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Shriver SP, Adams D, McKelvey BA, McCune JS, Miles D, Pratt VM, Ashcraft K, McLeod HL, Williams H, Fleury ME. Overcoming Barriers to Discovery and Implementation of Equitable Pharmacogenomic Testing in Oncology. J Clin Oncol 2024:JCO2301748. [PMID: 38386947 DOI: 10.1200/jco.23.01748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/08/2023] [Accepted: 12/12/2023] [Indexed: 02/24/2024] Open
Abstract
Pharmacogenomics (PGx), the study of inherited genomic variation and drug response or safety, is a vital tool in precision medicine. In oncology, testing to identify PGx variants offers patients the opportunity for customized treatments that can minimize adverse effects and maximize the therapeutic benefits of drugs used for cancer treatment and supportive care. Because individuals of shared ancestry share specific genetic variants, PGx factors may contribute to outcome disparities across racial and ethnic categories when genetic ancestry is not taken into account or mischaracterized in PGx research, discovery, and application. Here, we examine how the current scientific understanding of the role of PGx in differential oncology safety and outcomes may be biased toward a greater understanding and more complete clinical implementation of PGx for individuals of European descent compared with other genetic ancestry groups. We discuss the implications of this bias for PGx discovery, access to care, drug labeling, and patient and provider understanding and use of PGx approaches. Testing for somatic genetic variants is now the standard of care in treatment of many solid tumors, but the integration of PGx into oncology care is still lacking despite demonstrated actionable findings from PGx testing, reduction in avoidable toxicity and death, and return on investment from testing. As the field of oncology is poised to expand and integrate germline genetic variant testing, it is vital that PGx discovery and application are equitable for all populations. Recommendations are introduced to address barriers to facilitate effective and equitable PGx application in cancer care.
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Affiliation(s)
| | | | | | - Jeannine S McCune
- City of Hope/Beckman Research Institute Department of Hematologic Malignancies Translational Sciences, Duarte, CA
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Glewis S, Lingaratnam S, Krishnasamy M, H Martin J, Tie J, Alexander M, Michael M. Pharmacogenetics testing (DPYD and UGT1A1) for fluoropyrimidine and irinotecan in routine clinical care: Perspectives of medical oncologists and oncology pharmacists. J Oncol Pharm Pract 2024; 30:30-37. [PMID: 37021580 DOI: 10.1177/10781552231167554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Despite robust evidence and international guidelines, to support routine pharmacogenetic (PGx) testing, integration in practice has been limited. This study explored clinicians' views and experiences of pre-treatment DPYD and UGT1A1 gene testing and barriers to and enablers of routine clinical implementation. METHODS A study-specific 17-question survey was emailed (01 February-12 April 2022) to clinicians from the Medical Oncology Group of Australia (MOGA), the Clinical Oncology Society of Australia (COSA) and International Society of Oncology Pharmacy Practitioners (ISOPP). Data were analysed and reported using descriptive statistics. RESULTS Responses were collected from 156 clinicians (78% medical oncologists, 22% pharmacists). Median response rate of 8% (ranged from 6% to 24%) across all organisations. Only 21% routinely test for DPYD and 1% for UGT1A1. For patients undergoing curative/palliative intent treatments, clinicians reported intent to implement genotype-guided dosing by reducing FP dose for DPYD intermediate metabolisers (79%/94%), avoiding FP for DPYD poor metabolisers (68%/90%), and reducing irinotecan dose for UGT1A1 poor metabolisers (84%, palliative setting only). Barriers to implementation included: lack of financial reimbursements (82%) and perceived lengthy test turnaround time (76%). Most Clinicians identified a dedicated program coordinator, i.e., PGx pharmacist (74%) and availability of resources for education/training (74%) as enablers to implementation. CONCLUSION PGx testing is not routinely practised despite robust evidence for its impact on clinical decision making in curative and palliative settings. Research data, education and implementation studies may overcome clinicians' hesitancy to follow guidelines, especially for curative intent treatments, and may overcome other identified barriers to routine clinical implementation.
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Affiliation(s)
- Sarah Glewis
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | | | - Mei Krishnasamy
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Academic Nursing Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
- VCCC Alliance, Parkville, Australia
| | - Jennifer H Martin
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Jeanne Tie
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Marliese Alexander
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Michael Michael
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Glewis S, Krishnasamy M, Lingaratnam S, Harris S, Underhill C, Georgiou C, Warren M, Campbell R, IJzerman M, Fagery M, Campbell I, Martin JH, Tie J, Alexander M, Michael M. Patient and healthcare professional acceptability of pharmacogenetic screening for DPYD and UGT1A1: A cross sectional survey. Clin Transl Sci 2023; 16:2700-2708. [PMID: 37877594 PMCID: PMC10719470 DOI: 10.1111/cts.13664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/21/2023] [Accepted: 10/04/2023] [Indexed: 10/26/2023] Open
Abstract
This study explored the acceptability of a novel pharmacist-led pharmacogenetics (PGx) screening program among patients with cancer and healthcare professionals (HCPs) taking part in a multicenter clinical trial of PGx testing (PACIFIC-PGx ANZCTR:12621000251820). Medical oncologists, oncology pharmacists, and patients with cancer from across four sites (metropolitan/regional), took part in an observational, cross-sectional survey. Participants were recruited from the multicenter trial. Two study-specific surveys were developed to inform implementation strategies for scaled and sustainable translation into routine clinical care: one consisting of 21 questions targeting HCPs and one consisting of 17 questions targeting patients. Responses were collected from 24 HCPs and 288 patients. The 5-to-7-day PGx results turnaround time was acceptable to HCP (100%) and patients (69%). Most HCPs (92%) indicated that it was appropriate for the PGx clinical pharmacist to provide results to patients. Patients reported equal preference for receiving PGx results from a doctor/pharmacist. Patients and HCPs highly rated the pharmacist-led PGx service. HCPs were overall accepting of the program, with the majority (96%) willing to offer PGx testing to their patients beyond the trial. HCPs identified that lack of financial reimbursements (62%) and lack of infrastructure (38%) were the main reasons likely to prevent/slow the implementation of PGx screening program into routine clinical care. Survey data have shown overall acceptability from patients and HCPs participating in the PGx Program. Barriers to implementation of PGx testing in routine care have been identified, providing opportunity to develop targeted implementation strategies for scaled translation into routine practice.
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Affiliation(s)
- Sarah Glewis
- Department of PharmacyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Mei Krishnasamy
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Academic Nursing UnitPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- VCCC AllianceMelbourneVictoriaAustralia
| | - Senthil Lingaratnam
- Department of PharmacyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Sam Harris
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Craig Underhill
- VCCC AllianceMelbourneVictoriaAustralia
- Border Medical Oncology Research UnitAlbury Wodonga Regional Cancer CentreEast AlburyNew South WalesAustralia
- UNSW Rural Medical SchoolAlbury CampusAlburyNew South WalesAustralia
| | - Chloe Georgiou
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Mark Warren
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Robert Campbell
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Maarten IJzerman
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Cancer ResearchUniversity of MelbourneParkvilleVictoriaAustralia
- Melbourne School of Population and Global Health, Centre for Health PolicyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Mussab Fagery
- Cancer ResearchUniversity of MelbourneParkvilleVictoriaAustralia
| | - Ian Campbell
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Cancer Genetics LaboratoryPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Jennifer H. Martin
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNew South WalesAustralia
| | - Jeanne Tie
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Medical OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Personalised Oncology DivisionWalter and Eliza Hall Institute of Medical ResearchParkvilleVictoriaAustralia
| | - Marliese Alexander
- Department of PharmacyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Michael Michael
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Medical OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
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4
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Lim CX, Bozkurt A, Chen ZY, Hird A, Wickens J, Lazarakis S, Hussainy SY, Alexander M. Healthcare professionals' and consumers' knowledge, attitudes, perspectives, and education needs in oncology pharmacogenomics: A systematic review. Clin Transl Sci 2023; 16:2467-2482. [PMID: 37991131 PMCID: PMC10719462 DOI: 10.1111/cts.13672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 11/23/2023] Open
Abstract
Clinical implementation of pharmacogenomic (PGx)-guided prescribing in oncology lags behind research evidence generation. We aimed to identify healthcare professionals' (HCPs) and consumers' knowledge, attitudes, perspectives, and education needs to inform strategies for implementation of scalable and sustainable oncology PGx programs. Systematic review of original articles indexed in EMBASE, EMCARE, MEDLINE, and PsycInfo from January 2012 until June 2022, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and using the Mixed Methods Appraisal Tool. PROSPERO registration number CRD42022352348. Of 1442 identified studies; 23 met inclusion criteria with 87% assessed high quality. Of these, 52% reported on HCPs, 35% on consumers, and 13% on both HCPs and consumers. Most were conducted in the United States (70%) and included multiple cancer types (74%). Across studies, HCPs and consumers mostly perceived value in PGx, however, both groups reported barriers to utilization, including cost, lack of consistent recommendations across guidelines, and limited knowledge among HCPs; test accuracy, clear testing benefits, and genomic information confidentiality among consumers. HCPs and consumers value and want to engage in PGx strategies in oncology care, however, are inhibited by unmet needs and practice and knowledge gaps. Implementation strategies aimed at addressing these issues may best support increased PGx uptake in oncology practice.
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Affiliation(s)
- Chiao Xin Lim
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Alistair Bozkurt
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Zi Yue Chen
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Abbey Hird
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Joanne Wickens
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Safeera Y. Hussainy
- Pharmacy Department, Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyThe University of MelbourneMelbourneVictoriaAustralia
- Department of General Practice, School of Public Health and Preventive MedicineMonash UniversityClaytonVictoriaAustralia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyThe University of MelbourneMelbourneVictoriaAustralia
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5
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Shue SA, Rowe E, Bell LA, Damush T, DeLong A, Gowan T, Skaar T, Haggstrom D. Pharmacogenomics implementation across multiple clinic settings: a qualitative evaluation. Pharmacogenomics 2023; 24:881-893. [PMID: 37975236 DOI: 10.2217/pgs-2023-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Aim: To advance clinical adoption and implementation of pharmacogenomics (PGx) testing, barriers and facilitators to these efforts must be understood. This study identified and examined barriers and facilitators to active implementation of a PGx program across multiple clinic settings in an academic healthcare system. Materials & methods: 28 contributors to the PGx implementation (e.g., clinical providers, informatics specialists) completed an interview to elicit their perceptions of the implementation. Results: Qualitative analysis identified several barriers and facilitators that spanned different stages of the implementation process. Specifically, unclear test payment mechanisms, decision support tool development, rigid workflows and provider education were noted as barriers to the PGx implementation. A multidisciplinary implementation team and leadership support emerged as key facilitators. Furthermore, participants also suggested strategies to overcome or maintain these factors. Conclusion: Assessing real-world implementation perceptions and suggested strategies from a range of implementation contributors facilitates a more comprehensive framework and best-practice guidelines for PGx implementation.
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Affiliation(s)
- Sarah A Shue
- VA HSR&D Center for Health Information & Communication, Roudebush VA Medical Center, Indianapolis, IN 46202, USA
| | - Elizabeth Rowe
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Lauren A Bell
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Teresa Damush
- VA HSR&D Center for Health Information & Communication, Roudebush VA Medical Center, Indianapolis, IN 46202, USA
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Alexis DeLong
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Tayler Gowan
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Todd Skaar
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - David Haggstrom
- VA HSR&D Center for Health Information & Communication, Roudebush VA Medical Center, Indianapolis, IN 46202, USA
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
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6
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Hertz DL, Smith DM, Scott SA, Patel JN, Hicks JK. Response to the FDA Decision Regarding DPYD Testing Prior to Fluoropyrimidine Chemotherapy. Clin Pharmacol Ther 2023; 114:768-779. [PMID: 37350752 DOI: 10.1002/cpt.2978] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/31/2023] [Indexed: 06/24/2023]
Abstract
Fluoropyrimidine (FP) chemotherapy is associated with severe, life-threatening toxicities, particularly among patients who carry deleterious germline variants in the DPYD gene. Pretreatment DPYD testing is standard of care throughout most of Europe; however, it has not been recommended in clinical practice guidelines in the United States. Due to increased risk of severe toxicity, a Citizen's Petition asked the US Food and Drug Administration (FDA) to update language in FP drug labels to recommend DPYD testing as part of a boxed warning and recommend FP dose reduction in patients carrying deleterious germline variants. In response, the FDA updated the capecitabine package insert to inform patients about the toxicity risk and test availability and consider DPYD testing. However, the FDA did not include a testing recommendation or requirement, or a boxed warning. Additionally, the FDA did not recommend FP dose adjustment in DPYD variant carriers. This review provides a critical assessment of the DPYD-FP pharmacogenetic association using the FDA's previously published Pharmacogenetic Pyramid, demonstrating that the evidence is compelling for recommending DPYD testing prior to FP treatment. Additionally, the FDA's stated concerns about recommending DPYD testing and DPYD-guided FP dose adjustment are addressed and discussed in the context of the FDA's other genetic testing and dose adjustment recommendations. We call on the FDA to follow our European counterparts in recommending DPYD testing and genotype-based dose adjustment to ensure patients with cancer receive safe and effective FP chemotherapy.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - D Max Smith
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
- MedStar Health, Columbia, Maryland, USA
| | - Stuart A Scott
- Department of Pathology, Stanford University, Stanford, California, USA
- Clinical Genomics Laboratory, Stanford Medicine, Palo Alto, California, USA
| | - Jai N Patel
- Department of Cancer Pharmacology and Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, Florida, USA
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Morris SA, Moore DC, Musselwhite LW, Lopes KE, Hamilton A, Steuerwald N, Hanson SL, Larck C, Swift K, Smith M, Kadakia KC, Chai S, Hwang JJ, Patel JN. Addressing barriers to increased adoption of DPYD genotyping at a large multisite cancer center. Am J Health Syst Pharm 2023; 80:1342-1349. [PMID: 37235983 DOI: 10.1093/ajhp/zxad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE To describe the implementation of an in-house genotyping program to detect genetic variants linked to impaired dihydropyrimidine dehydrogenase (DPD) metabolism at a large multisite cancer center, including barriers to implementation and mechanisms to overcome barriers to facilitate test adoption. SUMMARY Fluoropyrimidines, including fluorouracil and capecitabine, are commonly used chemotherapy agents in the treatment of solid tumors, such as gastrointestinal cancers. DPD is encoded by the DPYD gene, and individuals classified as DPYD intermediate and poor metabolizers due to certain genetic variations in DPYD can experience reduced fluoropyrimidine clearance and an increased risk of fluoropyrimidine-related adverse events. Although pharmacogenomic guidelines provide evidence-based recommendations for DPYD genotype-guided dosing, testing has not been widely adopted in the United States for numerous reasons, including limited education/awareness of clinical utility, lack of testing recommendations by oncology professional organizations, testing cost, lack of accessibility to a comprehensive in-house test and service, and prolonged test turnaround time. Based on stakeholder feedback regarding barriers to testing, we developed an in-house DPYD test and workflow to facilitate testing in multiple clinic locations at Levine Cancer Institute. Across 2 gastrointestinal oncology clinics from March 2020 through June 2022, 137 patients were genotyped, and 13 (9.5%) of those patients were heterozygous for a variant and identified as DPYD intermediate metabolizers. CONCLUSION Implementation of DPYD genotyping at a multisite cancer center was feasible due to operationalization of workflows to overcome traditional barriers to testing and engagement from all stakeholders, including physicians, pharmacists, nurses, and laboratory personnel. Future directions to scale and sustain testing in all patients receiving a fluoropyrimidine across all Levine Cancer Institute locations include electronic medical record integration (eg, interruptive alerts), establishment of a billing infrastructure, and further refinement of workflows to improve the rate of pretreatment testing.
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Affiliation(s)
- Sarah A Morris
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Donald C Moore
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Laura W Musselwhite
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Karine Eboli Lopes
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Alicia Hamilton
- Molecular Biology and Genomics Core Facility, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Nury Steuerwald
- Molecular Biology and Genomics Core Facility, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Sarah L Hanson
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Chris Larck
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Kristen Swift
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Mathew Smith
- Molecular Biology and Genomics Core Facility, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Kunal C Kadakia
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Seungjean Chai
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Jimmy J Hwang
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Jai N Patel
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
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8
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Fariman SA, Jahangard Rafsanjani Z, Hasanzad M, Niksalehi K, Nikfar S. Upfront DPYD Genotype-Guided Treatment for Fluoropyrimidine-Based Chemotherapy in Advanced and Metastatic Colorectal Cancer: A Cost-Effectiveness Analysis. Value Health Reg Issues 2023; 37:71-80. [PMID: 37329861 DOI: 10.1016/j.vhri.2023.04.004] [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: 11/12/2022] [Revised: 03/26/2023] [Accepted: 04/29/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Fluoropyrimidines are the most widely used chemotherapy drugs for advanced and metastatic colorectal cancer (CRC). Individuals with certain DPYD gene variants are exposed to an increased risk of severe fluoropyrimidine-related toxicities. This study aimed to evaluate the cost-effectiveness of preemptive DPYD genotyping to guide fluoropyrimidine therapy in patients with advanced or metastatic CRC. METHODS Overall survival of DPYD wild-type patients who received a standard dose and variant carriers treated with a reduced dose were analyzed by parametric survival models. A decision tree and a partitioned survival analysis model with a lifetime horizon were designed, taking the Iranian healthcare perspective. Input parameters were extracted from the literature or expert opinion. To address parameter uncertainty, scenario and sensitivity analyses were also performed. RESULTS Compared with no screening, the genotype-guided treatment strategy was cost-saving ($41.7). Nevertheless, due to a possible reduction in the survival of patients receiving reduced-dose regimens, it was associated with fewer quality-adjusted life-years (9.45 vs 9.28). In sensitivity analyses, the prevalence of DPYD variants had the most significant impact on the incremental cost-effectiveness ratio. The genotyping strategy would remain cost-saving, as long as the genotyping cost is < $49 per test. In a scenario in which we assumed equal efficacy for the 2 strategies, genotyping was the dominant strategy, associated with less costs (∼$1) and more quality-adjusted life-years (0.1292). CONCLUSIONS DPYD genotyping to guide fluoropyrimidine treatment in patients with advanced or metastatic CRC is cost-saving from the perspective of the Iranian health system.
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Affiliation(s)
- Soroush Ahmadi Fariman
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mandana Hasanzad
- Medical Genomics Research Center, Tehran University of Medical Sciences, Tehran, Iran; Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kimia Niksalehi
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.
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Seligson ND, Kolesar JM, Alam B, Baker L, Lamba JK, Fridley BL, Salahudeen AA, Hertz DL, Hicks JK. Integrating pharmacogenomic testing into paired germline and somatic genomic testing in patients with cancer. Pharmacogenomics 2023; 24:731-738. [PMID: 37702060 DOI: 10.2217/pgs-2023-0125] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Precision medicine has revolutionized clinical care for patients with cancer through the development of targeted therapy, identification of inherited cancer predisposition syndromes and the use of pharmacogenetics to optimize pharmacotherapy for anticancer drugs and supportive care medications. While germline (patient) and somatic (tumor) genomic testing have evolved separately, recent interest in paired germline/somatic testing has led to an increase in integrated genomic testing workflows. However, paired germline/somatic testing has generally lacked the incorporation of germline pharmacogenomics. Integrating pharmacogenomics into paired germline/somatic genomic testing would be an efficient method for increasing access to pharmacogenomic testing. In this perspective, the authors argue for the benefits of implementing a comprehensive approach integrating somatic and germline testing that is inclusive of pharmacogenomics in clinical practice.
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Affiliation(s)
- Nathan D Seligson
- Department of Pharmacotherapy & Translational Research, The University of Florida, Jacksonville, FL 32209, USA
- Center for Pharmacogenomics & Translational Research, Nemours Children's Health, Jacksonville, FL 32207, USA
| | - Jill M Kolesar
- Markey Cancer Center, University of Kentucky, Lexington, KY 40536, USA
- Department of Pharmacy Practice & Science, University of Kentucky, Lexington, KY 40536, USA
| | - Benish Alam
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - Laura Baker
- Nemours Center for Cancer & Blood Disorders, Nemours Children's Health, Wilmington, DE 19803, USA
| | - Jatinder K Lamba
- Department of Pharmacotherapy & Translational Research, The University of Florida, Gainesville, FL 32611, USA
| | - Brooke L Fridley
- Department of Biostatistics & Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Ameen A Salahudeen
- Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
- Tempus Labs Inc., Chicago, IL 60654, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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10
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Peeters SL, Deenen MJ, Thijs AM, Hulshof EC, Mathijssen RH, Gelderblom H, Guchelaar HJ, Swen JJ. UGT1A1 genotype-guided dosing of irinotecan: time to prioritize patient safety. Pharmacogenomics 2023; 24:435-439. [PMID: 37470120 DOI: 10.2217/pgs-2023-0096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Tweetable abstract Pretreatment UGT1A1 genotyping and a 70% irinotecan dose intensity in poor metabolizers is safe, feasible, cost-effective and essential for safe irinotecan treatment in cancer patients. It is time to update guidelines to swiftly enable the implementation of UGT1A1 genotype-guided irinotecan dosing in routine oncology care.
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Affiliation(s)
- Sofía Lj Peeters
- Department of Clinical Pharmacy, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anna Mj Thijs
- Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Emma C Hulshof
- Department of Clinical Pharmacy, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Ron Hj Mathijssen
- Department of Medical Oncology, Erasmus University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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11
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Baker SD, Bates SE, Brooks GA, Dahut WL, Diasio RB, El-Deiry WS, Evans WE, Figg WD, Hertz DL, Hicks JK, Kamath S, Kasi PM, Knepper TC, McLeod HL, O'Donnell PH, Relling MV, Rudek MA, Sissung TM, Smith DM, Sparreboom A, Swain SM, Walko CM. DPYD Testing: Time to Put Patient Safety First. J Clin Oncol 2023; 41:2701-2705. [PMID: 36821823 PMCID: PMC10414691 DOI: 10.1200/jco.22.02364] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/02/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Affiliation(s)
- Sharyn D. Baker
- College of Pharmacy, The Ohio State University, Columbus, OH
| | - Susan E. Bates
- Herbert Irving Comprehensive Cancer Center, Columbia University, Irving Medical Center, New York, NY
| | | | | | | | | | | | - William D. Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD
| | - Dan L. Hertz
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - J. Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
| | - Suneel Kamath
- Cleveland Clinic, Lerner College of Medicine, Cleveland, OH
| | | | - Todd C. Knepper
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
| | | | | | | | | | | | - D. Max Smith
- Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Georgetown University, Washington, DC
| | - Alex Sparreboom
- College of Pharmacy, The Ohio State University, Columbus, OH
| | - Sandra M. Swain
- Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Georgetown University, Washington, DC
| | - Christine M. Walko
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
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12
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The past, present, and future of chemotherapy with a focus on individualization of drug dosing. J Control Release 2022; 352:840-860. [PMID: 36334860 DOI: 10.1016/j.jconrel.2022.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 10/14/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
While there have been rapid advances in developing new and more targeted drugs to treat cancer, much less progress has been made in individualizing dosing. Even though the introduction of immunotherapies such as CAR T-cells and checkpoint inhibitors, as well as personalized therapies that target specific mutations, have transformed clinical treatment of cancers, chemotherapy remains a mainstay in oncology. Chemotherapies are typically dosed on either a body surface area (BSA) or weight basis, which fails to account for pharmacokinetic differences between patients. Drug absorption, distribution, metabolism, and excretion rates can vary between patients, resulting in considerable differences in exposure to the active drugs. These differences result in suboptimal dosing, which can reduce efficacy and increase side-effects. Therapeutic drug monitoring (TDM), genotype guided dosing, and chronomodulation have been developed to address this challenge; however, despite improving clinical outcomes, they are rarely implemented in clinical practice for chemotherapies. Thus, there is a need to develop interventions that allow for individualized drug dosing of chemotherapies, which can help maximize the number of patients that reach the most efficacious level of drug in the blood while mitigating the risks of underdosing or overdosing. In this review, we discuss the history of the development of chemotherapies, their mechanisms of action and how they are dosed. We discuss substantial intraindividual and interindividual variability in chemotherapy pharmacokinetics. We then propose potential engineering solutions that could enable individualized dosing of chemotherapies, such as closed-loop drug delivery systems and bioresponsive biomaterials.
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13
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Hertz DL. Assessment of the Clinical Utility of Pretreatment DPYD Testing for Patients Receiving Fluoropyrimidine Chemotherapy. J Clin Oncol 2022; 40:3882-3892. [PMID: 36108264 DOI: 10.1200/jco.22.00037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Patients who carry pathogenic variants in DPYD have higher systemic fluoropyrimidine (FP) concentrations and greater risk of severe and fatal FP toxicity. Pretreatment DPYD testing and DPYD-guided FP dosing to reduce toxicity and health care costs is recommended by European clinical oncology guidelines and has been adopted across Europe, but has not been recommended or adopted in the United States. The cochairs of the National Comprehensive Cancer Network Guidelines for colon cancer treatment explained their concerns with recommending pretreatment DPYD testing, particularly the risk that reduced FP doses in DPYD carriers may reduce treatment efficacy. METHODS This special article uses previously published frameworks for assessing the clinical utility of cancer biomarker tests, including for germline indicators of toxicity risk, to assess the clinical utility of pretreatment DPYD testing, with a particular focus on the risk of reducing treatment efficacy. RESULTS There is no direct evidence of efficacy reduction, and the available indirect evidence demonstrates that DPYD-guided FP dosing results in similar systemic FP exposure and toxicity compared with standard dosing in noncarriers, and is well calibrated to the maximum tolerated dose, strongly suggesting there is minimal risk of efficacy reduction. CONCLUSION This article should serve as a call to action for clinicians and clinical guidelines committees in the United States to re-evaluate the clinical utility of pretreatment DPYD testing. If clinical utility has not been demonstrated, further dialogue is needed to clarify what additional evidence is needed and which of the available study designs, also described within this article, would be appropriate. Clinical guideline recommendations for pretreatment DPYD testing would increase clinical adoption and ensure that all patients receive maximally safe and effective FP treatment.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
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14
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Varughese LA, Bhupathiraju M, Hoffecker G, Terek S, Harr M, Hakonarson H, Cambareri C, Marini J, Landgraf J, Chen J, Kanter G, Lau-Min KS, Massa RC, Damjanov N, Reddy NJ, Oyer RA, Teitelbaum UR, Tuteja S. Implementing Pharmacogenetic Testing in Gastrointestinal Cancers (IMPACT-GI): Study Protocol for a Pragmatic Implementation Trial for Establishing DPYD and UGT1A1 Screening to Guide Chemotherapy Dosing. Front Oncol 2022; 12:859846. [PMID: 35865463 PMCID: PMC9295185 DOI: 10.3389/fonc.2022.859846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background Fluoropyrimidines (fluorouracil [5-FU], capecitabine) and irinotecan are commonly prescribed chemotherapy agents for gastrointestinal (GI) malignancies. Pharmacogenetic (PGx) testing for germline DPYD and UGT1A1 variants associated with reduced enzyme activity holds the potential to identify patients at high risk for severe chemotherapy-induced toxicity. Slow adoption of PGx testing in routine clinical care is due to implementation barriers, including long test turnaround times, lack of integration in the electronic health record (EHR), and ambiguity in test cost coverage. We sought to establish PGx testing in our health system following the Exploration, Preparation, Implementation, Sustainment (EPIS) framework as a guide. Our implementation study aims to address barriers to PGx testing. Methods The Implementing Pharmacogenetic Testing in Gastrointestinal Cancers (IMPACT-GI) study is a non-randomized, pragmatic, open-label implementation study at three sites within a major academic health system. Eligible patients with a GI malignancy indicated for treatment with 5-FU, capecitabine, or irinotecan will undergo PGx testing prior to chemotherapy initiation. Specimens will be sent to an academic clinical laboratory followed by return of results in the EHR with appropriate clinical decision support for the care team. We hypothesize that the availability of a rapid turnaround PGx test with specific dosing recommendations will increase PGx test utilization to guide pharmacotherapy decisions and improve patient safety outcomes. Primary implementation endpoints are feasibility, fidelity, and penetrance. Exploratory analyses for clinical effectiveness of genotyping will include assessing grade ≥3 treatment-related toxicity using available clinical data, patient-reported outcomes, and quality of life measures. Conclusion We describe the formative work conducted to prepare our health system for DPYD and UGT1A1 testing. Our prospective implementation study will evaluate the clinical implementation of this testing program and create the infrastructure necessary to ensure sustainability of PGx testing in our health system. The results of this study may help other institutions interested in implementing PGx testing in oncology care. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT04736472, identifier [NCT04736472].
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Affiliation(s)
- Lisa A. Varughese
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Madhuri Bhupathiraju
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Glenda Hoffecker
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Shannon Terek
- Center for Applied Genomics, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Margaret Harr
- Center for Applied Genomics, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christine Cambareri
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica Marini
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey Landgraf
- Information Services Applications, Penn Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jinbo Chen
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Genevieve Kanter
- Division of Medical Ethics and Health Policy, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kelsey S. Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Ryan C. Massa
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nevena Damjanov
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nandi J. Reddy
- Ann B. Barshinger Cancer Institute, Lancaster General Health, Penn Medicine, Lancaster, PA, United States
| | - Randall A. Oyer
- Ann B. Barshinger Cancer Institute, Lancaster General Health, Penn Medicine, Lancaster, PA, United States
| | - Ursina R. Teitelbaum
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Sony Tuteja,
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15
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Rivers ZT, Parsons HM, Jacobson PA, Kuntz KM, Farley JF, Stenehjem DJ. Opportunities for personalizing colorectal cancer care: an analysis of SEER-medicare data. THE PHARMACOGENOMICS JOURNAL 2022; 22:198-209. [PMID: 35361994 PMCID: PMC9156546 DOI: 10.1038/s41397-022-00276-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/04/2022] [Accepted: 03/17/2022] [Indexed: 11/22/2022]
Abstract
United States clinical practice guidelines for metastatic colorectal cancer recommend use of medications impacted by genetic variants but do not recommend testing. We analyzed real-world treatment using a cancer registry and claims dataset to explore pharmacogenomic (PGx) medication treatment patterns and characterize exposure. In a cohort of 6957 patients, most (86.9%) were exposed to at least one chemotherapy medication with PGx guidelines. In a cohort of 2223 patients with retail pharmacy claims available, most (79.2%) were treated with at least one non-chemotherapy (79.2%) medication with PGx guidelines. PGx-associated chemotherapy exposure was associated with age, race/ethnicity, educational attainment, and rurality. PGx-associated non-chemotherapy exposure was associated with medication use and comorbidities. The potential impact of PGx testing is large and policies aimed at increasing PGx testing at diagnosis may impact treatment decisions for patients with metastatic colorectal cancer as most patients are exposed to medications with pharmacogenomics implications during treatment.
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Affiliation(s)
- Zachary T Rivers
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, MN, USA.
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Helen M Parsons
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Pamala A Jacobson
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Karen M Kuntz
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Joel F Farley
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - David J Stenehjem
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, MN, USA
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