Availability, Affordability, Access, and Pricing of Anti-cancer Medicines in Low- and Middle-Income Countries: A Systematic Review of Literature

Optimising Cancer Medicine in Clinical Practices: Are Neoadjuvant and Adjuvant Immunotherapies Affordable for Cancer Patients in Low- and Middle-Income Countries?

Cancer immunotherapy, encompassing neoadjuvant and adjuvant interventions, has transformed treatment paradigms in multiple malignancies by leveraging the host immune system to combat tumour cells. While immunotherapies have demonstrated remarkable efficacy, particularly immune checkpoint inhibitors, high treatment costs undermine their accessibility and affordability in low- and middle-income countries (LMICs). This paper provides a prospective overview of the clinical benefits of neoadjuvant and adjuvant immunotherapies, examines the barriers to implementing these treatments in LMICs, and suggests potential strategies to improve equitable access. Such interventions necessitate a combined effort from healthcare providers, policymakers, and stakeholders to ensure their sustainable integration into global cancer care.

Dosing immune-checkpoint inhibitors: Opportunities for the future

With recent breakthroughs in immunotherapy, particularly with the approval of immune checkpoint inhibitors for various cancer indications, patients now have a wider array of treatment options, even for those with metastatic disease. Still, the survival benefit of immune-checkpoint inhibitors is modest, and there is concern about drug toxicity. In addition, there is ongoing exploration into combination therapy involving immune-checkpoint inhibitors, which come at the risk of increased toxicity. Unfortunately, due to the cost of the currently approved doses and dosing intervals, many patients in the community in the United States and low- and middle-income countries lack access to these transformative therapies. Further, the observation of resistance to immune-checkpoint inhibitors and limitations of currently approved doses and dosing intervals warrants changes in current practice. This review paper discusses both model-based and clinical studies in the current literature. Strategies for improving access to immune-checkpoint inhibitors and expanding their utilization, including weight-based dosing instead of fixed dosing, dose and dose interval adjustments, development of biomarkers and scoring systems for personalization of immune-checkpoint inhibitors, and alternative trial design, are discussed.

Supply-side and demand-side factors affecting allopathic primary care service delivery in low-income and middle-income country cities

Most people in low-income and middle-income countries (LMICs) now live in cities, as opposed to rural areas where access to care and provider choice is limited. Urban health-care provision is organised on very different patterns to those of rural care. We synthesise global evidence to show that health-care clinics are plentiful and easily accessible in LMIC cities and that they are seldom overcrowded. The costs that patients incur when they seek care are highly variable and driven mostly by drugs and diagnostics. We show that citizens have agency, often bypassing cheaper facilities to access preferred providers. Primary care service delivery in cities is thus best characterised as a market with a diverse range of private and public providers, where patients make active choices based on price, quality, and access. However, this market does not deliver high-quality consultations on average and does not provide continuity or integration of services for preventive care or long-term conditions. Since prices play a key role in accessing care, the most vulnerable groups of the urban population often remain unprotected.

Challenges and opportunities in ovarian cancer care: A qualitative study of clinician perspectives from 24 low- and middle-income countries

BACKGROUND

Ovarian cancer poses a significant and growing burden, particularly in low- and middle-income countries (LMICs) where incidence and mortality are projected to increase by over 50 % by 2050. However, there is a critical lack of qualitative data on the challenges and opportunities for improvement in treatment and care for women with ovarian cancer in these regions. The aim of this research is to investigate clinicians' perspectives on the matter in 24 LMICs.

METHODS

As part of the multi-country observational Every Woman Study™ (EWS), semi-structured interviews were conducted with clinicians between June 2022 and June 2023. The interview guide was developed by the EWS LMIC Oversight Committee, including patients, clinicians and data specialists. Relational content and inductive thematic analyses were employed and categories synthesized using the World Health Organization's six building blocks of the Health Systems Framework.

RESULTS

24 clinicians (54 % female; 79 % gynaecologic oncologists, 8 % gynaecologists, 8 % clinical oncologists not specializing in gynaecological cancers, and 4 % clinical oncologists specializing in gynaecological cancers; 42 % from Africa, 29 % from Asia, 29 % from Latin America) participated. Six dominant themes were identified: "Poor Ovarian Cancer Data'', "Inequity in Access to Treatment", "In-Country Inequities in Access to Care", "Role of Cultural Norms on Women's Health", "Increased Engagement of Men in Ovarian Cancer Control", and "Advocacy and Education for Empowering Women". Content analysis revealed system-level challenges such as delayed drug payments, lack of population-based cancer data, and limited imaging facilities. Patient-level challenges included disparities in access to specialists, limited medication affordability, poor symptom recognition, and reliance on alternative treatments.

CONCLUSIONS AND POLICY SUMMARY

This study reveals the complexity of ovarian cancer treatment and care in LMICs and the need to mitigate disparities in these regions, underscoring the need for patient-centred, context specific and intersectoral strategies to be considered in cancer planning to improve ovarian cancer care quality and equity in LMICs.

Next-generation cancer nanotherapeutics: Pluronic® F127 based mixed micelles for enhanced drug delivery

Cancer, projected to become the second leading cause of mortality globally, underscores the critical need for precise drug delivery systems. Nanotechnology, particularly micelles, has emerged as a promising avenue. These nano-sized colloidal dispersions (< 100 nm) utilize amphiphilic molecules featuring a hydrophilic tail and hydrophobic core, facilitating efficient drug encapsulation and delivery. Pluronic® F127, a triblock copolymer (PEO101-PPO56-PEO101), has emerged as a promising drug carrier due to its non-ionic, less-toxic nature, which prolongs drug circulation time and improves drug delivery across blood-brain and intestinal barriers. Mixed micelles, formed using Pluronic® F127 combined with other polymers, surfactants, and drugs, enhance drug solubility, stability, and targeted delivery. This review highlights the key features of mixed micelles, including enhanced pharmacokinetics and targeting abilities, folic acid (FA) conjugation strategies, superior cytotoxicity with reduced side effects, overcoming multidrug resistance, and versatility across various cancer types and compounds. Additionally, the potential for clinical translation of Pluronic® F127-based mixed micelle in cancer treatment is discussed, addressing current challenges and paving the way for optimized applications.

Harnessing the anticancer potential of Piper nigrum: a synergistic approach to chemotherapy enhancement and reduced side effects

Cancer therapy continues to face critical challenges, including drug resistance, recurrence, and severe side effects, which often compromise patient outcomes and quality of life. Exploring novel, cost-effective approaches, this review highlights the potential of Piper nigrum (black pepper) extract (PNE) as a complementary anticancer agent. Piper nigrum, a widely available spice with a rich history in traditional medicine, contains bioactive compounds such as piperine, which have demonstrated significant anticancer activities including cell cycle arrest, apoptosis induction, and inhibition of tumor growth and metastasis. The review evaluates the recent findings from in vitro, in vivo, and clinical studies, emphasizing PNE's capacity to enhance the efficacy of conventional chemotherapeutic agents while mitigating their side effects. Key mechanisms underlying these effects include oxidative stress modulation, suppression of pro-metastatic factors, and synergistic interactions with established drugs like doxorubicin and paclitaxel. These interactions suggest that PNE could play a pivotal role in overcoming chemoresistance and improving therapeutic outcomes. Furthermore, this review highlights the potential benefits of PNE in resource-limited settings, where the cost of cancer treatments often restricts access. However, challenges such as compositional variability, limited bioavailability, and the need for standardization and clinical validation need to be addressed to advance the integration of PNE into basic oncology. By providing a comprehensive analysis of the anticancer mechanisms of PNE and its potential as a cost-effective adjuvant therapy, this review provides new insight into the exploitation of Piper nigrum to improve cancer treatment efficacy while reducing side effects. Future research directions are discussed to address current limitations and facilitate clinical translation.

Global disparities in cancer care: Bridging the gap in affordability and access to medications between high and low-income countries

BACKGROUND

Cancer remains a significant challenge for health care systems, despite notable progress in the field. These advancements have significant financial implications that disproportionately affect low-income countries. This review article aims to explore the present state of drug development, assessing the availability of drugs in different income countries, and proposing potential solutions to address the inequality in access to new cancer treatments.

METHODS

A search was conducted on MEDLINE and PubMed on October 2, 2023 and updated on December 14, 2023, limited to English language articles.

RESULTS

There is a projected rise in cancer cases worldwide, particularly in low-income countries where most cancer-related deaths are expected. Although the approval rate of cancer treatments has risen, their excessive cost and lack of affordability pose significant barriers to widespread access. Disparities in the costs of crucial cancer medications are influenced by geographic location and procurement connections. Potential solutions to address the inequity in drug distribution include sharing production secrets, implementing price discrimination, international funding, improved primary health care measures, and the implementation of cost-effective screening methods.

CONCLUSION

Preventing, screening for, and treating cancer should be a global priority with minimal differences in access to therapy among various countries.

A novel social-network-analysis-based approach for analyzing complex network of actors involved in accessibility of anti-cancer medications in Iran

BACKGROUND

The access to anti-cancer medications is influenced by policies formed via the convergence of various stakeholders. The aim of this study is to identify and analyse the stakeholders involved in formulating and implementing policies related to the accessibility of anti-cancer medications in Iran and their interactions that are relevant to the outcomes of these policies for the first time.

METHODS

To achieve the objectives, a novel multistage social network analysis (SNA)-based approach that includes three phases is proposed. First, the actors were identified by a team consisting of multidisciplinary knowledgeable experts through 15 comprehensive interviews. Then, the influence relationships of these actors were comprehensively analysed through in-depth interviews with nine key informants involved in pharmaceutical policies through a structured questionnaire. Finally, a novel network of actors was determined accordingly, and a SNA-based approach proposed to reveal the intrinsic roles and various aspects of the importance of the network's actors.

RESULTS

The study identified a total of 45 actors, which were then classified into 4 categories on the basis of their public or private nature and their foreign or domestic origin. This established network helped in creating a comprehensive view of the main actors, and can help policymakers to solve the problems related to access to anti-cancer medications more effectively and prevent the creation of these problems in the future. In this way, the network identified specific actors that can benefit from increased attention and dialogue. The computational results revealed that the Iran Food and Drug Administration (IFDA), Pharmaceutical Importer Companies (PharIc) and Pharmaceutical Manufacturing Companies (PharMC) were highly important actors in terms of their connectivity to other actors. Additionally, law enforcement agencies (LEA) have shown limited effectiveness within this network.

CONCLUSIONS

This study highlights the importance of complex relationships among various actors and proposes a novel SNA-based approach to analyse them. Regarding the main steps of the proposed approach and the findings, it is imperative for pharmaceutical policy plans to involve a diverse group of experts from the beginning, prioritizing the preferences of stakeholders, and providing a patient-centred approach to prevent the worsening of resource shortages.

Patients' perception on quality of care for prostate cancer at tertiary hospitals in Tanzania: a qualitative study

Background

Prostate cancer is a common cancer among men globally and its treatment affects quality of life. Poor patients' perception of prostate cancer services may lead to their late presentation for care, often presenting with the advanced stage of the disease. This may vary from one region to another.

Objective

This study, therefore, aimed to explore patients' perceptions of the quality of care for prostate cancer in Tanzania.

Methods

This qualitative case study was conducted in five tertiary hospitals in Tanzania in November 2023. In-depth interviews were conducted with prostate cancer patients on treatment for not less than 6 months. Data on patients' perception of prostate cancer, quality of prostate cancer services, and quality of life among prostate cancer patients were collected. Thematic analysis used a hybrid inductive and deductive reasoning approach through NVivo 14 software.

Results

A total of 17 interviews were conducted, resulting in four themes. These were perception of prostate cancer on the causes and diagnostic methods, delays of care leading to late presentation, perception of quality of life after treatment for prostate cancer recovery versus cancer progression, and quality of service in terms of organization of service delivery for prostate cancer at tertiary hospitals in Tanzania.

Conclusion

Quality of services for prostate cancer was well-perceived, especially communication for psychosocial support. A good perception of the quality of service was found to influence the uptake of prostate cancer services. Prostate cancer patients have mixed perceptions about the quality of life after treatment, which delays health seeking, leading to late presentation. Despite efforts in awareness campaigns through different platforms, more effort is needed in determining the causes of prostate cancer, the diagnostic/screening methods necessary for prostate cancer, timely health seeking, the available treatment options for prostate cancer, and the expected quality of life after treatment.

Global Disparities in the Characteristics and Outcomes of Leukemia Clinical Trials: A Cross-Sectional Study of the ClinicalTrials.gov Database

PURPOSE

Most clinical trials are conducted exclusively in high-income countries (HICs), with only a small fraction involving centers from low-middle income countries (LMICs). However, studies evaluating the global distribution of clinical trials in leukemia are limited. Therefore, we sought to assess the present state of leukemia clinical trials that involve centers from LMICs and to compare those with trials conducted exclusively in HICs.

MATERIALS AND METHODS

We searched ClinicalTrials.gov to identify leukemia trials initiated between 2000 and 2020. In this cross-sectional study, the search strategy was developed by a medical librarian using controlled vocabulary and free-text terms. Data abstraction was independently executed by two reviewers. Trials were defined to be LMIC trials if they included centers from LMICs according to the World Bank Atlas country's income level classification for 2022-2023. Conversely, if a trial included centers from HICs only, the study was classified as a HIC trial.

RESULTS

Of 3,345 leukemia-related clinical trials identified, only 160 (4.8%) included centers from LMICs. Compared with HIC trials, LMIC trials had lower termination rates (12.5% v 27.5%; P < .001) and were more likely randomized (52.5% v 18.2%; P < .001), larger (sample sizes >50 patients: 69.0% v 33.6%; P < .001), multicenter (81.9% v 47.9%; P < .001), and later phase (phase III: 36.2% v 8.98%; P < .001; phase IV: 6.25% v 2.17%; P < .001). There was an increase in the proportion of randomized and diseased-focused clinical trials within the trials that involved LMIC centers between 2000-2005 and 2010-2015 (57.1% v 47.1% and 85.7% v 52.9%; P = .013 and 0.014, respectively).

CONCLUSION

We found a marked underrepresentation of LMICs in leukemia clinical trials reflecting limited access to novel leukemia therapies in LMICs.

Understanding medicine access strategies for innovator medicines registered in South Africa

BACKGROUND

South Africa is composed of a two-tier healthcare system. One tier is a private healthcare system that is funded through medical insurance, and comprised of people who can afford to make monthly payments towards their medical insurance. Second tier is a government-funded public healthcare system, which covers the majority of the population. This study explored the perceived barriers and current strategies being utilised by the pharmaceutical industry to increase access to innovator medicines.

OBJECTIVES

The objectives of the study were to: (1) quantify and classify innovator medicines registered between 2010 and 2020 by the South African Health Products Regulatory Authority (SAHPRA); (2) identify barriers to accessing innovator medicines in South Africa through interviews with market access managers from innovator companies; and (3) explore the current market access strategies used by the pharmaceutical industry.

DESIGN

This study employed a quantitative and qualitative methodology. Whereby the former involved the extraction of a list of innovator medicines from the regulator database, and the latter involved 9 semi structured interviews. Purposive sampling was conducted through pharmaceutical association member companies. The interviews included seven market access managers and two medicine managers from one of the payers in South Africa. Thematic analysis was used to interpret the data collected from the study.

RESULTS

According to the regulator database during the review period, 238 innovator medicines were registered. Only 14.77% were available in the public sector in the form of tenders, whereas in the private sector (based on the products having a SEP), 76.92% were available. From the interviews six themes emerged: reimbursement of medicines, types of reimbursement, partnerships, technology, legislative challenges, and other factors (e.g., real-world evidence).

CONCLUSION

Access to innovator medicines in South Africa is a challenge, as the price of these therapies is high. Therefore, various stakeholders in the health sector must collaborate to identify and implement solutions that are locally relevant. The government needs to proactively update policies that would allow for alternative reimbursement methods to be explored.

Disparities in availability of new cancer drugs worldwide: 1990-2022

INTRODUCTION

Despite progress in the development of new cancer drugs, concerns about equity of access remain. This study aimed to examine the availability and timeliness of availability of new cancer drugs around the globe over the past three decades and their associations with country characteristics.

METHODS

From a pharmaceutical intelligence database we identified new cancer drugs launched between 1990 and 2022. We calculated the number of new drugs launched in each country and the delay in launches. Using a multivariable linear regression and a Cox regression model with shared frailty, we examined the associations of the country's Gross National Income (GNI) per capita, cancer incidence, number of physicians per population, and Gini index with the number of new cancer drug launches and launch delay in a country, respectively.

RESULTS

A total of 568 cancer drugs were launched for the first time globally between 1990 and 2022. Among these, 35% had been launched in only one country by 2022, 22% in 2-5 countries, 15% in 6-10 countries, and 28% in more than 10 countries. The number of new cancer drugs launched in a country in this period ranged from 0 to 345. The average delays from the first global launch to the second, third, fourth, and fifth launch were 18.0 months, 24.3 months, 32.5 months, and 39.4 months, respectively. Our multivariate models showed that higher GNI per capita and cancer incidence in a country were associated with more launches and shorter delays.

CONCLUSION

This research reveals significant disparities in the availability and timeliness of availability of new cancer drugs across countries. These disparities are likely to have contributed to the poor cancer outcomes observed in many countries.

Global epidemiology of liver cancer 2022: An emphasis on geographic disparities

BACKGROUND

Liver cancer remains the sixth most commonly diagnosed cancer and the third leading cause of cancer-related deaths worldwide, causing a heavy burden globally. An updated assessment of the global epidemiology of the liver cancer burden that addresses geographical disparities is necessary to better understand and promote healthcare delivery.

METHODS

Data were extracted from the GLOBOCAN 2022 database, including the number, crude, and age-standardized rates of incidence and mortality at the global, country, continent, and human development index (HDI) regional levels. Age-standardized rates (incidence and mortality) per 100,000 person-years were adjusted based on the Segi-Doll World standard population. The mortality-to-incidence ratios (MIR) for each region and country were calculated. The HDI and gross national income (GNI) for 2022 were obtained, and a Pearson correlation analysis was conducted with the incidence, mortality, and MIR.

RESULTS

In 2022, approximately 866,136 new liver cancer cases and 758,725 related deaths were recorded worldwide, with a global MIR of 0.86. Males had a disproportionately higher burden than females across all levels, and the highest burden was observed in the elderly population. Geographically, the regions with the highest incidence rates included Micronesia, Eastern Asia, and Northern Africa, and the regions with the highest mortality rates included Northern Africa, Southeastern Asia, Eastern Asia, and Micronesia. Notably, Mongolia had a strikingly high burden compared to other countries. The highest MIR was observed in North America and the lowest in Africa. Negative associations of HDI and GNI with liver cancer mortality and MIR were identified, irrespective of sex.

CONCLUSIONS

The current liver cancer burden underscores the presence of remarkable geographic heterogeneity, which is particularly evident across countries with varying HDI levels, highlighting the urgent need to prioritize health accessibility and availability to achieve health inequities.

Economics of Antibody Drug Conjugates (ADCs): Innovation, Investment and Market Dynamics

PURPOSE OF REVIEW

This review aims to explore the intricate interplay between scientific advancements and economic considerations in the development, production, and commercialization of Antibody Drug Conjugates (ADCs). The focus is on understanding the challenges and opportunities at this unique intersection, highlighting how scientific innovation and economic dynamics mutually influence the trajectory of ADCs in the pharmaceutical landscape.

RECENT FINDINGS

There has been a significant increase in interest and investment in the development of ADCs. Initially focused on hematological malignancies, ADCs are now being researched for use in treating solid tumors as well. Pharmaceutical companies are heavily investing to broaden the range of indications for which ADCs can be effective. According to a report from the end of 2023, the global ADCs market grew from USD 1.4 billion in 2016 to USD 11.3 billion in 2023, with projections estimating a value of USD 23.9 billion by 2032, growing at a CAGR of 10.7%. ADCs represent a promising class of biopharmaceuticals in oncology, with expanding applications beyond hematological malignancies to solid tumors. The significant growth in the ADC market underscores the impact of scientific and economic factors on their development. This review provides valuable insights into how these factors drive innovation and commercialization, shaping the future of ADCs in cancer treatment.

Disparities in 36 cancers across 185 countries: secondary analysis of global cancer statistics

Cancer is a major public health problem and represents substantial disparities worldwide. This study reported estimates for 36 cancers across 185 countries by incidence, mortality, 5-year prevalence, mortality-to-prevalence ratio (MPR), and mortality-to-incidence ratio (MIR) to examine its association with human development index (HDI) and gross national income (GNI). Data were collected from the GLOBOCAN 2020. MPR and MIR were calculated by sex, age group, country, and cancer type and then summarized into totals. Segi's population and global cancer spectrum were used to calculate age- and type-standardized ratios. Correlation analyses were conducted to assess associations. Results showed that breast cancer was the most diagnosed cancer globally. Low- and middle-income countries had high MPR and MIR. Cancers of esophagus, pancreas, and liver had the highest ratios. Males and the older population had the highest ratios. HDI and GNI were positively correlated with incidence and mortality but negatively correlated with MPR/MIR. Substantial disparities in cancer burden were observed among 36 cancer types across 185 countries. Socioeconomic development may contribute to narrowing these disparities, and tailored strategies are crucial for regional- and country-specific cancer control.

Provision of prostate cancer services in Tanzania: perspectives from five tertiary hospitals

BACKGROUND

Access to quality prostate cancer services remains a global challenge, particularly in Low- and Middle-Income countries. This is often due to weak health systems that struggle to meet the population's needs. The provision of quality health services to patients with prostate cancer requires a comprehensive approach involving multiple stakeholders and structural inputs. However, few studies have comprehensively assessed the relationship between these structural inputs and prostate cancer treatment outcomes. This study, therefore, aimed to determine the availability of selected structural inputs and descriptions of how they influence the provision of quality services to patients with prostate cancer in Tanzania.

METHODS

We conducted a cross-sectional study using an explanatory sequential mixed-method approach to collect data from five tertiary hospitals providing cancer services in Tanzania. A validated checklist was used to collect information on available structural inputs for prostate services at tertiary hospitals. A semi-structured interview guide was used to conduct 42 in-depth interviews with 20 healthcare providers, five hospital managers, and 17 patients undergoing treatment for prostate cancer. Descriptive analysis was performed for the quantitative data, and thematic analysis was conducted with the aid of NVivo 14 qualitative software for the interview transcripts.

RESULTS

All five assessed tertiary hospitals had inadequate human resources for health to provide prostate cancer services. Only one had 70% of the required HRH, while none had above 40% of the required HRH. Within the hospitals, the skill mix imbalance was severe across cadres. Five themes emerged: inadequate infrastructure, delays in diagnosis, delays in treatment, shortage of human resources for health (HRH), and inefficient organization of prostate cancer services.

CONCLUSION

The findings of this study, underscore the major health system deficiencies for the provision of prostate cancer services in tertiary hospitals. With the increased aging population, strong health systems are vital in addressing conditions of old aging, including prostate cancers. Studies on optimization of the available HRH and infrastructure are needed to improve the provision of prostate cancer in tertiary hospitals as an interim solution while long-term measures are needed for improving the HRH availability and conducive infrastructure.

Cytotoxic Activity of Lepidium virginicum L. Methanolic Extract on Human Colorectal Cancer Cells, Caco-2, through p53-Mediated Apoptosis

Colorectal cancer (CRC) is the third most common type of cancer worldwide. Its treatment options have had a limited impact on cancer remission prognosis. Therefore, there is an ongoing need to discover novel anti-cancer agents. Medicinal plants have gained recognition as a source of anti-cancer bioactive compounds. Recently, ethanolic extract of L. virginicum stems ameliorated dinitrobenzene sulfonic acid (DNBS)-induced colitis by modulating the intestinal immune response. However, no scientific study has demonstrated this potential cytotoxic impact on colon cancer cells. The objective of this study was to evaluate the cytotoxic effect of the methanolic extract of L. virginicum (ELv) on a human colorectal adenocarcinoma cell line (Caco-2) and to identify and quantify the phenolic compounds present in ELv extracts by liquid chromatography-mass spectrometry analysis. The cytotoxic activity was assessed using cell viability assays by reduction in the compound 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and lactate dehydrogenase (LDH). MTT and LDH assays revealed that the ELv decreases cell viability in the Caco-2 cell line in a concentration-dependent manner. Cell death was a result of DNA fragmentation and p53-mediated apoptosis. Eight phenolic acids and five flavonoids were identified and quantified in the stems. In conclusion, our findings demonstrate that the extract of L. virginicum possesses cytotoxic properties on Caco-2 cell line, suggesting that it could be a potential source of new drugs against CRC.

Anticancer Effect of PtIIPHENSS, PtII5MESS, PtII56MESS and Their Platinum(IV)-Dihydroxy Derivatives against Triple-Negative Breast Cancer and Cisplatin-Resistant Colorectal Cancer

Development of resistance to cisplatin, oxaliplatin and carboplatin remains a challenge for their use as chemotherapies, particularly in breast and colorectal cancer. Here, we compare the anticancer effect of novel complexes [Pt(1,10-phenanthroline)(1S,2S-diaminocyclohexane)](NO3)2 (PtIIPHENSS), [Pt(5-methyl-1,10-phenanthroline)(1S,2S-diaminocyclohexane)](NO3)2 (PtII5MESS) and [Pt(5,6-dimethyl-1,10-phenanthroline)(1S,2S-diaminocyclohexane)](NO3)2 (PtII56MESS) and their platinum(IV)-dihydroxy derivatives with cisplatin. Complexes are greater than 11-fold more potent than cisplatin in both 2D and 3D cell line cultures with increased selectivity for cancer cells over genetically stable cells. ICP-MS studies showed cellular uptake occurred through an active transport mechanism with considerably altered platinum concentrations found in the cytoskeleton across all complexes after 24 h. Significant reactive oxygen species generation was observed, with reduced mitochondrial membrane potential at 72 h of treatment. Late apoptosis/necrosis was shown by Annexin V-FITC/PI flow cytometry assay, accompanied by increased sub-G0/G1 cells compared with untreated cells. An increase in S and G2+M cells was seen with all complexes. Treatment resulted in significant changes in actin and tubulin staining. Intrinsic and extrinsic apoptosis markers, MAPK/ERK and PI3K/AKT activation markers, together with autophagy markers showed significant activation of these pathways by Western blot. The proteomic profile investigated post-72 h of treatment identified 1597 MDA-MB-231 and 1859 HT29 proteins quantified by mass spectroscopy, with several differentially expressed proteins relative to no treatment. GO enrichment analysis revealed a statistically significant enrichment of RNA/DNA-associated proteins in both the cell lines and specific additional processes for individual drugs. This study shows that these novel agents function as multi-mechanistic chemotherapeutics, offering promising anticancer potential, and thereby supporting further research into their application as cancer therapeutics.

Survey and analysis of accessibility, availability, and affordability of topical glaucoma medicines

PURPOSE

Affordability and availability of medicines is a growing global challenge for health-care systems. Access to medicines is recognized as an important determinant of treatment adherence. The access to glaucoma medicines and how it affects glaucoma management are not known. The purpose of this study was to determine the availability, affordability, and accessibility of topical intraocular pressure (IOP) -lowering eye drops in Haryana state of northern India using the World Health Organization (WHO)/Health Action International (HAI) methods.

METHODS

A cross-sectional study was done to collect data on prices and availability of glaucoma topical medications in public and private sector pharmacies and retail outlets using the WHO/HAI methodology between October 2021 and January 2022. The availability and affordability of topical glaucoma medicines was determined. Comparison of the local price with international prices was done by calculating the median price ratio (MPR).

RESULTS

A total of 191 facilities were randomly sampled across 11 ( n = 55) urban, 29 ( n = 92) semi-urban, and 44 ( n = 44) rural places during the study period. The availability of topical medication for glaucoma was low (35.7 ± 22.3) across all sampled sites and all classes of topical glaucoma medications. The median price of topical medication and availability were negatively correlated, Pearson's coefficient r (18) = -0.44, P 0.05, though the relationship was weak. A lowest paid, unskilled Indian government worker must spend between 15% and 203% of their daily wage to acquire a glaucoma medication.

CONCLUSION

The availability and accessibility of topical glaucoma medications was low in this survey.

Updates in global oncology: Advancements and future directions

Globally, cancer is the second leading cause of death, and low- and middle-income countries bear most of the disease burden. While cancer is increasingly recognized as a major global health issue, more work remains. Understanding the status of global cancer care will shape the next steps in ensuring equitable global access to cancer care. This article highlights ongoing initiatives in global oncology and the next steps in advancing the field.

Economic value of toripalimab plus axitinib as first-line treatment for advanced renal cell carcinoma in China: a model-based cost-effectiveness analysis

OBJECTIVE

The current analysis aimed to evaluate the economic benefit of toripalimab plus axitinib for previously untreated RCC patients from the Chinese healthcare system perspective.

METHODS

The partitioned survival model was developed to simulate 3-week patients' transition in 20-year time horizon to evaluate the cost-effectiveness of toripalimab plus axitinib compared with sunitinib for advanced RCC. Survival data were gathered from the RENOTORCH trial, and cost and utility inputs were obtained from the database and published literature. Total cost, life-years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were the model outputs. Subgroup analyses and sensitivity analyses were conducted to increase the comprehensiveness and estimate the robustness of the model results.

RESULTS

In the base-case analysis, compared with sunitinib, toripalimab plus axitinib could bring additional 1.19 LYs and 0.65 QALYs, with the marginal cost of $41,499.23, resulting in the ICER of $64,337.49/QALY, which is higher than the WTP threshold. And ICERs were always beyond the WTP threshold of all subgroups. Sensitivity analyses demonstrated the model results were robust.

CONCLUSIONS

Toripalimab plus axitinib was unlikely to be the cost-effective first-line therapy for patients with previously untreated advanced RCC compared with sunitinib from the Chinese healthcare system perspective.

Cost-effectiveness of additional serplulimab to chemotherapy in metastatic squamous non-small cell lung cancer patients

Objective

To estimate the cost-effectiveness of adding serplulimab to chemotherapy for metastatic squamous non-small cell lung cancer (NSCLC) patients in a first-line setting from a Chinese perspective.

Methods

A three-health state partitioned survival model was constructed to simulate disease development. The clinical data used in the model were derived from the ASTRUM-004 clinical trial. Only direct medical costs were included, and the utilities were derived from published literature. The quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were employed to evaluate health outcomes. Additionally, a sensitivity analysis was performed to verify the robustness of the results.

Results

Compared with chemotherapy alone, the addition of serplulimab resulted in an increase of 0.63 QALYs with an incremental cost of $5,372.73, leading to an ICER of $8,528.14 per QALY. This ICER was significantly lower than 3 times China's per capita GDP. The one-way sensitivity analysis suggested that the utility of PFS was the most sensitive factor on ICERs, followed by the price of serplulimab.

Conclusion

The combination of serplulimab and chemotherapy has been shown to be a cost-effective initial treatment option for patients with metastatic squamous NSCLC with the commonly accepted willingness-to-pay threshold of 3 times the GDP per capita per QALY in China.

Different outcomes among patients with intermediate-risk metastastic renal cell carcinoma treated with first-line tyrosine-kinase inhibitors

INTRODUCTION

Systemic therapy of patients with metastatic renal cell carcinoma (mRCC) has improved in the past years, with the advent of new immunotherapy-based combinations as a standard treatment option for first-line therapy. Nevertheless, particularly in good-risk patients by IMDC criteria, tyrosine-kinase inhibitors (TKI) may remain as an option for some patients. We reviewed our experience with TKI as first-line therapy for mRCC patients, trying to identify subgroups of patients that may still benefit from this strategy.

MATERIAL AND METHODS

All patients with mRCC treated with first-line TKI, and adequate follow-up, in University Hospital La Paz (Madrid, Spain) between 2007 and 2020 were analyzed. Patients treated inside a clinical trial were excluded from this analysis.

RESULTS

A total of 90 patients treated with first-line TKI were included. Regarding IMDC criteria, 33 patients (36.7%) were good-risk, 41 patients (45.5%) intermediate-risk, and 16 patients (17.8%) poor-risk. With a median follow-up of 49 months, the median overall survival (OS) for good, intermediate, and poor-risk patients was 54, 24, and 16 months (p = 0.004). When intermediate-risk was divided into patients with 1 or 2 risk factors, differences in OS were also statistically significant: patients with 1 risk factor had a median OS of 33 months, while patients with 2 risk factors had a median OS of 16 months, the same as poor-risk patients (p = 0.003). In the multivariate analysis, trying to find out which of the IMDC factors had a more remarkable weight in the prognosis of the patients, both ECOG and hemoglobin levels by themselves were significantly associated with OS.

CONCLUSION

In our group of patients, survival outcomes were different among patients with intermediate-risk with 1 or 2 risk factors by IMDC criteria. These could help select patients that may benefit from first-line treatment with a TKI, particularly in settings with difficult access to novel therapies, such as immunotherapy-based combinations.

Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

State of Cancer Control in South America: Challenges and Advancement Strategies

Cancer is a major public health problem in South America. The cancer mortality burden is increasing in the region due to its presentation at later stages, which is related to limited access to cancer care. This results in a noticeable inequity in provisions of cancer care including specialized screening programs, as well as cancer-related treatments such as personalized medicine, radiation therapy, palliative care, and survivorship services. Consequently, South America faces many challenges for cancer control, most of them deriving from a lack of funding and unequal distribution of resources and cancer services, affecting mostly the underserved populations in the region.

Is the Availability of Biosimilar Adalimumab Associated with Budget Savings? A Difference-in-Difference Analysis of 14 Countries

OBJECTIVE

The aim was to assess the influence of the presence of biosimilar adalimumab on adalimumab budget savings in 14 high- and upper-middle-income countries.

METHODS

This study analyzed Multinational Integrated Data Analysis System (MIDAS)-IQVIA data from the fourth quarter (Q4) of 2018 to the Q4 of 2019, comparing adalimumab expenditure (in United States dollars) and consumption (in standard units [SU]) across 14 countries (Australia, Austria, Brazil, Canada, France, Germany, Italy, Japan, Korea, Singapore, South Africa, Spain, Sweden, and Taiwan). The countries were divided into two groups based on the availability of adalimumab biosimilars during the study period. A difference-in-difference design was employed to analyze the groups, focusing on changes from Q4 2018 to Q4 2019. Additionally, changes in adalimumab expenditure were decomposed into price, quantity, and drug mix during the study period.

RESULTS

Among countries with adalimumab biosimilars, there was a significant decrease in expenditure (- $371.0 per gross domestic product per capita; p = 0.03) over four quarters, while the consumption significantly increased (1.0 SU per 1000 population; p = 0.02). This was consistent with visual observations and differed from countries without adalimumab biosimilar. Sensitivity analysis with a narrowed list of countries (12 high-income countries) showed a consistent trend. Adalimumab expenditure decreased by 14% during the study period in countries where adalimumab biosimilars were available, mainly due to the price changes (Pt = 0.85; - 15%) and the drug-mix effect (εt  = 0.88; - 12%). Yet, adalimumab expenditure (Et = 1.04; +4%) changed in a quantity-dependent manner (Qt = 1.06; +6%) in countries where adalimumab biosimilars were absent.

CONCLUSION

The availability of biosimilars was associated with a decrease in adalimumab expenditure without compromising the consumption of adalimumab.

Moving forward through consensus: a national Delphi approach to determine the top research priorities in prostate cancer in Uganda

OBJECTIVE

To identify key areas for research in prostate cancer (PC) in the Ugandan context by establishing the major health system, socioeconomic and clinical barriers to seeking, reaching and receiving high-quality cancer care.

DESIGN

Modified Delphi Technique.

SETTING

Government and private-not-for-profit hospitals.

METHODS

We applied a two-stage modified Delphi technique to identify the consensus view across cancer experts. In round 1, experts received a questionnaire containing 21 statements drawn from a systematic review identifying the reason for the delay in accessing cancer care. Each statement was scored out of 20. Statements scoring ≥15 from over 70% of participants were prioritised for inclusion while statements for which <30% of participants gave a score of ≥15 were excluded. Sixteen statements were included in round 2 as they did not receive consensus for inclusion or exclusion.

RESULTS

We found that the top six research priority areas arise from challenges including: (1) lack of diagnostic services-ultrasound, laboratory tests and biopsy facilities; (2) high costs of services, for example, surgery, radiotherapy, hormone therapy are unaffordable to most patients, (3) lack of essential medicines, (4) limited radiotherapy capacity, (5) lack of awareness of cancer as a disease and low recognition of symptoms, (6) low healthcare literacy. The lack of critical surgical supplies, high diagnostic and treatment costs were ranked highest in order of importance in round 1. Round 2 also revealed lack of diagnostic services, unavailability of critical medicines, lack of radiotherapy options, high costs of treatments and lack of critical surgical supplies as the top priorities.

CONCLUSION

These research priority areas ought to be addressed in future research to improve prompt PC diagnosis and care in Uganda. There is need to improve the supply of high-quality affordable anticancer medicines for PC patients so as to improve the survivorship from the cancer.

Impact of healthcare inequities on survival in Mexican patients with metastatic renal cell carcinoma

Introduction

The survival of patients with metastatic renal cell carcinoma (mRCC) has improved dramatically due to novel systemic treatments. However, mRCC mortality continues to rise in Latin America.

Methods

A retrospective, multicenter study of patients diagnosed with mRCC between 2010-2018 in Mexico City was conducted. The aim of the study was to evaluate the impact of healthcare insurance on access to treatment and survival in patients with mRCC.

Results

Among 924 patients, 55.4%, 42.6%, and 1.9% had no insurance (NI), social security, (SS) and private insurance (PI), respectively. De novo metastatic disease was more common in NI patients (70.9%) compared to SS (47.2%) and PI (55.6%) patients (p<0.001). According to IMDC Prognostic Index, 20.2% were classified as favorable, 49% as intermediate, and 30.8% as poor-risk disease. Access to systemic treatment differed by healthcare insurance: 36.1%, 99.5%, and 100% for the NI, SS, and PI patients, respectively (p<0.001). NI patients received fewer lines of treatment, with 24.8% receiving only one line of treatment (p<0.001). Median overall survival (OS) was 13.9 months for NI, 98.9 months for SS, and 147.6 months for NI patients (p<0.001). In multivariate analysis, NI status, brain metastases, sarcomatoid features, bone metastases, no treatment were significantly associated with worse OS.

Conclusion

OS in mRCC was affected by insurance availability in this resource-limited cohort of Mexican patients. These results underscore the need for effective strategies to achieve equitable healthcare access in an era of effective, yet costly systemic treatments.

Design, Synthesis, In Vitro, and In Silico Studies of New N5-Substituted-pyrazolo[3,4-d]pyrimidinone Derivatives as Anticancer CDK2 Inhibitors

CDK2 is a key player in cell cycle processes. It has a crucial role in the progression of various cancers. Hepatocellular carcinoma (HCC) and colorectal cancer (CRC) are two common cancers that affect humans worldwide. The available therapeutic options suffer from many drawbacks including high toxicity and decreased specificity. Therefore, there is a need for more effective and safer therapeutic agents. A series of new pyrazolo[3,4-d]pyrimidine analogs was designed, synthesized, and evaluated as anticancer agents against the CRC and HCC cells, HCT116, and HepG2, respectively. Pyrazolo[3,4-d]pyrimidinone derivatives bearing N5-2-(4-halophenyl) acetamide substituents were identified as the most potent amongst evaluated compounds. Further evaluation of CDK2 kinase inhibition of two potential cytotoxic compounds 4a and 4b confirmed their CDK2 inhibitory activity. Compound 4a was more potent than the reference roscovitine regarding the CDK2 inhibitory activity (IC50 values: 0.21 and 0.25 µM, respectively). In silico molecular docking provided insights into the molecular interactions of compounds 4a and 4b with important amino acids within the ATP-binding site of CDK2 (Ile10, Leu83, and Leu134). Overall, compounds 4a and 4b were identified as interesting CDK2 inhibitors eliciting antiproliferative activity against the CRC and HCC cells, HCT116 and HepG2, respectively, for future further investigations and development.

Assessment of barriers to optimal cancer control in adult cancer treatment centres in Cameroon

Approximately 20,745 new cases of cancer were registered annually with 13,199 (64%) deaths in 2020 in Cameroon. Despite the increasing cancer burden, there is a paucity of reliable data that can enhance decision-making for cancer control in Cameroon. This assessment was, therefore, designed to generate data that may enable stakeholders, policymakers and funders to make data-driven decisions on cancer control. We conducted a cross-sectional survey in July 2020, which enabled us to collect data on key cancer variables from six adult cancer treatment centres in Cameroon. The key components of the assessment included case detection, service availability, human resource capacity, cost of chemotherapy and radiotherapy, the safety of chemotherapy sessions, data systems, patient education, palliative care, funding for chemotherapy and chemotherapy stock. Data were compiled and analysed using Microsoft Excel 2016. Data from four of the 6 sites show that 1,636 new cases were recorded representing an annual case detection rate of 11.8%. All the six assessed facilities offered chemotherapy services, 5/6 (83.3%) offered surgery for cancers, while just 1 (16.7%) offered radiotherapy services. In addition, none offered nuclear medicine services for cancer care and treatment. Similarly, none of the facilities had the WHO-recommended number of human resources for optimal cancer care. Overall, there were only 6 medical oncologists, 2 surgical oncologists, 3 radiation oncologists and 14 oncology nurses providing services across the 6 cancer treatment centres. Treatment services are expensive for an average national, with a complete course of chemotherapy followed by radiotherapy costing ~XAF 1,240,000 (~$2,480). None of the survey facilities had a recommended safe biosafety cabinet and clean room for the preparation of chemotherapies, rendering the preparation of chemotherapies suboptimal and hazardous. Data collection tools were manual, relatively available and very different across all the surveyed sites and the interval for data collection and transmission was collectively undefined. Optimal cancer care in adult cancer treatment centres is limited by several health systems and socio-economic factors. The identification of these barriers has enabled the formulation of action-oriented interventions, leveraging on the recently adopted national strategy for the prevention and control of cancers in the country.

Diffuse Large B-Cell Lymphoma Treated With R-CHOP in a Resource-Limited Setting in South Africa: A Real-World Study

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin's lymphoma worldwide and particularly in Africa, where the incidence of HIV is the highest in the world. R-CHOP is the standard of care regimen for DLBCL, but access to rituximab is limited in developing countries.

METHODS

This is a retrospective cohort study that included all HIV-negative patients with DLBCL who received R-CHOP at a single institution from January 2012 to December 2017. Clinical and demographic data were collected to assess factors that influenced survival.

RESULTS

Seventy-three patients were included. Median age was 55 (17-76), 67.1% of patients were younger than 60 years, and 60.3% were female. Most presented with stages III/IV disease (53.5%) but with good performance status (56.% PS 0 and 1). Progression-free survival at 3 and 5 years was 75% and 69%, and overall survival at 3 and 5 years was 77% and 74%, respectively. Median survival had not been reached with a median follow-up of 3.5 years(0.13-7.9). Overall survival was significantly affected by performance status (P = .04), but not by IPI or age. Survival was significantly associated with response to chemotherapy after 4-5 cycles of R-CHOP (P = 0.005).

CONCLUSIONS

Treatment of DLBCL with R-CHOP is feasible and can achieve good outcomes in resource-limited settings with rituximab-based chemotherapy. Poor performance status was the most important adverse prognostic factor in this cohort of HIV-negative patients.

Global Cancer Drug Development-A Report From the 2022 Accelerating Anticancer Agent Development and Validation Meeting

Rapidly expanding systemic treatment options, combined with improved screening, diagnostic, surgical, and radiotherapy techniques, have led to improved survival outcomes for many cancers over time. However, these overall survival gains have disproportionately benefited patients in high-income countries, whereas patients in low- and middle-income countries (LMICs) continue to experience challenges in accessing timely and guideline concordant care. In September 2022, the Accelerating Anticancer Agent Development and Validation workshop was held, focusing on global cancer drug development. Panelists discussed key barriers such as the lack of diagnostic services and human resources, drug accessibility and affordability, lack of research infrastructure, and regulatory and authorization challenges, with a particular focus on Africa and Latin America. Potential opportunities to improve access and affordability were reviewed, such as the importance of prioritizing investments in diagnostics, investing health infrastructure and work force planning, coordinated drug procurement efforts and streamlined regulatory processing, incentivized pricing through regulatory change, and the importance of developing and promoting clinical trials that can answer relevant clinical questions for patients in LMICs. As a cancer community, we must continue to advocate for and work toward equitable access to high-quality interventions for patients, regardless of their geographical location.

Nanoparticle-Based Antioxidants in Stress Signaling and Programmed Cell Death in Breast Cancer Treatment

Breast cancer (BC) is a complex and heterogeneous disease, and oxidative stress is a hallmark of BC. Oxidative stress is characterized by an imbalance between the production of reactive oxygen species (ROS) and antioxidant defense mechanisms. ROS has been implicated in BC development and progression by inducing DNA damage, inflammation, and angiogenesis. Antioxidants have been shown to scavenge ROS and protect cells from oxidative damage, thereby regulating signaling pathways involved in cell growth, survival, and death. Plants contain antioxidants like ascorbic acid, tocopherols, carotenoids, and flavonoids, which have been found to regulate stress signaling and PCD in BC. Combining different antioxidants has shown promise in enhancing the effectiveness of BC treatment. Antioxidant nanoparticles, when loaded with antioxidants, can effectively target breast cancer cells and enhance their cellular uptake. Notably, these nanoparticles have shown promising results in inducing PCD and sensitizing breast cancer cells to chemotherapy, even in cases where resistance is observed. This review aims to explore how nanotechnology can modulate stress signaling and PCD in breast cancer. By summarizing current research, it underscores the potential of nanotechnology in enhancing antioxidant properties for the treatment of breast cancer.

Availability and affordability of anticancer medicines at cancer treating hospitals in Rwanda

BACKGROUND

Availability and accessibility of anti-cancer medicines is the pillar of cancer management, and it is one of the main concerns in low-income countries including Rwanda. The objective of this study was to assess the availability and affordability of anticancer medicines at cancer-treating hospitals in Rwanda.

METHODOLOGY

A descriptive cross-sectional study was conducted at 5 cancer-treating hospitals in Rwanda. Quantitative data were collected from stock cards and software that manage medicines and included the availability of anti-cancer medicines at the time of data collection, their stock status within the last two years, and the selling price.

RESULTS

The study found the availability of anti-cancer medicines at 41% in public hospitals at the time of data collection, and 45% within the last two years. We found the availability of anti-cancer medicines at 45% in private hospitals at the time of data collection, and 61% within the last two years. 80% of anti-cancer medicines in private hospitals were unaffordable while 20% were affordable. The public hospital that had most of the anti-cancer medicines in the public sector provided free services to the patients, and no cost was applied to the anti-cancer medicines.

CONCLUSION

The availability of anti-cancer medicines in cancer-treating hospitals is low in Rwanda, and most of them are unaffordable. There is a need to design strategies that can increase the availability and affordability of anti-cancer medicines, for the patients to get recommended cancer treatment options.

Global application of National Comprehensive Cancer Network resource-stratified guidelines for systemic treatment of colon cancer: a population-based, customisable model for cost, demand, and procurement

BACKGROUND

Resource-stratified guidelines (RSGs) can inform systemic treatment decisions in the face of limited resources. The objective of this study was to develop a customisable modelling tool to predict the demand, cost, and drug procurement needs of delivering National Comprehensive Cancer Network (NCCN) RSG-based systemic treatment for colon cancer.

METHODS

We developed decision trees for first-course systemic therapy for colon cancer based on the NCCN RSGs. Decision trees were merged with data from the Surveillance, Epidemiology, and End Results programme, the International Agency for Research on Cancer's GLOBOCAN 2020 national estimates for colon cancer incidence, country-level income data, and data on drug costs from Redbook (USA), the Pharmaceutical Benefits Scheme (Australia), and the Management Sciences for Health 2015 International Medical Products price guide to estimate global treatment needs and costs, and forecast drug procurement. Simulations and sensitivity analyses were used to explore the effect of scaling up services globally and the effect of alternative stage distributions on treatment demand and cost. We generated a customisable model, in which estimates can be tailored to local incidence, epidemiological, and costing data.

FINDINGS

First-course systemic therapy is indicated in 608 314 (53·6%) of 1 135 864 colon cancer diagnoses in 2020. Indications for first-course systemic therapy are projected to rise to 926 653 in 2040; the indications in 2020 might be as high as 826 123 (72·7%), depending on stage distribution assumptions. Adhering to NCCN RSGs, patients with colon cancer in low-income and middle income countries (LMICs) would constitute 329 098 (54·1%) of 608 314 global systemic therapy demands, but only 10% of global expenditure on systemic therapies. The total cost of NCCN RSG-based first-course systemic therapy for colon cancer in 2020 would be between about US$4·2 and about $4·6 billion, depending on stage distribution. If all patients with colon cancer in 2020 were treated according to maximal resources, global expenditure on systemic therapy for colon cancer would rise to around $8·3 billion.

INTERPRETATION

We have developed a customisable model that can be applied at global, national, and subnational levels to estimate systemic treatment needs, forecast drug procurement, and calculate expected drug costs on the basis of local data. This tool can be used to plan resource allocation for colon cancer globally.

FUNDING

None.

Variations in global prices of chemotherapy for childhood cancer: a descriptive analysis

Background

The stark disparity in survival for children with cancer across the world has inspired a global call to expand chemotherapy access in low and middle income countries. Among the numerous barriers to success, a paucity of reliable information regarding chemotherapy pricing hinders the ability of governments and other key stakeholders to make informed budget decisions or negotiate lower medication prices. The aim of this study was to generate comparative price information on both individual chemotherapy agents and comprehensive treatment regimens for common childhood cancers using real-world data.

Methods

Chemotherapy agents were selected based on their inclusion in the World Health Organization (WHO) Essential Medicines List for Children (EMLc) and their use in frontline regimens for the tracer cancer types prioritized by the WHO's Global Initiative for Childhood Cancer (GICC). Sources included IQVIA MIDAS data, obtained under license from IQVIA, and publicly available data from Management Sciences for Health (MSH). Data on chemotherapy prices and purchase volumes spanning 2012-2019 were aggregated according to WHO region and World Bank (WB) income classification. Cumulative chemotherapy prices for treatment regimens were compared across WB income classification.

Findings

Data representing an estimated 1.1 billion doses of chemotherapy were obtained for 97 countries: 43 high income countries (HICs), 28 upper middle income countries (UMICs), and 26 low and lower middle income countries (LLMICs). Median drug prices in HICs were 0.9-20.4 times those of UMICs and 0.9-15.5 times those of LMICs. Regimen prices were generally higher for HICs, hematologic malignancies, non-adapted protocols, and higher risk stratification or stage, albeit with notable exceptions.

Interpretation

This study represents the largest price analysis to date of chemotherapy agents used globally in childhood cancer therapy. The findings of this study form a basis for future cost-effectiveness analysis in pediatric cancer and should inform efforts of governments and stakeholders to negotiate drug prices and develop pooled purchasing strategies.

Funding

NB received funding support from the American Lebanese Syrian Associated Charities and Cancer Center Support grant (CA21765) from the National Cancer Institute through the National Institutes of Health. TA received funding through the University of North Carolina Oncology K12 (K12CA120780) and the University Cancer Research Fund from the UNC Lineberger Comprehensive Cancer Center.

The price and affordability of essential medicines, progress and regional distribution in China: a systematic review

Background: Essential medicine is a vital component to assure universal access to quality healthcare. However, the trend of affordability to essential medicines in China and its regional differences were not yet fully understood. This study aimed to systematically evaluate the price and affordability of essential medicines, their progress, and regional distribution in China in the last decades. Methods: We searched seven databases and three websites for potentially eligible studies from inception until March 2022. Studies on the price and affordability of essential medicines investigated in China were included. Median and interquartile range (IQR) was used to describe the price and affordability of essential medicines, and compared in three periods, before 2009, from 2009 to 2014, and from 2015 to 2019. Subgroup analysis was performed to examine the price and affordability by regions, health facilities, and ATC categories of medicines. The study was registered with PROSPERO (CRD42022310173). Results: A total of 65 studies including 11,639 health facilities investigated between 2006 and 2019 were included in this review. Median price ratios (MPR) and affordability of essential medicines were reported in 44 studies and 50 studies, respectively. The median MPRs of essential medicines in China was 1.59 (IQR: 5.39), with a tendency to rise first and then fall from 2006 to 2019. And the median affordability was equal to 0.88 (IQR: 2.58) days' wage of the lowest paid unskilled government worker, but steadily rose from 2006 to 2019. Subgroup analysis showed that the affordability in the western region (1.40, IQR: 2.88), urban area (0.95, IQR: 2.80), private sector (0.90, IQR: 2.30), of originator brands (OB) (2.90, IQR: 6.68), and antineoplastic and immunomodulating agents (5.68, IQR: 56.47) were worse than their counterparts. Conclusion: The prices of essential medicine were higher than international level, the overall affordability of essential medicines in China is acceptable but poor in the western region, for OB drugs and anti-cancer medicines. Further national essential medicine policies are needed to reduce regional disparities and improve the affordability of expensive drugs. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Platelets for advanced drug delivery in cancer

INTRODUCTION

Cancer-related drug expenses are rising with the increasing cancer incidence and cost may represent a severe challenge for drug access for patients with cancer. Consequently, strategies for increasing therapeutic efficacy of already available drugs may be essential for the future health-care system.

AREAS COVERED

In this review, we have investigated the potential for the use of platelets as drug-delivery systems. We searched PubMed and Google Scholar to identify relevant papers written in English and published up to January 2023. Papers were included at the authors' discretion to reflect an overview of state of the art.

EXPERT OPINION

It is known that cancer cells interact with platelets to gain functional advantages including immune evasion and metastasis development. This platelet-cancer interaction has been the inspiration for numerous platelet-based drug delivery systems using either drug-loaded or drug-bound platelets, or platelet membrane-containing hybrid vesicles combining platelet membranes with synthetic nanocarriers. Compared to treatment with free drug or synthetic drug vectors, these strategies may improve pharmacokinetics and selective cancer cell targeting. There are multiple studies showing improved therapeutic efficacy using animal models, however, no platelet-based drug delivery systems have been tested in humans, meaning the clinical relevance of this technology remains uncertain.

Substantial Increase in Accessibility to Essential Anticancer Medicines in Anhui, China: A Longitudinal Study

The study aimed to evaluate the change in accessibility of essential anticancer medicines, from 2015 to 2018 in a pilot province for health care reform in China. Data on access to 23 essential anticancer medicines was obtained from 6 provincial tertiary hospitals. A comprehensive analysis was applied to explore these trends. The total utilization of anticancer medicines had increased by an average of 2.57 times (P < .001) during the study period, of which targeted anticancer medicines had the fastest growth rate of 6.45 times (P < .001). The prices of all targeted medicines and original brands (OBs) were showing a downward trend, with the average change rate of -32% and -28% respectively (both P < .001). In contrast, the price of non-targeted medicines and lowest-price generics (LPG) increased by an average of 98% (P < .001) and 117% (P < .004) respectively. All targeted anticancer medicines were found to be unaffordable under this standard of this study, but the affordability of these medicines is on the rise. The study suggested positive changes in the utilization, price, and affordability of the most essential anticancer medicines. In the future, comprehensive strategies need to be conducted to further increase the affordability of targeted anticancer medicines.

Activities against Lung Cancer of Biosynthesized Silver Nanoparticles: A Review

Nanomedicine is an interdisciplinary field where nanostructured objects are applied to treat or diagnose disease. Nanoparticles (NPs) are a special class of materials at nanometric scale that can be prepared from lipids, polymers, or noble metals through bottom-up approaches. Biological synthesis is a reliable, sustainable, and non-toxic bottom-up method that uses phytochemicals, microorganisms, and enzymes to induce the reduction of metal ions into NPs. Silver (Ag) NPs exhibit potent therapeutic properties that can be exploited to overcome the limitations of current treatment modalities for human health issues such as lung cancer (LC). Here, we review the preparation of AgNPs using biological synthesis and their application against LC using in vitro and in vivo models. An overview of the staging, diagnosis, genetic mutations, and treatment of LC, as well as its main subtypes, is presented. A summary of the reaction mechanisms of AgNPs using microbial cell cultures, plant extracts, phytochemicals, and amino acids is included. The use of capping agents in the biosynthesis of AgNPs with anticancer activity is also detailed. The history and biological activities of metal-based nanostructures synthesized with gold, copper, palladium, and platinum are considered. The possible anticancer mechanisms of AgNPs against LC models are covered. Our perspective about the future of AgNPs in LC treatment and nanomedicine is added.

PARP1pred: a web server for screening the bioactivity of inhibitors against DNA repair enzyme PARP-1

Cancer is the leading cause of death worldwide, resulting in the mortality of more than 10 million people in 2020, according to Global Cancer Statistics 2020. A potential cancer therapy involves targeting the DNA repair process by inhibiting PARP-1. In this study, classification models were constructed using a non-redundant set of 2018 PARP-1 inhibitors. Briefly, compounds were described by 12 fingerprint types and built using the random forest algorithm concomitant with various sampling approaches. Results indicated that PubChem with an oversampling approach yielded the best performance, with a Matthews correlation coefficient > 0.7 while also affording interpretable molecular features. Moreover, feature importance, as determined from the Gini index, revealed that the aromatic/cyclic/heterocyclic moiety, nitrogen-containing fingerprints, and the ether/aldehyde/alcohol moiety were important for PARP-1 inhibition. Finally, our predictive model was deployed as a web application called PARP1pred and is publicly available at https://parp1pred.streamlitapp.com, allowing users to predict the biological activity of query compounds using their SMILES notation as the input. It is anticipated that the model described herein will aid in the discovery of effective PARP-1 inhibitors.

Treatment patterns, adherence to international guidelines, and financial mechanisms of the market access of advanced breast cancer therapy in Bulgaria

Introduction

Breast cancer is the most common type of cancer affecting women in Europe. Advanced breast cancer (ABC) poses a significant therapeutic challenge, and therefore, timely access to treatment is crucial. The aim of the present study was to evaluate the treatment patterns and patients' access to new therapies for ABC in Bulgaria.

Methods

We conducted a retrospective study in the period 2008-2021. Based on the European Medicines Agency (EMA) database, we analyzed a number of medicinal products with marketing authorization for ABC in the last 13 years. Time to market access was evaluated as the degree of availability, which is measured by the number of medicines that are available to patients (availability index, AI), and the average time elapsed between obtaining a marketing authorization and time to inclusion in the Positive Drug List. Data were analyzed through descriptive statistics via Microsoft Excel version 10.

Results

The average time to access was 564 days for targeted therapy. The availability and compliance index for chemotherapy and hormonal therapy in advanced breast cancer was 1, while the average AI for targeted therapy was 0.67. Patient access to targeted oncology therapy of ABC is above average for Europe and takes 1-2 years.

Conclusion

Faster access is more evident for biosimilars. National regulatory requirements for pricing and reimbursement have a major impact on market access.

A comprehensive survey of cancer medicines prices, availability and affordability in Ghana

INTRODUCTION

In Ghana, prices for cancer medicines are characterized by high retail markups, forex fluctuations and high variation in prices of medicines. Most patients cannot afford the cancer medicines. There is a problem of unaffordability and limited availability of essential cancer medicines which suggests potential inequity in patient access to cancer medicines. The study objective was to assess the prices, availability, and affordability of cancer medicines in Ghana. Prices of cancer medicines are a major contributor to the cost of treatment for cancer patients and the comparison of these cost was assessed to determine the affordability.

METHOD

The methods developed and standardized by the World Health Organization (WHO) in collaboration with the Health Action International (HAI), was adapted and used to measure prices, availability, and affordability of cancer medicines in Ghana. The availability of cancer medicines was assessed as percentage of health facilities stocked with listed medicines. The price of cancer medicines (of different brands as well as the same medicine manufactured by different pharmaceutical industries) available in the public hospitals, private hospitals, and private pharmacies was assessed, and the percentage variation in prices was calculated. Medicine prices were compared with the Management Sciences Health's International Reference Prices to obtain a Median Price Ratio (MPR). The affordability of cancer medicines was determined using the treatment cost of a course of therapy for cancer conditions in comparison with the daily wage of the unskilled Lowest-Paid Government Worker.

RESULTS

Overall availability of cancer medicines was very low. The availability of Lowest Priced Generic (LPG) in public hospitals, private hospitals, and private pharmacies was 46%, 22%, and 74% respectively. The availability of Originator Brand (OB) in public hospitals, private hospitals, and private pharmacies was 14%, 11%, and 23% respectively. The lowest median price [United States Dollars (USD)] for the LPG was 0.25, and the highest median price was 227.98. For the OB, the lowest median price was 0.41 and the highest median price was 1321.60. The lowest and highest adjusted MPRs of OBs and LPGs was 0.01 and 10.15 respectively. Some prices were 20.60 times more expensive. Affordability calculations showed that patients with colorectal and multiple myeloma cancer would need 2554 days wages (5286.40 USD) and 1642 days wages (3399.82 USD) respectively to afford treatment.

CONCLUSION

The availability of cancer medicines was very low, and less than the WHO target of 80%. There were considerable variations in the prices of different brands of cancer medicines, and affordability remains suboptimal, as most patients cannot afford the cancer medicines. Comprehensive policies, regulations and multifaceted interventions that provides tax incentives, health insurance, and use of generics to improve cancer medicines availability, prices, and affordability, for the masses should be developed and implemented in Ghana.

The impacts of the National Medication Price-Negotiated Policy on the financial burden of cancer patients in Shandong province, China: an interrupted time series analysis

BACKGROUND

In order to further regulate the price of anticancer medication and alleviate the financial burden of cancer patients, the Chinese government implemented the National Medication Price-Negotiated Policy (NMPNP) in 2017. This study aims to assess the impacts of implementation of the NMPNP on the access of anticancer medication and the financial burden for cancer patients in Shandong province, and to provide evidence to inform the design of similar policies in other developing countries.

METHODS

A quasi-experiment design of an interrupt time series analysis was conducted. The month of September 2017 was taken as the intervention point when the Shandong Provincial Reimbursement Drug Lists was updated based on the result of the NMPNP in 2017. The data used were the aggregated monthly claim data of cancer patients from 2016 to 2021, which were obtained from four cities in Shandong province. The outpatient and inpatient care visits per capita, proportion of OOP expenditure and medication costs in outpatient and inpatient medical costs were used as outcome variables. A segmented regression model was used to analyze the change of the access of anticancer medication and the financial burden for cancer patients.

RESULTS

The outpatient care visits per capita significantly decreased after the intervention. Compared to preintervention trend, the proportion of OOP expenditure in outpatient medical costs decreased by average 0.25 percentage point per month (p <  0.0001) after the intervention, however the proportion of OOP expenditure in inpatient medical costs increased by 0.02 percentage point per month (p = 0.76). Since the intervention, the proportion of medication costs in outpatient medical costs averagely rose by 0.28 percentage point (p <  0.0001), and its implementation caused the proportion of medication costs in inpatient medical costs averagely decreased 0.2 percentage point (p <  0.0001).

CONCLUSIONS

The NMPNP improved the access of anticancer medication, and relieved the financial burden of outpatient care. However, it did not effectively alleviate the financial burden of inpatient care. Additionally, the NMPNP impacted the behavior of the healthcare providers. The policymakers should closely monitor the change of providers behaviors, and dynamically adjust financial incentives policies of healthcare providers during the implementation of similar medication price negotiated policies.

The health system and access to treatment in patients with cervical cancer in Mexico

Cervical cancer (CC) is tightly related to a low Human Development Index. Mexico is an upper-middle-income country with 126 million inhabitants, and its public health system aims to provide universal health coverage. Currently, employment-based social insurance covers approximately 60% of the population, and the scope of the remaining 40% is on course via the "IMSS-Bienestar" Institute. However, the annual government spending on health remains at 3% of the Gross Domestic Product, which is well below the 6% recommended by the Organization for Economic Cooperation and Development. CC is the second in incidence and mortality among women. Regarding primary prevention with the Human Papilloma Virus-vaccine, the current coverage for girls aged 9 to 14 years is only around 7%. Among secondary prevention with screening, the program is yet to cover the total number of women at risk; nevertheless, the age-standardized CC mortality rate has decreased from 12 per 100,000 women in 1979 to 5.7 per 100,000 women in 2020 due in part to increased screening coverage. Still, around two-thirds of patients present with locally advanced disease at diagnosis. Data from our country demonstrate that even socially disadvantaged CC patients achieve "standard" survival outcomes if treatment is granted. Nevertheless, there is a shortage in almost every aspect regarding CC treatment, including oncologists, chemotherapy units, medical physicists, radiation technicians, and both teletherapy and brachytherapy facilities. In conclusion, advances in the public health system in Mexico are urgently required to achieve CC control and reduce the mortality from this neoplasia that mainly targets socially disadvantaged women.

Chemotherapy supply chain management, safe-handling and disposal in Ethiopia: the case of Tikur Anbessa specialized hospital

Optimal chemotherapy management is substandard in low and middle-income countries. We aimed to identify major gaps to design interventional strategies for improved chemotherapy management at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. This study was conducted using an observational checklist, open-ended questions, record review, and key informant interviews of department heads and focal persons at TASH. Findings were categorized into specific themes that developed. Chemotherapy represented 60.2% of the hospital medication budget. Drug utilization was quantified via monthly consumption documentation and forecasting. However, unreliable data resulted in frequent stockouts (unavailability of the item when it is needed) of chemotherapy with only 67.8% availability. Thirteen healthcare personnel (9 nurses, 2 pharmacists and 2 hospital cleaners) were interviewed: all clinical staff but neither of hospital cleaners believed that they were at risk of hazardous agents. Challenges identified included inadequate and frequent stockouts (unavailability of the item when it is needed) of personal protective equipment, lack of standardized guidelines for chemotherapy handling, admixture, and disposal, lack of designated preparation rooms, and lack of training. All nine nurses handled chemotherapy admixtures despite only two nurses previously receiving in-service training. Most of the participants had never witnessed the disposal of anticancer drugs. Prompted by the results of this study, a dialogue was initiated among members of TASH, the American Cancer Society and the University of North Carolina to implement action-oriented projects to address the gaps identified at TASH. These gaps directly and indirectly affect care and treatment outcomes of patients at a large cancer center. Collaborations with well-resourced centers are potential models for improving chemotherapy management.

How Can Genomic Innovations in Pediatric Brain Tumors Transform Outcomes in Low- and Middle-Income Countries?

Pragmatic ways to apply molecular innovation to childhood brain cancer diagnosis and therapy in LMICs