meta-comparison of maintenance treatments for stage IIIb/IV non-small-cell lung cancer (NSCLC) patients with good performance status not progressing after first-line induction chemotherapy: results by performance status, EGFR mutation, histology and response to previous induction

BACKGROUND

Recent trials have suggested that maintenance treatments improve outcomes for patients not progressing after first-line therapy for advanced non-small-cell lung cancer (NSCLC). However, physicians have little guidance on selecting which patients benefit the most and what drug or regimen is optimal. Here, we report a systematic review and network meta-analysis of maintenance treatments in subgroups determined by performance status (PS), epidermal growth factor receptor (EGFR) mutation, histology and response to induction.

METHODS

PubMed and conference proceedings were reviewed and individual study relative efficacy measures were meta-analysed in a Bayesian hierarchical model. The primary outcome, overall survival (OS), was evaluated in terms of (i) posterior surface under cumulative ranking curve (SUCRA), (ii) probability of being best treatment, (iii) probability of outperforming no maintenance, and (iv) posterior median hazard ratio (95% credible interval). Secondary outcomes were progression-free survival (PFS) and adverse events.

FINDINGS

Twelve trials evaluating eight maintenance treatments in 3850 patients were meta-analysed. Selected maintenance treatments showed clinically meaningful benefits of ⩾20% reduction in hazards of death with ⩾90% probability of outperforming no maintenance in terms of OS: (i) switch to or continue pemetrexed (nonsquamous), continue gemcitabine, or switch to EGFR tyrosine kinase inhibitors (TKIs) for PS 0 patients, (ii) switch to pemetrexed (nonsquamous) for PS 1 patients, (iii) switch to EGFR TKI for EGFR mutation positive patients, (iv) switch to or continue pemetrexed or switch to EGFR TKI for nonsquamous patients, (v) continue gemcitabine for squamous patients, (vi) switch to docetaxel or continue gemcitabine for responders to induction, or (vii) switch to or continue pemetrexed (nonsquamous) or switch to EGFR TKI for patients with stable disease post-induction.

INTERPRETATION

Maintenance treatments show clinically meaningful survival benefits in good performance status patients with advanced NSCLC not progressing after first-line chemotherapy. Benefits are optimised by targeting specific maintenance to individual patients guided by PS, EGFR mutation status, histology and response to induction.

QoL analyses from INFORM study, a phase III study of gefitinib versus placebo as maintenance therapy in advanced NSCLC

This report aimed to provide the full results of QoL assessment in INFORM study. QoL was assessed by FACT-L questionnaire. QoL improvement ratio in gefitinib arm was higher than placebo arm (FACT-L: 46% vs. 22%, p < 0.001; TOI: 41% vs. 18%, p < 0.001; LCS: 46% vs. 22%, p < 0.001). Gefitinib prolonged time-to-worsening of QoL (FACT-L: 2.8 m vs 1.4 m, p = 0.019; TOI: 3.5 m vs 1.4 m, p = 0.006; LCS: 2.8 vs 1.4 m, p = 0.028). Patients with an improvement in QoL had longer PFS (FACT-L: 9.4 m vs. 2.8 m vs. 2.7 m, P < 0.001; TOI: 9.9 m vs. 2.8 m vs. 2.1 m, P < 0.001; LCS: 9.4 m vs. 2.9 m vs. 2.1 m, P < 0.001) and OS (FACT-L: 25.4 m vs. 19.9 m vs. 14.4 m, P = 0.003; TOI: 25.7 m vs. 19.0 m vs. 12.7 m, P = 0.002; LCS: 25.4 m vs. 19.3 m vs. 14.7 m, P = 0.004) compared with patients with stable or worsened QoL. Furthermore, in patients with good QoL at baseline, the treatment of gefitinib couldn't improve OS compared to placebo, whereas patients with low QoL experienced marginal significant improvement in OS (20.6 m vs 14.4, p = 0.051). Our study indicated that gefitinib could improve patients' QoL, confirmed the prognostic value of QoL changes during treatment, and implied patients with low QoL at baseline may be the potential population which will gain OS benefit from maintenance EGFR-TKI therapy.

Quality of Life in Patients with NSCLC Receiving Maintenance Therapy

Introduction: In the past few years many trials have evaluated the use of maintenance therapy in the treatment of NSCLC stage IV. Both switch as well as continuation maintenance show an improved PFS and overall survival. HRQoL data was only partially published. The aim of this article is to review the published effects of maintenance therapy on HRQoL. Methods: Two PubMed searches were performed using the terms: “maintenance therapy and NSCLC” and “maintenance therapy and NSCLC and HRQoL”. The published data was compared, analysed and evaluated. Results: 272 articles were found dealing with maintenance therapy, and of these 85 articles were found regarding maintenance therapy and HRQoL in NSCLC. Maintenance therapy showed no negative impact on HRQoL but failed to show a real benefit. Some symptoms showed positive trends during maintenance therapy. HRQoL can be used to select patients for maintenance therapy. Conclusions: Maintenance therapy is very safe, improves PFS and OS without impairing HRQoL. Although a positive impact on general QoL could not be demonstrated this is possibly due to the mode of evaluating HRQoL. Patient reported outcomes should be simplified and examined for a longer period of time.

PARAMOUNT: Descriptive subgroup analyses of final overall survival for the phase III study of maintenance pemetrexed versus placebo following induction treatment with pemetrexed plus cisplatin for advanced nonsquamous non-small-cell lung cancer

INTRODUCTION

The PARAMOUNT phase III trial demonstrated that pemetrexed continuation maintenance significantly reduced the risk of disease progression (hazard ratio = 0.62) and death (hazard ratio = 0.78) versus placebo in patients with advanced nonsquamous non-small-cell lung cancer. To further understand the survival data, descriptive subgroup analyses were undertaken.

METHODS

Nine hundred thirty-nine patients received induction therapy (four 21-day cycles pemetrexed 500 mg/m and cisplatin 75 mg/m), after which 539 nonprogressing patients with an Eastern Cooperative Oncology Group performance status (PS) of 0/1 were randomized (2:1) to maintenance pemetrexed (500 mg/m) cycles or placebo until disease progression.

RESULTS

Baseline characteristics of patients surviving for longer periods were comparable to patients surviving shorter periods, suggesting overall survival (OS) benefit for all subgroups of patients on maintenance therapy. An examination of type and severity of induction adverse events also found no association with survival duration. Response to induction (tumor response versus stable disease) was not determinate of pemetrexed maintenance OS outcome as assessed by waterfall plot and scattergrams and by the distribution of patients among various OS intervals. The length of the interval before beginning maintenance therapy (<7 days versus ≥7/≤30 days) also did not impact the survival results. PS, a known prognostic factor, was the only baseline characteristic associated with improved OS; however, both PS 0 and PS 1 patients exhibited a survival benefit from pemetrexed maintenance.

CONCLUSIONS

In PARAMOUNT, the OS benefit was seen across all subgroups. Other than PS, no baseline or clinical parameter clearly identified a subgroup more likely to benefit. Maintenance treatment decisions should be made on an individual basis.