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Spees LP, Wheeler SB, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Leapman M, Gross CP, Dinan MA. Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma. Cancer Med 2021; 10:6653-6665. [PMID: 34480518 PMCID: PMC8495289 DOI: 10.1002/cam4.4201] [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: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/25/2023] Open
Abstract
Background Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC). Methods We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence. Results Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87). Conclusions Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Bradford E Jackson
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA.,Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, North Carolina, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Deborah R Kaye
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Tian Zhang
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Daniel George
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Michael Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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Borrelli EP, McGladrigan CG. Five Year Analysis Assessing the Trend in Prescribing and Expenditures of Oral Oncolytics for Medicare Part D: 2013-2017. J Pharm Pract 2021; 35:580-586. [PMID: 33722080 DOI: 10.1177/08971900211000208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Oral oncolytics are becoming a mainstay in oncology, representing first-line therapies for numerous different malignancies. In addition, the cost of oncology drugs has increased dramatically in recent years. Given the increasing number of oral oncolytics available, as well as the increase in medication costs in recent years, it is important to assess the trend in prescriptions and expenditures of these agents. METHODS A descriptive retrospective analysis of the Medicare Part D Provider Utilization and Payment Data Public Use File (PUF) was conducted for the years 2013 through 2017. Outcomes of interest included total aggregate prescriptions per year, total aggregate expenditures per year, mean expenditure per prescription per year, and mean expenditure per standardized 30-day prescription per year. Chi-square tests were conducted to assess statistical significance of differences in proportions of prescriptions as well as expenditures between 2013 and 2017. RESULTS The number of prescriptions for oral oncolytics dispensed to Medicare Part D beneficiaries increased from 7,017,902 in 2013 to 8,164,883 in 2017. Medicare Part D expenditures for oral oncolytics increased greater than 2.5-fold from $5,631,224,307 in 2013 to $14,422,681,331 in 2017 after adjusting for inflation. The mean expenditure per prescription for oral oncolytics increased from $802 in 2013 to $1,766 in 2017. CONCLUSIONS This study found oral oncolytic utilization has been increasing in recent years with a slight, but statistically significant increase in the proportion of oncolytics for all Medicare prescriptions from 2013 through 2017.
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Affiliation(s)
- Eric P Borrelli
- University of Rhode Island College of Pharmacy, Kingston, RI, USA
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Han J, Li Q, Li P, Wang S, Zhang R, Qiao Y, Song Q, Fu Z. Reassessment of American Joint Committee on Cancer Staging for Stage III Renal Cell Carcinoma With Nodal Involvement: Propensity Score Matched Analyses of a Large Population-Based Study. Front Oncol 2020; 10:365. [PMID: 32266145 PMCID: PMC7096477 DOI: 10.3389/fonc.2020.00365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 03/02/2020] [Indexed: 11/24/2022] Open
Abstract
Background: To assess the role of nodal involvement in stage III renal cell carcinoma (RCC) according to the American Joint Committee on Cancer (AJCC) 8th staging system. We compared the survival outcomes of RCC patients with pT1-3N1M0 disease and those with pT3N0M0 or stage IV (stratified as pT4NanyM0 and pTanyNanyM1) disease in a large population-based cohort. Methods: A cohort of 3,112 eligible patients with RCC was identified from the Surveillance, Epidemiology, and End Results (SEER) database, registered between January 2004 and December 2015. Kaplan-Meier and Cox proportional hazards models were used to evaluate the overall survival (OS), and cancer-specific survival (CSS). The prognostic value of the modified stage for pT1-3N1M0 disease was assessed by nomogram-based analyses. Propensity score matching (PSM) was used to adjust for potential baseline confounding. Results: Patients with pT1-3N1M0 disease showed similar survival outcomes (median OS 41.0 vs. 38.0 months, P = 0.77; CSS 45.0 vs. 39.0 months, P = 0.59) to pT4NanyM0 patients, whereas the significantly better survival outcome was found for pT3N0M0 patients. After PSM, comparable survival rates were observed between pT1-3N1M0 group and pT4NanyM0 group, which were still significantly worse than the survival of pT3N0M0 patients. The modified stage IIIA (pT3N0M0), IIIB (pT1-3N1M0, pT4NanyM0), and IV (pTanyNanyM1) showed higher predictive accuracy than AJCC stage system in the nomogram-based analyses (concordance index: 0.70 vs. 0.68, P < 0.001 for OS; 0.71 vs. 0.69, P < 0.001 for CSS). Conclusions: The pT1-3N1M0 RCC might be reclassified as stage IIIB together with pT4NanyM0 disease for better prediction of prognosis, further examination and validation are warranted.
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Affiliation(s)
| | | | | | | | | | | | | | - Zhenming Fu
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
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Pal S, Gong J, Mhatre SK, Lin SW, Surinach A, Ogale S, Vohra R, Wallen H, George D. Real-world treatment patterns and adverse events in metastatic renal cell carcinoma from a large US claims database. BMC Cancer 2019; 19:548. [PMID: 31174493 PMCID: PMC6555983 DOI: 10.1186/s12885-019-5716-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/14/2019] [Indexed: 02/02/2023] Open
Abstract
Background Vascular endothelial growth factor (VEGF), tyrosine kinase (TK) and mechanistic target of rapamycin kinase (mTOR) inhibitors are common first-line (1 L) treatments for metastatic renal cell carcinoma (mRCC). Despite treatment availability, the 5-year survival rate in patients diagnosed at the metastatic stage is only ≈ 10%. To gain contemporary insights into RCC treatment trends that may inform clinical, scientific and payer considerations, treatment patterns and adverse events (AEs) associated with 1 L therapy were examined in a retrospective, longitudinal, population-based, observational study of patients with mRCC. Methods US administrative claims data (Truven Health MarketScan Commercial Databases) were used to assess trends in 1 L treatment initiation in mRCC (2006–2015) and characterize patterns of individual 1 L treatments, baseline characteristics, comorbidities and treatment-related AEs from 2011 through 2015. Outcomes were evaluated by drug class and route of administration. Results Ten-year trend analysis (n = 4270) showed that TK/VEGF-directed therapy rapidly became more common than mTOR-directed therapy, and oral treatments were favored over intravenous (IV) treatments. Overall, 1992 eligible patients initiated 1 L treatment for mRCC from 2011 through 2015: 1752 (88%) received TK/VEGF-directed agents and 233 (12%) received mTOR-directed agents; 1674 (84%) received oral treatments, and 318 (16%) received IV treatments. The most common 1 L treatment was sunitinib (n = 849), followed by pazopanib (n = 631), temsirolimus (n = 157) and bevacizumab (n = 154). Patient characteristics and comorbidities, including age, diabetes and congestive heart failure, were independent predictors of 1 L mRCC treatment choice. The three most common potentially 1 L treatment–related AEs were nausea/vomiting (128.2 per 100 patient-years [PY]), hypertension (69 per 100 PY) and renal insufficiency (44.6 per 100 PY). A wide variety of agents were used as second-line (2 L) therapy. Substantial latency of onset was observed for several potentially treatment-related toxicities in patients treated with TK/VEGF- or mTOR-directed agents. Conclusions In the US, 1 L TK/VEGF inhibitor uptake in recent years appears largely in line with national approvals and guidelines, with varied 2 L agent use. Although retrospective evaluation of claims data cannot assess underlying causality, insights from these real-world RCC treatment and AE patterns will be useful in informing medical and payer decisions. Electronic supplementary material The online version of this article (10.1186/s12885-019-5716-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sumanta Pal
- Department of Medical Oncology and Experimental Therapeutics, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA.
| | - Jun Gong
- Department of Hematology/Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Shivani K Mhatre
- Real World Data Science (Oncology), Genentech, Inc, 1 DNA Way, MS 352B, South San Francisco, CA, 94080, USA
| | - Shih-Wen Lin
- Real World Data Science (Oncology), Genentech, Inc, 1 DNA Way, MS 352B, South San Francisco, CA, 94080, USA
| | - Andy Surinach
- Genesis Research, 5 Marine View Plaza, Hoboken, NJ, 07030, USA
| | - Sarika Ogale
- US Medical Affairs, Genentech, Inc, 1 DNA Way, MS 352B, South San Francisco, CA, 94080, USA
| | - Rini Vohra
- School of Pharmacy, West Virginia University, P.O. Box 9500, Morgantown, WV, 26506, USA
| | - Herschel Wallen
- Oncology and Hematology Care Clinic, Providence Cancer Center, 4805 NE Glisan Street, Suite 6N40, Portland, OR, 97213, USA
| | - Daniel George
- Department of Medicine, Medical Oncology, Duke University School of Medicine, Box 103861, Durham, NC, 27710, USA
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Shao N, Wang HK, Zhu Y, Ye DW. Modification of American Joint Committee on cancer prognostic groups for renal cell carcinoma. Cancer Med 2018; 7:5431-5438. [PMID: 30306741 PMCID: PMC6247054 DOI: 10.1002/cam4.1790] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022] Open
Abstract
Background To compare the predictive value of the current AJCC stage grouping for renal cell carcinoma (RCC) to our modifications. Patients and methods A total of 2120 patients with RCC from Fudan University Shanghai Cancer Center (FUSCC) database and 74 506 counterparts from SEER database were included. Cox regression was used to calculate the relative impacts between prognostic groups. The predictive accuracy of overall survival (OS) was assessed using the concordance index (C‐index), which was compared by likelihood ratio test. Results In FUSCC cohort, the 5‐year‐OS rate for T3N0M0 patients was higher than T1‐3N1M0 (72.7% vs 38.1%). The 5‐year‐OS rate for T4N0M0 was 36.2%, which was close to T1‐3N1M0 but not to T4N1M0 (0%) and TanyNanyM1 (12.6%). The elements of AJCC groups were regrouped according to the ranks of hazard ratios. The modified stages II (T3N0M0), III (T1‐3N1M0, T4N0M0), and IV (T4N1M0, TanyNanyM1) exhibited greater survival stratification than AJCC groups. The modifications were validated in SEER cohort and yielded similar survival outcomes. The predictive accuracy of OS in modified prognostic groups was significantly higher than AJCC groups in stages II‐IV subgroups in both FUSCC (C‐index: 0.801 vs 0.779, P < 0.001) and SEER cohort (C‐index: 0.770 vs 0.764, P < 0.001). Conclusions The modified AJCC prognostic groups for RCC provided significantly improved survival prediction compared with the 8th AJCC edition. A precise risk stratification of modified stages II‐IV disease provides an important basis for risk‐equivalent treatment recommendation.
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Affiliation(s)
- Ning Shao
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hong-Kai Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yao Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ding-Wei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Gao X, McDermott DF. Ipilimumab in combination with nivolumab for the treatment of renal cell carcinoma. Expert Opin Biol Ther 2018; 18:947-957. [PMID: 30124333 PMCID: PMC6289271 DOI: 10.1080/14712598.2018.1513485] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/15/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Renal cell carcinoma (RCC) is a highly immunogenic neoplasm, and cytokine-based immunotherapies have been used for decades with limited success. In recent years, antibody-based immunotherapies targeting immune checkpoint receptors PD-1 and CTLA-4 have demonstrated clinical efficacy in metastatic RCC (mRCC) patients, leading to FDA approval of the combination of nivolumab and ipilimumab in treatment-naïve patients with intermediate- or poor-risk disease in April 2018. Areas covered: The pharmacodynamics and pharmacokinetics of nivolumab and ipilimumab are reviewed. Clinical safety and efficacy results from pivotal phase I and III trials of the combination of nivolumab plus ipilimumab in mRCC are summarized, and the combination is reviewed in the context of other available systemic therapies for RCC. Ongoing clinical studies involving the combination of nivolumab plus ipilimumab in RCC are discussed. Expert opinion: The combination of nivolumab and ipilimumab has demonstrated superior efficacy for treatment-naïve patients with intermediate- and poor-risk mRCC with clear cell histology and is likely to replace anti-angiogenic therapies as the treatment-of-choice in this patient population in the United States. Development of additional combination strategies, novel trial designs, and predictive biomarkers of response will be important to further optimize therapeutic selection and clinical outcomes.
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Affiliation(s)
- Xin Gao
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - David F McDermott
- b Biologic Therapy and Cutaneous Oncology Programs , Beth Israel Deaconess Medical Center , Boston , MA , USA
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Hilar fat infiltration: A new prognostic factor in metastatic clear cell renal cell carcinoma with first-line sunitinib treatment. Urol Oncol 2017; 35:603.e7-603.e14. [PMID: 28619630 DOI: 10.1016/j.urolonc.2017.05.015] [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: 11/25/2016] [Revised: 05/13/2017] [Accepted: 05/20/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The selection of patients with metastatic clear cell renal cell carcinoma (ccRCC) who may benefit from targeted tyrosine kinase inhibitors has been a challenge, even more so now with the advent of new therapies. Hilar fat infiltration (HFI) is a validated prognostic factor in nonmetastatic ccRCC (TNM 2009 staging system) but has never been studied in metastatic patients. We aimed to assess its phenotype and prognostic effect in patients with metastatic ccRCC treated with first-line sunitinib. MATERIALS AND METHODS In a multicentric study, we retrospectively included 90 patients and studied the corresponding ccRCC at the pathological, immunohistochemical, and molecular levels. Patient and tumor characteristics were compared using univariate and multivariate analysis. All the features were then studied by Cox models for prognostic effect. RESULTS HFI was found in 42 patients (46.7%), who had worse prognosis (Heng criteria) (P = 0.003), liver metastases (P = 0.036), and progressive diseases at first radiological evaluation (P = 0.024). The corresponding ccRCC was associated with poor pathological prognostic factors that are well known in nonmetastatic ccRCC. For these patients, median progression-free survival was 4 months vs. 13 months (P = 0.02), and median overall survival was 14 months vs. 29 months (P = 0.006). In a multivariate Cox model integrating all the variables, only poor prognosis, according to the Heng criteria and HFI, remained independently associated with both progression-free survival and overall survival. CONCLUSION HFI was demonstrated for the first time to be an independent poor prognostic factor. Its potential role in predicting resistance to antiangiogenic therapy warrants further investigation.
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