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Meernik C, Raveendran Y, Kolarova M, Rahman F, Olunuga E, Hammond E, Shivaramakrishnan A, Hendren S, Bosworth HB, Check DK, Green M, Strickler JH, Akinyemiju T. Racial and ethnic disparities in genomic testing among lung cancer patients: a systematic review. J Natl Cancer Inst 2024; 116:812-828. [PMID: 38321254 PMCID: PMC11160502 DOI: 10.1093/jnci/djae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Racial and ethnic disparities in genomic testing could exacerbate disparities in access to precision cancer therapies and survival-particularly in the context of lung cancer where genomic testing has been recommended for the past decade. However, prior studies assessing disparities in genomic testing have yielded mixed results. METHODS We conducted a systemic review to examine racial and ethnic disparities in the use of genomic testing among lung cancer patients in the United States. Two comprehensive searches in PubMed, Embase, and Scopus were conducted (September 2022, May 2023). Original studies that assessed rates of genomic testing by race or ethnicity were included. Findings were narratively synthesized by outcome. RESULTS The search yielded 2739 unique records, resulting in 18 included studies. All but 1 study were limited to patients diagnosed with non-small cell lung cancer. Diagnosis years ranged from 2007 to 2022. Of the 18 studies, 11 found statistically significant differences in the likelihood of genomic testing by race or ethnicity; in 7 of these studies, testing was lower among Black patients compared with White or Asian patients. However, many studies lacked adjustment for key covariates and included patients with unclear eligibility for testing. CONCLUSIONS A majority of studies, though not all, observed racial and ethnic disparities in the use of genomic testing among patients with lung cancer. Heterogeneity of study results throughout a period of changing clinical guidelines suggests that minoritized populations-Black patients in particular-have faced additional barriers to genomic testing, even if not universally observed at all institutions.
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Affiliation(s)
- Clare Meernik
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Michaela Kolarova
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Fariha Rahman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Emmery Hammond
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Steph Hendren
- Medical Center Library and Archives, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Duke University School of Nursing, Duke University School of Medicine, Durham, NC, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Michelle Green
- Duke Pathology, Duke University School of Medicine, Durham, NC, USA
| | - John H Strickler
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
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Ferreira-Gonzalez A, Hocum B, Ko G, Shuvo S, Appukkuttan S, Babajanyan S. Next-Generation Sequencing Trends among Adult Patients with Select Advanced Tumor Types: A Real-World Evidence Evaluation. J Mol Diagn 2024; 26:292-303. [PMID: 38296192 DOI: 10.1016/j.jmoldx.2024.01.005] [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: 07/11/2023] [Revised: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
There are limited data on the prevalence of next-generation sequencing (NGS) in the United States, especially in light of the increasing importance of identifying actionable oncogenic variants due to molecular biomarker-based therapy approvals. This retrospective study of adult patients with select metastatic solid tumors and central nervous system tumors from the Optum Clinformatics Data Mart US health care claims database (January 1, 2014, to June 30, 2021; N = 63,209) examined NGS use trends over time. A modest increase in NGS was observed across tumor types from 2015 (0.0% to 1.5%) to 2021 (2.1% to 17.4%). A similar increase in NGS rates was also observed across key periods; however, rates in the final key period remained <10% for patients with breast, colorectal, head and neck, soft tissue sarcoma, and thyroid cancers, as well as central nervous system tumors. The median time to NGS from diagnosis was shortest among patients with non-small-cell lung cancer and longest for patients with breast cancer. Predictors of NGS varied by tumor type; test rates for minorities in select tumor types appeared comparable to the White population. Despite improving payer policies to expand coverage of NGS and molecular biomarker-based therapy approvals, NGS rates remained low across tumor types. Given the potential for improved patient outcomes with molecular biomarker-based therapy, further efforts to improve NGS rates are warranted.
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Affiliation(s)
| | - Brian Hocum
- Bayer HealthCare Pharmaceuticals, Inc., Whippany, New Jersey
| | - Gilbert Ko
- Bayer HealthCare Pharmaceuticals, Inc., Whippany, New Jersey.
| | - Sohul Shuvo
- Bayer HealthCare Pharmaceuticals, Inc., Whippany, New Jersey
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Zhao Y, Dimou A, Fogarty ZC, Jiang J, Liu H, Wong WB, Wang C. Real-world Trends, Rural-urban Differences, and Socioeconomic Disparities in Utilization of Narrow versus Broad Next-generation Sequencing Panels. CANCER RESEARCH COMMUNICATIONS 2024; 4:303-311. [PMID: 38276870 PMCID: PMC10840454 DOI: 10.1158/2767-9764.crc-23-0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/07/2023] [Accepted: 01/23/2024] [Indexed: 01/27/2024]
Abstract
Advances in genetic technology have led to the increasing use of genomic panels in precision oncology practice, with panels ranging from a couple to hundreds of genes. However, the clinical utilization and utility of oncology genomic panels, especially among vulnerable populations, is unclear. We examined the association of panel size with socioeconomic status and clinical trial matching. We retrospectively identified 9,886 eligible adult subjects in the Mayo Clinic Health System who underwent genomic testing between January 1, 2016 and June 30, 2020. Patient data were retrieved from structured and unstructured data sources of institutional collections, including cancer registries, clinical data warehouses, and clinical notes. Socioeconomic surrogates were approximated using the Area Deprivation Index (ADI) corresponding to primary residence addresses. Logistic regression was performed to analyze relationships between ADI or rural/urban status and (i) use of genomic test by panel size; (ii) clinical trial matching status. Compared with patients from the most affluent areas, patients had a lower odds of receiving a panel test (vs. a single-gene test) if from areas of higher socioeconomic deprivation [OR (95% confidence interval (CI): 0.71 (0.61-0.83), P < 0.01] or a rural area [OR (95% CI): 0.85 (0.76-0.96), P < 0.01]. Patients in areas of higher socioeconomic deprivation were less likely to be matched to clinical trials if receiving medium panel tests [(OR) (95% CI): 0.69 (0.49-0.97), P = 0.03]; however, there was no difference among patients receiving large panel tests (P > 0.05) and rural patients were almost 2x greater odds of being matched if receiving a large panel test [(OR) (95% CI): 1.76 (1.21-2.55), P < 0.01]. SIGNIFICANCE We identified socioeconomic and rurality disparities in the use of genomic tests and trial matching by panel size, which may have implications for equal access to targeted therapies. The lack of association between large panel tests and clinical trial matching by socioeconomic status, suggests a potential health equity impact, while removing barriers in access to large panels for rural patients may improve access to trials. However, further research is needed.
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Affiliation(s)
- Yiqing Zhao
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Zachary C. Fogarty
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jun Jiang
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Hongfang Liu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Chen Wang
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
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Ortendahl JD, Cuyun Carter G, Thakkar SG, Bognar K, Hall DW, Abdou Y. Value of next generation sequencing (NGS) testing in advanced cancer patients. J Med Econ 2024; 27:519-530. [PMID: 38466204 DOI: 10.1080/13696998.2024.2329009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/07/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE The availability of targeted therapies for oncology patients is increasing. Available genomic tests to identify treatment-eligible patients include single gene tests and gene panel tests, including the whole-exome, whole-transcriptome OncoExTra test. We assessed the costs and clinical benefits of test choice. METHODS A Microsoft Excel-based model was developed to evaluate test choice in patients with advanced/metastatic non-small cell lung cancer (NSCLC), breast, prostate, and colorectal cancer. Treatment pathways were based on NCCN guidelines and medical expert opinion. Inputs were derived from published literature. Annual economic results and lifetime clinical results with OncoExTra testing were projected per-tested-patient and compared with single gene testing and no testing. Separately, results were estimated for a US health plan without the OncoExTra test and with its use in 5% of patients. RESULTS Compared with no genomic testing, OncoExTra test use increased costs by $4,915 per patient; however, 82%-92% of individuals across tumour types were identified as eligible for targeted therapy or a clinical trial. Compared with single gene testing, OncoExTra test use decreased costs by $9,966 per-patient-tested while increasing use of approved or investigational targeted therapies by 20%. When considering a hypothetical health plan with 1 million members, 858 patients were eligible for genomic testing. Using the OncoExTra test in 5% of those eligible, per-member per-month costs decreased by $0.003, ranging from cost-savings of $0.026 in NSCLC patients to a $0.009 increase in prostate cancer patients. Cost-savings were driven by reduced treatment costs with increased clinical trial enrolment and reduced direct and indirect medical costs associated with targeted treatments. LIMITATIONS Limitations include the required simplifications in modelling complex conditions that may not fully reflect evolving real-world testing and treatment patterns. CONCLUSIONS Compared to single-gene testing, results indicate that using next generation sequencing test such as OncoExTra identified more actionable alterations, leading to improved outcomes and reduced costs.
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Affiliation(s)
- Jesse D Ortendahl
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| | | | | | - Katalin Bognar
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
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Figueiredo A, Rodrigues A, Gaspar C, Felizardo M. Diagnosis and Treatment of Advanced ALK Rearrangement-Positive Non-Small-Cell Lung Cancer in Portugal: Results of a National Questionnaire. Drugs Real World Outcomes 2023; 10:545-555. [PMID: 37787868 PMCID: PMC10730491 DOI: 10.1007/s40801-023-00393-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Rearrangements in the anaplastic lymphoma kinase (ALK) gene define a molecular subgroup of non-small-cell lung carcinoma (NSCLC) that should be treated with ALK-targeting tyrosine kinase inhibitors (TKIs). OBJECTIVE This study aimed to portray the Portuguese reality about the diagnosis and treatment of stage IV ALK-positive NSCLC. METHODS Institutions that treat lung cancer in Portugal were invited to participate in an anonymous electronic questionnaire. A total of 22/35 geographically dispersed institutions responded. A descriptive statistical analysis of the results was performed. RESULTS Reflex molecular testing was done in 54.6% of the institutions. Next-generation sequencing (NGS) was the preferred diagnostic method (90.9%). Typically, physicians obtained molecular study results within 14-21 days. Alectinib was the most commonly used first-line treatment. For patients with brain metastases, 86.4% of the physicians preferred alectinib and 13.6% preferred first-line brigatinib. In the case of asymptomatic oligoprogression in the central nervous system, 85.7% of physicians performed local treatment and kept the patient on a TKI; if symptomatic, 66.7% gave local treatment and stayed with the TKI, while 28.6% gave local treatment and altered the TKI. For patients with symptomatic systemic progression, 47.6% and 38.1% of physicians prescribed lorlatinib after initial treatment with alectinib or brigatinib, respectively. After progression on lorlatinib, 42.9% of respondents chose chemotherapy and 57.1% requested detection of resistance mutations. CONCLUSIONS NGS is widely used for the molecular characterization of ALK-positive NSCLC in Portugal. The country has access to up-to-date therapy. Overall, national clinical practice follows international recommendations for the diagnosis and treatment of ALK-positive NSCLC.
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Affiliation(s)
- Ana Figueiredo
- Department of Pulmonology, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal.
| | - Ana Rodrigues
- Department of Medical Oncology, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Carina Gaspar
- Medical & Scientific Management, Syneos Health, Avenida Duque d Ávilla, nº46, 3ºC, 1050-083, Lisboa, Portugal
| | - Margarida Felizardo
- Department of Pulmonology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal
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Norris RP, Dew R, Greystoke A, Todd A, Sharp L. Socioeconomic Inequalities in Novel NSCLC Treatments During the Era of Tumor Biomarker-Guided Therapy: A Population-Based Cohort Study in a Publicly Funded Health Care System. J Thorac Oncol 2023; 18:990-1002. [PMID: 37146751 DOI: 10.1016/j.jtho.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/03/2023] [Accepted: 04/20/2023] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Socioeconomic inequalities in the utilization of conventional NSCLC treatments are well documented. Nevertheless, it is not known whether these inequalities are also observed with novel anticancer therapies. This study evaluated associations between deprivation and utilization of novel anticancer therapies targeting tumor biology, the immune system, or both, within the English national publicly funded health care system. METHODS A retrospective analysis of 90,785 patients diagnosed with having a histologically confirmed stage IV NSCLC from January 1, 2012, to December 31, 2017, sourced from the English national population-based cancer registry and linked Systemic Anti-Cancer Therapy database, was undertaken. Multivariable logistic regression evaluated the likelihood of novel anticancer therapy utilization by deprivation category of area of residence at diagnosis (measured by quintiles of the income domain of the index of multiple deprivation). RESULTS Multivariable analyses revealed marked treatment inequalities by deprivation. Patients residing in the most deprived areas were more than half as likely to use any novel therapy (multivariable OR [mvOR] = 0.45, 95% confidence interval [CI]: 0.41-0.49) compared with patients residing in the most affluent areas. Deprivation associations with treatment utilization were slightly stronger with targeted treatments ([most versus least deprived] mvOR = 0.39, 95% CI: 0.35-0.43) than immune checkpoint inhibitors (mvOR = 0.58, 95% CI: 0.51-0.66). CONCLUSIONS There are marked socioeconomic inequalities in NSCLC novel treatment utilization, even in the English National Health Service where treatment is free at the point of delivery. These findings have important implications for equitable delivery of drugs, which have transformed outcomes in metastatic lung cancer. Further work exploring the underlying causes is now needed.
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Affiliation(s)
- Ruth P Norris
- School of Pharmacy, Newcastle University, Newcastle-upon-Tyne, United Kingdom; Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle-upon-Tyne, United Kingdom
| | - Rosie Dew
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle-upon-Tyne, United Kingdom; Present Address: Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, United Kingdom
| | - Alastair Greystoke
- Northern Centre for Cancer, Freeman Hospital, Newcastle Hospital Trust, Newcastle-upon-Tyne, United Kingdom
| | - Adam Todd
- School of Pharmacy, Newcastle University, Newcastle-upon-Tyne, United Kingdom; Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle-upon-Tyne, United Kingdom
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle-upon-Tyne, United Kingdom.
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Osazuwa-Peters OL, Wilson LE, Check DK, Roberts MC, Srinivasan S, Clark AG, Crawford J, Chrischilles E, Carnahan RM, Campbell WS, Cowell LG, Greenlee R, Abbott AM, Mosa ASM, Mandhadi V, Stoddard A, Dinan MA. Factors Associated With Receipt of Molecular Testing and its Impact on Time to Initial Systemic Therapy in Metastatic Non-Small Cell Lung Cancer. Clin Lung Cancer 2023; 24:305-312. [PMID: 37055337 DOI: 10.1016/j.cllc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/13/2023] [Accepted: 03/10/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Despite recommendations for molecular testing irrespective of patient characteristics, differences exist in receipt of molecular testing for oncogenic drivers amongst metastatic non-small cell lung cancer (mNSCLC) patients. Exploration into these differences and their effects on treatment is needed to identify opportunities for improvement. PATIENTS AND METHODS We conducted a retrospective cohort study of adult patients diagnosed with mNSCLC between 2011 and 2018 using PCORnet's Rapid Cycle Research Project dataset (n = 3600). Log-binomial, Cox proportional hazards (PH), and time-varying Cox regression models were used to ascertain whether molecular testing was received, and time from diagnosis to molecular testing and/or initial systemic treatment in the context of patient age, sex, race/ethnicity, and multiple comorbidities status. RESULTS The majority of patients in this cohort were ≤ 65 years of age (median [25th, 75th]: 64 [57, 71]), male (54.3%), non-Hispanic white individuals (81.6%), with > 2 comorbidities in addition to mNSCLC (54.1%). About half the cohort received molecular testing (49.9%). Patients who received molecular testing had a 59% higher probability of initial systemic treatment than patients who were yet to receive testing. Multiple comorbidity status was positively associated with receipt of molecular testing (RR, 1.27; 95% CI 1.08, 1.49). CONCLUSION Receipt of molecular testing in academic centers was associated with earlier initiation of systemic treatment. This finding underscores the need to increase molecular testing rates amongst mNSCLC patients during a clinically relevant period. Further studies to validate these findings in community centers are warranted.
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Affiliation(s)
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Megan C Roberts
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Swetha Srinivasan
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Amy G Clark
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Jeffrey Crawford
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA
| | - W Scott Campbell
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE
| | - Lindsay G Cowell
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinical Research Institute, Marshfield, WI
| | - Andrea M Abbott
- Department of Surgery, Medical University of South Carolina, Clinical Sciences, Charleston, SC
| | - Abu S M Mosa
- Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia, MO
| | - Vasanthi Mandhadi
- Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia, MO
| | - Alexander Stoddard
- Biomedical Informatics, Clinical and Translational Science Institute, Medical College of Wisconsin, Milwaukee, WI
| | - Michaela A Dinan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT.
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Roberts TJ, Kehl KL, Brooks GA, Sholl L, Wright AA, Landrum MB, Keating NL. Practice-Level Variation in Molecular Testing and Use of Targeted Therapy for Patients With Non-Small Cell Lung Cancer and Colorectal Cancer. JAMA Netw Open 2023; 6:e2310809. [PMID: 37115543 PMCID: PMC10148196 DOI: 10.1001/jamanetworkopen.2023.10809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/15/2023] [Indexed: 04/29/2023] Open
Abstract
Importance All patients with newly diagnosed non-small cell lung cancer (NSCLC) and colorectal cancer (CRC) should receive molecular testing to identify those who can benefit from targeted therapies. However, many patients do not receive recommended testing and targeted therapies. Objective To compare rates of molecular testing and targeted therapy use by practice type and across practices. Design, Setting, and Participants This cross-sectional study used 100% Medicare fee-for-service data from 2015 through 2019 to identify beneficiaries with new metastatic NSCLC or CRC diagnoses receiving systemic therapy and to assign patients to oncology practices. Hierarchical linear models were used to characterize variation by practice type and across practices. Data analysis was conducted from June 2019 to October 2022. Exposures Oncology practice providing care. Outcomes Primary outcomes were rates of molecular testing and targeted therapy use for patients with NSCLC and CRC. Secondary outcomes were rates of multigene testing for NSCLC and CRC. Results There were 106 228 Medicare beneficiaries with incident NSCLC (31 521 [29.7%] aged 65-69 years; 50 348 [47.4%] female patients; 2269 [2.1%] Asian, 8282 [7.8%] Black, and 91 215 [85.9%] White patients) and 39 512 beneficiaries with incident CRC (14 045 [35.5%] aged 65-69 years; 17 518 [44.3%] female patients; 896 [2.3%] Asian, 3521 [8.9%] Black, and 32 753 [82.9%] White patients) between 2015 and 2019. Among these beneficiaries, 18 435 (12.9%) were treated at National Cancer Institute (NCI)-designated centers, 8187 (5.6%) were treated at other academic centers, and 94 329 (64.7%) were treated at independent oncology practices. Molecular testing rates increased from 74% to 85% for NSCLC and 45% to 65% for CRC. First-line targeted therapy use decreased from 12% to 8% among patients with NSCLC and was constant at 5% for patients with CRC. For NSCLC, molecular testing rates were similar across practice types while rates of multigene panel use (13.2%) and targeted therapy use (16.6%) were highest at NCI-designated cancer centers. For CRC, molecular testing rates were 3.8 (95% CI: 1.2-6.5), 3.3 (95% CI, 0.4-6.1), and 12.2 (95% CI, 9.1-15.3) percentage points lower at hospital-owned practices, large independent practices, and small independent practices, respectively. Rates of targeted therapy use for CRC were similar across practice types. After adjusting for patient characteristics, there was moderate variation in molecular testing and targeted therapy use across oncology practices. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, molecular testing rates for NSCLC and CRC increased in recent years but remained lower than recommended levels. Rates of targeted therapy use decreased for NSCLC and remained stable for CRC. Variation across practices suggests that where a patient was treated may have affected access to recommended testing and efficacious treatments.
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Affiliation(s)
- Thomas J. Roberts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Kenneth L. Kehl
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A. Brooks
- Section of Medical Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lynette Sholl
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexi A. Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Real-world ALK Testing Trends in Patients With Advanced Non-Small-Cell Lung Cancer in the United States. Clin Lung Cancer 2023; 24:e39-e49. [PMID: 36376172 DOI: 10.1016/j.cllc.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/15/2022] [Accepted: 09/29/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Patients with non-small-cell lung cancer (NSCLC) whose tumors harbor anaplastic lymphoma kinase (ALK) rearrangements can be treated with ALK tyrosine kinase inhibitors. We assessed real-world ALK biomarker testing and treatment patterns of patients with NSCLC in the United States. PATIENTS AND METHODS Data were extracted from the Flatiron Health electronic health record-derived deidentified database for patients aged ≥18 years with stage IIIB or IV NSCLC and ≥2 clinic visits between January 2011 and December 2019. RESULTS Among 60,025 eligible patients, tumors from 36,691 (61.1%) patients were tested for ALK rearrangements, and 1042 (2.8%) tested positive (ALK+). From 2011 to 2019, ALK testing rates increased from 33.1% to 73.0%; testing via fluorescence in situ hybridization declined from 68.3% to 32.1% while next-generation sequencing increased from <1% to 52.2%. Although tissue samples were more commonly used than blood (85.1% vs. 13.5% of tests), blood sample testing increased from 0.1% in 2011 to 28.2% in 2019. Median (interquartile range) time from diagnosis of advanced NSCLC to first ALK+ test result was 23 (13-43) days, including laboratory processing time of 9 (6-14) days. For the 24.7% of patients with an ALK+ test result who began treatment before receiving the positive result, chemotherapy was initiated most often overall until 2018 when immuno-oncology agents became most common. CONCLUSION Although ALK testing in NSCLC increased over time, testing rates among eligible patients did not reach 100% during the study period. Treatment decisions for some patients with NSCLC may have been made without important, guideline-recommended biomarker data.
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Bosserman LD, Mambetsariev I, Ladbury C, Barzi A, Johnson D, Morse D, Deaville D, Smith W, Rajurkar S, Merla A, Hajjar G, Kim D, Fricke J, Trisal V, Salgia R. Pyramidal Decision Support Framework Leverages Subspecialty Expertise across Enterprise to Achieve Superior Cancer Outcomes and Personalized, Precision Care Plans. J Clin Med 2022; 11:jcm11226738. [PMID: 36431215 PMCID: PMC9697355 DOI: 10.3390/jcm11226738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
The complexity of cancer care requires integrated and continuous support to deliver appropriate care. An expert network with complementary expertise and the capability of multidisciplinary care is an integral part of contemporary oncology care. Appropriate infrastructure is necessary to empower this network to deliver personalized precision care to their patients. Providing decision support as cancer care becomes exponentially more complex with new diagnostic and therapeutic choices remains challenging. City of Hope has developed a Pyramidal Decision Support Framework to address these challenges, which were exacerbated by the COVID pandemic, health plan restrictions, and growing geographic site diversity. Optimizing efficient and targeted decision support backed by multidisciplinary cancer expertise can improve individual patient treatment plans to achieve improved care and survival wherever patients are treated.
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Affiliation(s)
- Linda D. Bosserman
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
| | - Afsaneh Barzi
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Deron Johnson
- Department of Clinical Informatics, City of Hope, Duarte, CA 91010, USA
| | - Denise Morse
- Department of Quality, Risk and Regulatory Management, City of Hope, Duarte, CA 91010, USA
| | - Debbie Deaville
- Department of Enterprise Business Intelligence, City of Hope, Irwindale, CA 91706, USA
| | - Wade Smith
- Department of Medical Oncology and Therapeutics Research, City of Hope, Newport Beach, CA 92660, USA
| | - Swapnil Rajurkar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Upland, CA 91784, USA
| | - Amartej Merla
- Department of Medical Oncology and Therapeutics Research, City of Hope, Antelope Valley, CA 93534, USA
| | - George Hajjar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Mission Hills, CA 91345, USA
| | - Daniel Kim
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Vijay Trisal
- Department of Medicine, City of Hope, Duarte, CA 91010, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
- Correspondence:
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11
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Curtin M, Dickerson SS. Precision Medicine Testing and Disparities in Health Care for Individuals With Non-Small Cell Lung Cancer: A Narrative Review. Oncol Nurs Forum 2022; 49:257-272. [PMID: 35446830 DOI: 10.1188/22.onf.257-272] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PROBLEM IDENTIFICATION Precision medicine initiatives provide opportunities for optimal targeted therapy in individuals with non-small cell lung cancer. However, there are barriers to these initiatives that reflect social determinants of health. LITERATURE SEARCH MEDLINE®, CINAHL®, PsycINFO®, Embase®, and Google ScholarTM databases were searched for articles published in English in the United States from 2016 to 2020. DATA EVALUATION Data that were collected included individual demographic information, specific diagnosis, status of targeted genomic testing, and receipt of targeted therapy. All studies were retrospective and involved database review of insurance claims or medical records. SYNTHESIS Individuals with non-small cell lung cancer received less genetic testing and targeted therapy if they were of a lower socioeconomic status, had public health insurance or no health insurance, were Black, or lived in rural communities. IMPLICATIONS FOR NURSING Social determinants of health affect health equity, including in precision medicine initiatives for individuals with lung cancer. Gaining an understanding of this impact is the first step in mitigating inequities.
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12
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Sheinson DM, Wong WB, Meyer CS, Stergiopoulos S, Lofgren KT, Flores C, Adams DV, Fleury ME. Trends in Use of Next-Generation Sequencing in Patients With Solid Tumors by Race and Ethnicity After Implementation of the Medicare National Coverage Determination. JAMA Netw Open 2021; 4:e2138219. [PMID: 34882180 PMCID: PMC8662372 DOI: 10.1001/jamanetworkopen.2021.38219] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/12/2021] [Indexed: 12/23/2022] Open
Abstract
Importance In March 2018, Medicare issued a national coverage determination (NCD) for next-generation sequencing (NGS) to facilitate access to NGS testing among Medicare beneficiaries. It is unknown whether the NCD affected health equity issues for Medicare beneficiaries and the overall population. Objective To examine the association between the Medicare NCD and NGS use by insurance types and race and ethnicity. Design, Setting, and Participants A retrospective cohort analysis was conducted using electronic health record data derived from a real-world database. Data originated from approximately 280 cancer clinics (approximately 800 sites of care) in the US. Patients with advanced non-small cell lung cancer (aNSCLC), metastatic colorectal cancer (mCRC), metastatic breast cancer (mBC), or advanced melanoma diagnosed from January 1, 2011, through March 31, 2020, were included. Exposure Pre- vs post-NCD period. Main Outcomes and Measures Patients were classified by insurance type and race and ethnicity to examine patterns in NGS testing less than or equal to 60 days after diagnosis. Difference-in-differences models examined changes in average NGS testing in the pre- and post-NCD periods by race and ethnicity, and interrupted time-series analysis examined whether trends over time varied by insurance type and race and ethnicity. Results Among 92 687 patients with aNSCLC, mCRC, mBC, or advanced melanoma, mean (SD) age was 66.6 (11.2) years, 51 582 (55.7%) were women, and 63 864 (68.9%) were Medicare beneficiaries. The largest racial and ethnic categories according to the database used and further classification were Black or African American (8605 [9.3%]) and non-Hispanic White (59 806 [64.5%]). Compared with Medicare beneficiaries, changes in pre- to post-NCD NGS testing trends were similar in commercially insured patients (odds ratio [OR], 1.03; 95% CI, 0.98-1.08; P = .25). Pre- to post-NCD NGS testing trends increased at a slower rate among patients in assistance programs (OR, 0.93; 95% CI, 0.87-0.99; P = .03) compared with Medicare beneficiaries. The rate of increase for patients receiving Medicaid was not statistically significantly different compared with those receiving Medicare (OR, 0.92; 95% CI, 0.84-1.01; P = .07). The NCD was not associated with statistically significant changes in NGS use trends by racial and ethnic groups within Medicare beneficiaries alone or across all insurance types. Compared with non-Hispanic White individuals, increases in average NGS use from the pre-NCD to post-NCD period were 14% lower (OR, 0.86; 95% CI, 0.74-0.99; P = .04) among African American and 23% lower (OR, 0.77; 95% CI, 0.62-0.96; P = .02) among Hispanic/Latino individuals; increases among Asian individuals and those with other races and ethnicities were similar. Conclusions and Relevance The findings of this study suggest that expansion of Medicare-covered benefits may not occur equally across insurance types, thereby further widening or maintaining disparities in NGS testing. Additional efforts beyond coverage policies are needed to ensure equitable access to the benefits of precision medicine.
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Affiliation(s)
| | | | | | | | | | | | - Devon V. Adams
- American Cancer Society Cancer Action Network, Washington, DC
| | - Mark E. Fleury
- American Cancer Society Cancer Action Network, Washington, DC
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13
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Allen TC, Xiao Y, Yang B, Croix D, Abraham A, Redpath S, Engstrom-Melynk J, Shah R, Madala J, Bernicker EH. Anaplastic lymphoma kinase rearrangement prevalence in patients with advanced non-small cell lung cancer in the United States: retrospective real world data. Oncotarget 2021; 12:2308-2315. [PMID: 34786182 PMCID: PMC8590819 DOI: 10.18632/oncotarget.28114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/25/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE This study assessed the prevalence of anaplastic lymphoma kinase (ALK) rearrangements in US oncology practices. MATERIALS AND METHODS Using a nationwide real-world database, we included adults with advanced non-small cell lung cancer (aNSCLC, stage IIIB- IV) diagnosed January 2015 - May 2019, with documented ALK testing results and smoking status. Rearrangement prevalence was assessed overall and then stratified by patient characteristics. RESULTS The cohort included 19,895 eligible patients with a mean age 68.5 years, majority ever-smokers (85.5%) and from community centers (92.2%). The overall ALK rearrangement prevalence was 2.6%. Positivity rate varied by histology and smoking status; it was the highest among non-smoking patients with non-squamous histology (9.3%). Differences in ALK status also varied by age and race, with young patients (18-39 years) having a higher prevalence (21.6%) vs. older patients (age ≥55 = 2.2%); Asian patients had a prevalence of 6.3%. Patients that were positive for other mutations or rearrangements had a lower ALK positivity rate (0.5%) and patients positive for PD-L1 had a rate of 3.0%. CONCLUSIONS The likelihood of finding an ALK translocation was highest in younger patients and nonsmokers; however, age and smoking history were not discriminative enough to exclude testing based on clinical variables.
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Affiliation(s)
- Timothy Craig Allen
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Yan Xiao
- Data Services, Roche Information Solutions, Pleasanton, CA, USA
- Current affiliation: Digital Health, AstraZeneca R&D, Beijing, China
| | - Baiyu Yang
- Data Services, Roche Information Solutions, Pleasanton, CA, USA
| | - Denise Croix
- Medical and Scientific Affairs, Roche Diagnostics Corporation, Indianapolis, IN, USA
| | - Anup Abraham
- Evidence Strategy, Genesis Research, Hoboken, NJ, USA
| | - Stella Redpath
- Medical and Scientific Affairs, Roche Diagnostics Corporation, Indianapolis, IN, USA
- Current affiliation: Medical Diagnostics, AstraZeneca, Gaithersburg, MD, USA
| | - Julia Engstrom-Melynk
- Medical and Scientific Affairs, Roche Diagnostics Corporation, Indianapolis, IN, USA
- Current affiliation: Medical Diagnostics, AstraZeneca, Gaithersburg, MD, USA
| | - Roma Shah
- Data Services, Roche Information Solutions, Pleasanton, CA, USA
| | - Jaya Madala
- Data Services, Roche Information Solutions, Pleasanton, CA, USA
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14
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Bernicker EH, Xiao Y, Croix DA, Yang B, Abraham A, Redpath S, Engstrom-Melnyk J, Shah R, Allen TC. Understanding Factors Associated With Anaplastic Lymphoma Kinase Testing Delays in Patients With Non-Small Cell Lung Cancer in a Large Real-World Oncology Database. Arch Pathol Lab Med 2021; 146:975-983. [PMID: 34752598 DOI: 10.5858/arpa.2021-0029-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— With multiple therapeutic options available for patients with advanced non-small cell lung cancer, the timely ordering and return of results to determine therapy are of critical importance. OBJECTIVE.— To assess factors impacting anaplastic lymphoma kinase (ALK) test ordering and time to result delivery. DESIGN.— A retrospective study using a de-identified electronic health record database was performed. Postdiagnosis ALK tests (n = 14 657) were analyzed from 14 197 patients with advanced non-small cell lung cancer diagnosed between January 2015 and May 2019. Time from non-small cell lung cancer diagnosis to ALK sample receipt in the laboratory was a surrogate for test order time. Test ordering was considered delayed if order time was more than 20 days. Turnaround time from sample received to test result was calculated and considered delayed if more than 10 days. Multivariable logistic regression was used to assess factors associated with order time and turnaround time delays. RESULTS.— Median ALK test order time was 15 days, and 36.4% (5342) of all 14 657 orders were delayed. Factors associated with delays were non-fluorescent in situ hybridization testing, send-out laboratories, testing prior to 2018, nonadenocarcinoma histology, and smoking history. Median turnaround time was 9 days, and 40.3% (5906) of all 14 657 test results were delayed. Non-fluorescent in situ hybridization testing, tissue sample, and orders combining ALK with other biomarkers were associated with delayed ALK result reporting. CONCLUSIONS.— This study provides a snapshot of real-world ALK test ordering and reporting time in US community practices. Multiple factors impacted both test ordering time and return of results, revealing opportunities for improvement. It is imperative that patients eligible for targeted therapy be identified in a timely fashion.
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Affiliation(s)
- Eric H Bernicker
- From the Cancer Center, Houston Methodist Hospital, Houston, Texas (Bernicker)
| | - Yan Xiao
- Data Services, Roche Information Solutions, Pleasanton, California (Xiao, Yang, Shah).,Xiao is now at Digital Health, AstraZeneca R&D, Beijing, China
| | - Denise A Croix
- Medical and Scientific Affairs, Roche Diagnostics Corporation, Indianapolis, Indiana (Croix, Redpath, Engstrom-Melnyk)
| | - Baiyu Yang
- Data Services, Roche Information Solutions, Pleasanton, California (Xiao, Yang, Shah)
| | - Anup Abraham
- Evidence Strategy, Genesis Research, Hoboken, New Jersey (Abraham)
| | - Stella Redpath
- Medical and Scientific Affairs, Roche Diagnostics Corporation, Indianapolis, Indiana (Croix, Redpath, Engstrom-Melnyk)
| | - Julia Engstrom-Melnyk
- Medical and Scientific Affairs, Roche Diagnostics Corporation, Indianapolis, Indiana (Croix, Redpath, Engstrom-Melnyk).,Engstrom-Melnyk is now at Medical Diagnostics, AstraZeneca, Gaithersburg, Maryland
| | - Roma Shah
- Data Services, Roche Information Solutions, Pleasanton, California (Xiao, Yang, Shah)
| | - Timothy Craig Allen
- the Department of Pathology, University of Mississippi Medical Center, Jackson (Allen)
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15
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Dalurzo ML, Avilés-Salas A, Soares FA, Hou Y, Li Y, Stroganova A, Öz B, Abdillah A, Wan H, Choi YL. Testing for EGFR Mutations and ALK Rearrangements in Advanced Non-Small-Cell Lung Cancer: Considerations for Countries in Emerging Markets. Onco Targets Ther 2021; 14:4671-4692. [PMID: 34511936 PMCID: PMC8420791 DOI: 10.2147/ott.s313669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/08/2021] [Indexed: 12/24/2022] Open
Abstract
The treatment of patients with advanced non-small-cell lung cancer (NSCLC) in recent years has been increasingly guided by biomarker testing. Testing has centered on driver genetic alterations involving the epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) rearrangements. The presence of these mutations is predictive of response to targeted therapies such as EGFR tyrosine kinase inhibitors (TKIs) and ALK TKIs. However, there are substantial challenges for the implementation of biomarker testing, particularly in emerging countries. Understanding the barriers to testing in NSCLC will be key to improving molecular testing rates worldwide and patient outcomes as a result. In this article, we review EGFR mutations and ALK rearrangements as predictive biomarkers for NSCLC, discuss a selection of appropriate tests and review the literature with respect to the global uptake of EGFR and ALK testing. To help improve testing rates and unify procedures, we review our experiences with biomarker testing in China, South Korea, Russia, Turkey, Brazil, Argentina and Mexico, and propose a set of recommendations that pathologists from emerging countries can apply to assist with the diagnosis of NSCLC.
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Affiliation(s)
- Mercedes L Dalurzo
- Department of Pathology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Yingyong Hou
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yuan Li
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People’s Republic of China
| | - Anna Stroganova
- N.N. Blokhin National Medical Research Centre of Oncology, Russian Academy of Medical Sciences, Moscow, Russia
| | - Büge Öz
- Cerrahpaşa School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Arif Abdillah
- Takeda Pharmaceuticals International AG – Singapore Branch, Singapore, Singapore
| | - Hui Wan
- Takeda Pharmaceuticals International AG – Singapore Branch, Singapore, Singapore
| | - Yoon-La Choi
- Department of Pathology and Translational Genomics, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Nadal E, Bautista D, Cabezón-Gutiérrez L, Ortega AL, Torres H, Carcedo D, Ruiz de Alda L, Garcia JF, Vieitez P, Rojo F. Clinical and economic impact of current ALK rearrangement testing in Spain compared with a hypothetical no-testing scenario. BMC Cancer 2021; 21:689. [PMID: 34112097 PMCID: PMC8194132 DOI: 10.1186/s12885-021-08407-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/25/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Currently biomarkers play an essential role in diagnosis, treatment, and management of cancer. In non-small cell lung cancer (NSCLC) determination of biomarkers such as ALK, EGFR, ROS1 or PD-L1 is mandatory for an adequate treatment decision. The aim of this study is to determine the clinical and economic impact of current anaplastic lymphoma kinase testing scenario in Spain. METHODS A joint model, composed by decision-tree and Markov models, was developed to estimate the long-term health outcomes and costs of NSCLC patients, by comparing the current testing scenario for ALK in Spain vs a hypothetical no-testing. The current distribution of testing strategies for ALK determination and their sensitivity and specificity data were obtained from the literature. Treatment allocation based on the molecular testing result were defined by a panel of Spanish experts. To assess long-term effects of each treatment, 3-states Markov models were developed, where progression-free survival and overall survival curves were extrapolated using exponential models. Medical direct costs (expressed in €, 2019) were included. A lifetime horizon was used and a discount rate of 3% was applied for both costs and health effects. Several sensitivity analyses, both deterministic and probabilistic, were performed in order test the robustness of the analysis. RESULTS We estimated a target population of 7628 NSCLC patients, including those with non-squamous histology and those with squamous carcinomas who were never smokers. Over the lifetime horizon, the current ALK testing scenario produced additional 5060 and 3906 life-years and quality-adjusted life-years (QALY), respectively, compared with the no-testing scenario. Total direct costs were increased up to € 51,319,053 for testing scenario. The incremental cost-effectiveness ratio was 10,142 €/QALY. The sensitivity analyses carried out confirmed the robustness of the base-case results, being the treatment allocation and the test accuracy (sensitivity and specificity data) the key drivers of the model. CONCLUSIONS ALK testing in advanced NSCLC patients, non-squamous and never-smoker squamous, provides more than 3000 QALYs in Spain over a lifetime horizon. Comparing this gain in health outcomes with the incremental costs, the resulting incremental cost-effectiveness ratio reinforces that testing non-squamous and never-smoker squamous NSCLC is a cost-effective strategy in Spain.
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Affiliation(s)
- Ernest Nadal
- Catalan Institute of Oncology, Hospital Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Spain
| | | | | | | | - Héctor Torres
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | | | - Federico Rojo
- Hospital Universitario Fundacion Jimenez Diaz - CIBERONC, Madrid, Spain
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17
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Arici S, Sakin A, Cekin R, Secmeler S, Yasar N, Cihan S. Does the Waiting Period for Genetic Tests Affect the Prognosis in Chemotherapy-Treated de novo Metastatic Non-Small Cell Lung Cancer Patients without a Driver Mutation? Oncol Res Treat 2020; 44:12-19. [PMID: 33242864 DOI: 10.1159/000511773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/21/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The length of the necessary waiting period to test driver mutations may generate anxiety in patients and clinicians. For this reason, an investigation was conducted to determine whether the duration between diagnosis and the start of first-line chemotherapy (DDC) in non-small cell lung cancer (NSCLC) patients without driver mutations has an impact on prognosis. METHODS The study included 303 de novo metastatic NSCLC patients without a driver mutation and patients were divided into 2 groups according to DDC: ≤30 days (group A) or >30 days (group B). The determinant factors for progression-free survival (PFS) and overall survival (OS) were examined by Cox regression analysis. RESULTS The mean DDC was calculated as 38.2 ± 54.5 days. The number of patients in group A and B were 183 and 120, respectively. The median PFS in groups A and B was 5.0 and 6.0 months (p = 0.268) and the median OS was 10.0 and 11 months, respectively (p = 0.341). Univariate and multivariate analyses revealed that DDC was not a factor associated with PFS and OS. CONCLUSION Our results show that a higher DDC was not associated with a worse prognosis in metastatic NSCLC patients without driver mutations. In this context, it is safer for patients and their physicians to wait for test results before starting chemotherapy.
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Affiliation(s)
- Serdar Arici
- Department of Medical Oncology, University of Health Sciences, Okmeydani Training and Research Hospital, Istanbul, Turkey,
| | - Abdullah Sakin
- Department of Medical Oncology, Yuzuncu Yil University Medical School, Van, Turkey
| | - Ruhper Cekin
- Department of Medical Oncology, University of Health Sciences, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Saban Secmeler
- Department of Medical Oncology, University of Health Sciences, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Nurgül Yasar
- Department of Medical Oncology, University of Health Sciences, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Sener Cihan
- Department of Medical Oncology, University of Health Sciences, Okmeydani Training and Research Hospital, Istanbul, Turkey
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18
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Griesinger F, Eberhardt W, Nusch A, Reiser M, Zahn MO, Maintz C, Bernhardt C, Losem C, Stenzinger A, Heukamp LC, Büttner R, Marschner N, Jänicke M, Fleitz A, Spring L, Sahlmann J, Karatas A, Hipper A, Weichert W, Heilmann M, Sadjadian P, Gleiber W, Grah C, Waller CF, Reck M, Rittmeyer A, Christopoulos P, Sebastian M, Thomas M. Biomarker testing in non-small cell lung cancer in routine care: Analysis of the first 3,717 patients in the German prospective, observational, nation-wide CRISP Registry (AIO-TRK-0315). Lung Cancer 2020; 152:174-184. [PMID: 33358484 DOI: 10.1016/j.lungcan.2020.10.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES An increasing number of treatment-determining biomarkers has been identified in non-small cell lung cancer (NSCLC) and molecular testing is recommended to enable optimal individualized treatment. However, data on implementation of these recommendations in the "real-world" setting are scarce. This study presents comprehensive details on the frequency, methodology and results of biomarker testing of advanced NSCLC in Germany. PATIENTS AND METHODS This analysis included 3,717 patients with advanced NSCLC (2,921 non-squamous; 796 squamous), recruited into the CRISP registry at start of systemic therapy by 150 German sites between December 2015 and June 2019. Evaluated were the molecular biomarkers EGFR, ALK, ROS1, BRAF, KRAS, MET, TP53, RET, HER2, as well as expression of PD-L1. RESULTS In total, 90.5 % of the patients were tested for biomarkers. Testing rates were 92.2 % (non-squamous), 70.7 % (squamous) and increased from 83.2 % in 2015/16 to 94.2% in 2019. Overall testing rates for EGFR, ALK, ROS1, and BRAF were 72.5 %, 74.5 %, 66.1 %, and 53.0 %, respectively (non-squamous). Testing rates for PD-L1 expression were 64.5 % (non-squamous), and 58.5 % (squamous). The most common testing methods were immunohistochemistry (68.5 % non-squamous, 58.3 % squamous), and next-generation sequencing (38.7 % non-squamous, 14.4 % squamous). Reasons for not testing were insufficient tumor material or lack of guideline recommendations (squamous). No alteration was found in 37.8 % (non-squamous), and 57.9 % (squamous), respectively. Most common alterations in non-squamous tumors (all patients/all patients tested for the respective biomarker): KRAS (17.3 %/39.2 %), TP53 (14.1 %/51.4 %), and EGFR (11.0 %/15.1 %); in squamous tumors: TP53 (7.0 %/69.1 %), MET (1.5 %/11.1 %), and EGFR (1.1 %/4.4 %). Median PFS (non-squamous) was 8.7 months (95 % CI 7.4-10.4) with druggable EGFR mutation, and 8.0 months (95 % CI 3.9-9.2) with druggable ALK alterations. CONCLUSION Testing rates in Germany are high nationwide and acceptable in international comparison, but still leave out a significant portion of patients, who could potentially benefit. Thus, specific measures are needed to increase implementation.
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Affiliation(s)
- Frank Griesinger
- Pius-Hospital Oldenburg, Universitätsklinik für Innere Medizin, Oldenburg, Germany.
| | - Wilfried Eberhardt
- Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätszentrum Essen, Germany
| | - Arnd Nusch
- Praxis für Hämatologie und internistische Onkologie, Ratingen, Germany
| | - Marcel Reiser
- PIOH - Praxis internistische Onkologie und Hämatologie, Köln, Germany
| | | | | | | | - Christoph Losem
- MVZ für Onkologie und Hämatologie im Rhein-Kreis, Neuss, Germany
| | | | - Lukas C Heukamp
- Hämatopathologie Hamburg, Hamburg, Germany; Lungen Netzwerk NOWEL.org, Oldenburg, Germany
| | - Reinhard Büttner
- Institut für Pathologie des Universitätsklinikums Köln, Köln, Germany
| | - Norbert Marschner
- Praxis für interdisziplinäre Onkologie und Hämatologie, Freiburg, Germany
| | - Martina Jänicke
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Annette Fleitz
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Lisa Spring
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | | | | | | | - Wilko Weichert
- Institut für Pathologie, Technische Universität München und German Cancer Consortium (DKTK), partner site Munich, München, Germany
| | | | - Parvis Sadjadian
- Universitätsklinik für Hämatologie, Onkologie, Hämostaseologie und Palliativmedizin, Johannes Wesling Klinikum, Universitätsklinikum der Ruhr Universität Bochum, Minden, Germany
| | - Wolfgang Gleiber
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Schwerpunkt Pneumologie/Allergologie, Frankfurt, Germany
| | - Christian Grah
- MVZ Havelhöhe am Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Cornelius F Waller
- Medizinische Klinik I, Hämatologie, Onkologie und Stammzelltransplantation; Fakultät für Medizin, Universitätsklinikum Freiburg, Germany
| | - Martin Reck
- LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | | | - Petros Christopoulos
- Onkologie der Thoraxtumore, Thoraxklinik Heidelberg gGmbH, German Center for Lung Research (DZL), Germany
| | - Martin Sebastian
- Medizinische Klinik II, Hämatologie/Onkologie, Universitätsklinikum Frankfurt, Germany
| | - Michael Thomas
- Onkologie der Thoraxtumore, Thoraxklinik Heidelberg gGmbH, German Center for Lung Research (DZL), Germany
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John A, Shah RA, Wong WB, Schneider CE, Alexander M. Value of Precision Medicine in Advanced Non-Small Cell Lung Cancer: Real-World Outcomes Associated with the Use of Companion Diagnostics. Oncologist 2020; 25:e1743-e1752. [PMID: 32627882 PMCID: PMC7648341 DOI: 10.1634/theoncologist.2019-0864] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 06/18/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Companion diagnostic (CDx) testing for patients with advanced non-small cell lung cancer (aNSCLC) identifies patients more likely to benefit from biomarker-driven treatments. METHODS Patients with nonsquamous cell (non-Sq) aNSCLC from the Flatiron Health database (diagnosed January 1, 2011-May 31, 2018) who had CDx testing were compared with those who had no reported evidence of testing. The association between CDx testing and overall survival was evaluated by unadjusted and adjusted Cox proportional hazards regression models. Logistic regression analysis identified characteristics associated with CDx testing. The revised modified Lung Cancer Prognostic Index and other factors identified a priori were included in the adjusted models. RESULTS A total of 17,555 patients with non-Sq aNSCLC (CDx, n = 14,732; no CDx, n = 2,823) with mean ± SD age of 67.2 ± 10.0 years were included. Most were insured (91.7%) and white (67.1%). Asian patients and those who were never-smokers were more likely to undergo CDx testing. Those with CDx testing lived longer than those without (median [95% confidence interval (CI)] survival, 13.04 [12.62-13.40] vs. 6.01 [5.72-6.24] months) and had a decreased mortality risk (adjusted hazard ratio [95% CI], 0.72 [0.69-0.76]). A survival advantage was also seen for patients with CDx testing who received biomarker-driven first-line therapy. CONCLUSION Patients with non-Sq aNSCLC who had CDx testing had a greater survival benefit than those without, supporting broader use of CDx testing in routine clinical practice to identify patients more likely to benefit from precision medicine. IMPLICATIONS FOR PRACTICE Companion diagnostic (CDx) testing coupled with biomarker-driven treatment offers a greater survival benefit for patients with advanced non-small cell lung cancer (aNSCLC). In this study, patients with nonsquamous aNSCLC from Flatiron Health, a large, real-world oncology database, with CDx testing had a reduced mortality risk and lived longer than patients without reported evidence of CDx testing; those who received biomarker-driven therapy as their first line of treatment were likely to survive three times longer than those who did not. These results demonstrate the clinical utility of CDx testing as the first step in treating nonsquamous aNSCLC in real-world clinical practice.
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Affiliation(s)
- Ani John
- Roche Diagnostics Information SolutionsPleasanton, CaliforniaUSA
| | - Roma A. Shah
- Roche Diagnostics Information SolutionsPleasanton, CaliforniaUSA
| | | | | | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of Oncology, University of MelbourneVictoriaAustralia
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20
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Mendoza DP, Piotrowska Z, Lennerz JK, Digumarthy SR. Role of imaging biomarkers in mutation-driven non-small cell lung cancer. World J Clin Oncol 2020; 11:412-427. [PMID: 32821649 PMCID: PMC7407925 DOI: 10.5306/wjco.v11.i7.412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/31/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023] Open
Abstract
Lung cancer remains the leading cause of cancer-related deaths worldwide. The treatment of non-small cell lung cancer (NSCLC), which accounts for a vast majority of lung cancers, has shifted to personalized, targeted therapy following discoveries of several targetable oncogenic mutations. Targeting of specific mutations has improved outcomes in many patients. This success has led to several target-specific agents replacing chemotherapy as first-line treatment in certain mutated NSCLC. Several researchers have reported that there may be imaging biomarkers that may be predictive of the presence of these mutations. These features, when present, have the potential in triaging patients into the most appropriate diagnostic and treatment algorithms. Distinct imaging features and patterns of metastases that have been associated with NSCLC with various targetable oncogenic mutations are presented in this review.
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Affiliation(s)
- Dexter P Mendoza
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Zofia Piotrowska
- Massachusetts General Hospital Cancer Center and Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Jochen K Lennerz
- Center for Integrated Diagnostics, Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Subba R Digumarthy
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, United States
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21
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Rajurkar S, Mambetsariev I, Pharaon R, Leach B, Tan T, Kulkarni P, Salgia R. Non-Small Cell Lung Cancer from Genomics to Therapeutics: A Framework for Community Practice Integration to Arrive at Personalized Therapy Strategies. J Clin Med 2020; 9:E1870. [PMID: 32549358 PMCID: PMC7356243 DOI: 10.3390/jcm9061870] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease, and therapeutic management has advanced with the identification of various key oncogenic mutations that promote lung cancer tumorigenesis. Subsequent studies have developed targeted therapies against these oncogenes in the hope of personalizing therapy based on the molecular genomics of the tumor. This review presents approved treatments against actionable mutations in NSCLC as well as promising targets and therapies. We also discuss the current status of molecular testing practices in community oncology sites that would help to direct oncologists in lung cancer decision-making. We propose a collaborative framework between community practice and academic sites that can help improve the utilization of personalized strategies in the community, through incorporation of increased testing rates, virtual molecular tumor boards, vendor-based oncology clinical pathways, and an academic-type singular electronic health record system.
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Affiliation(s)
| | | | | | | | | | | | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (S.R.); (I.M.); (R.P.); (B.L.); (T.T.); (P.K.)
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22
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Sheinson D, Wong WB, Wu N, Mansfield AS. Impact of delaying initiation of anaplastic lymphoma kinase inhibitor treatment on survival in patients with advanced non-small-cell lung cancer. Lung Cancer 2020; 143:86-92. [PMID: 32276206 DOI: 10.1016/j.lungcan.2020.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/24/2020] [Accepted: 03/05/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Several obstacles may delay receipt of targeted treatment in patients with anaplastic lymphoma kinase positive (ALK+) non-small-cell lung cancer (NSCLC). This study examined the factors associated with delayed initiation of ALK inhibitor (ALKi) treatment and its impact on overall survival (OS) as well as the impact of initiating chemotherapy before biomarker test results. MATERIALS AND METHODS Advanced NSCLC (aNSCLC) patients selected from the deidentified Flatiron Health electronic health record-derived database were stratified into early- and delayed-use cohorts based on initiation of ALKi treatment relative to time since receiving ALK+ biomarker test results; cohorts were further stratified by timing of chemotherapy initiation relative to availability of ALK+ test results. Prescription-time matching (PTM) was used to examine the effect of delayed ALKi treatment and chemotherapy on survival; Cox proportional hazards models adjusting for baseline characteristics before and after PTM were used to examine factors associated with delayed ALKi treatment and the effects of delayed ALKi treatment and chemotherapy on OS, respectively. RESULTS Comparison of OS between early- and delayed-use cohorts (N = 442 ALK + aNSCLC patients) demonstrated that a >3-week delay in the initiation of ALKi treatment was associated with a >2-fold higher risk of death (adjusted hazard ratio [HR] [95 % CI] 2.05 [1.13, 3.71]. The number of office visits, age factors, and use of chemotherapy were associated with an increased risk of being untreated >3 weeks after ALK+ test results. There were no significant differences in survival outcomes regardless of whether patients received chemotherapy before the ALK+ test result or ALKi treatment (adjusted HR [95 % CI] 1.02 [0.64, 1.63]). Completing the chemotherapy regimen after receiving ALK+ test results did not appear to improve survival (adjusted HR [95 % CI] 0.84 [0.38, 1.9]). CONCLUSION Initiating ALKi treatment for aNSCLC patients in a timely manner may have a positive impact on survival outcomes.
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Affiliation(s)
| | | | - Ning Wu
- Genentech, South San Francisco, CA, United States
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