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Cavillon A, Pouessel D, Houédé N, Mathevet F, Dauxois JY, Chevreau C, Culine S, Delord JP, Porcher R, Filleron T. Assessing Long-term Treatment Benefits Using Complementary Statistical Approaches: An In Silico Analysis of the Phase III Keynote-045 and Checkmate-214 Immune Checkpoint Inhibitor Trials. Eur Urol 2024; 85:293-300. [PMID: 36849297 DOI: 10.1016/j.eururo.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/17/2023] [Accepted: 02/08/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND The Keynote-045 trial illustrates that the long-term benefit (LTB) of treatment does not always translate to improved progression-free survival (PFS). Milestone survival and flexible parametric survival model with cure (FPCM) have been proposed as complementary statistical approaches to more comprehensively evaluate LTBs of treatments. OBJECTIVE The current study compares milestone survival and FPCM analyses to evaluate treatment effects of immune checkpoint inhibitor (ICI) phase III trials. DESIGN, SETTING, AND PARTICIPANTS Individual patient data, from initial and follow-up analyses of Keynote-045 (urothelial cancer) and Checkmate-214 (advanced renal cell carcinoma), were reconstructed for PFS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Each trial was reanalyzed using the Cox proportional hazard regression and two complementary methods (milestone survival and FPCM) to estimate treatment impact on the LTB. RESULTS AND LIMITATIONS For each trial, there was evidence of nonproportional hazards. For the long-term analysis of the Keynote-045 trial, FPCM identified a time-dependent effect on PFS, but the Cox model found no statistical difference in PFS (hazard ratio, 0.90; 95% confidence interval, 0.75-1.08). Milestone survival and FPCM identified improvements in the LTB fractions. This was consistent with the results from the reanalysis of Keynote-045, based on the shorter follow-up, although the LTB fraction was not retained. The increase in PFS in Checkmate-214 was identified by both Cox model and FPCM. Experimental treatment-dependent improvement in the LTB fraction was demonstrated using milestone survival and FPCM. The LTB fraction estimated with FPCM was consistent with the results from the reanalysis of the shorter follow-up period. CONCLUSIONS Although ICIs show substantial shifts toward LTBs in terms of PFS, based on a conventional Kaplan-Meier or Cox model analysis, our approach provides an alternative assessment of benefit-risk ratios for new therapeutics and facilitates communicating risk to patients. Kidney patients treated with ICIs can be counseled that they are potentially cured, but future work will need to definitively validate this conclusion. PATIENT SUMMARY Although immune checkpoint inhibitor treatments show substantial shifts toward long-term benefits in terms of progression-free survival, a more rigorous attempt to quantify this shift, rather than simply using a Kaplan-Meier estimate or comparing progression-free survival curves using the classic Cox model, is warranted. Our results suggest that advanced renal cell carcinoma patients who had not received a previous treatment are functionally cured by nivolumab and ipilimumab, which is not the case for second-line urothelial carcinoma.
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Affiliation(s)
- Ana Cavillon
- Biostatistics & Health Data Science Unit, Institut Claudius Regaud - IUCT-Oncopole, Toulouse, France
| | - Damien Pouessel
- Department of Medical Oncology, Institut Claudius Regaud - IUCT-Oncopole, Toulouse, France
| | - Nadine Houédé
- Institut de Cancérologie du Gard, CHU Nîmes, Nîmes Cedex, France
| | - Fanny Mathevet
- Biostatistics & Health Data Science Unit, Institut Claudius Regaud - IUCT-Oncopole, Toulouse, France
| | - Jean Yves Dauxois
- Institut de Mathématiques de Toulouse, UMR 5219, Université de Toulouse, CNRS, INSA, Toulouse, France
| | - Christine Chevreau
- Department of Medical Oncology, Institut Claudius Regaud - IUCT-Oncopole, Toulouse, France
| | - Stéphane Culine
- Department of Medical Oncology, UCOG, AP-HP, Saint-Louis Hospital, Paris, France; Paris Curie University, Paris, France
| | - Jean-Pierre Delord
- Department of Medical Oncology, Institut Claudius Regaud - IUCT-Oncopole, Toulouse, France
| | - Raphael Porcher
- Université Paris Cité, Centre de Recherche Épidémiologie et Statistiques (CRESS-UMR1153), INSERM, INRAE, Paris, France; Centre d'Épidémiologie Clinique, AP-HP, Hôtel-Dieu, Paris, France
| | - Thomas Filleron
- Biostatistics & Health Data Science Unit, Institut Claudius Regaud - IUCT-Oncopole, Toulouse, France.
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Orozco-Leal G, Johnson EE, Hosseinijebeli S, Robinson T, Homer T, Eastaugh CH, Richmond C, Tanner L, Meader N, Kenny R, Wallace SA, Rice S. Considerations for the Cure Assumption in an NICE Single Technology Appraisal of Nivolumab with Chemotherapy for Neoadjuvant Treatment of Resectable Non-Small Cell Lung Cancer: Evidence Assessment Group Perspective. Pharmacoeconomics 2024; 42:133-136. [PMID: 37985576 DOI: 10.1007/s40273-023-01328-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/22/2023]
Affiliation(s)
| | | | | | | | - Tara Homer
- Newcastle University, Newcastle upon Tyne, UK
| | | | - Catherine Richmond
- Clinical Effectiveness Librarian, Tyne and Wear NHS Foundation Trust, Gateshead, UK
| | | | - Nick Meader
- Newcastle University, Newcastle upon Tyne, UK
| | - Ryan Kenny
- Newcastle University, Newcastle upon Tyne, UK
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Kayauchi N, Nagatsu T, Satoh H. Using Compression Therapy to Treat Bilateral Lower Limb Edema in Patients with Lung Cancer: A Case Series. Adv Skin Wound Care 2023; 36:1-6. [PMID: 37861673 DOI: 10.1097/asw.0000000000000053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
ABSTRACT Although rare, marked bilateral leg edema (BLE) can occur in patients with lung cancer. Systemic therapy for the underlying disease is important, but adjunct therapy might also be helpful. In this case series, the authors report on treating BLE in patients with lung cancer with compression therapy using elastic stockings and bandages. From April 2013 to March 2022, the authors conducted a retrospective survey of seven patients who developed marked BLE and received compression therapy. They evaluated effects based on improvements in subjective symptoms as well as objective findings 2 months after the start of the therapy. The bandage therapy was useful in patients who were driver-gene negative, but it was not effective in those who already had "progressive disease" with specific agents for their driver genes. No adverse events were observed. Compression therapy, even when attached or detached by nonmedical personnel, may provide favorable effects and should be considered as an adjunct treatment option in this population, in addition to effective systemic cancer therapy. These results indicate that a prospective clinical trial would be worthwhile.
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Affiliation(s)
- Naomi Kayauchi
- In the College of Nursing, Ibaraki Christian University, Hitachi, Ibaraki, Japan, Naomi Kayauchi, MSN, RN, is Assistant Professor and Takako Nagatsu, MSN, RN, is Associate Professor. Hiroaki Satoh, MD, PhD, is Professor, Mito Medical Center, University of Tsukuba, Mito, Ibaraki. The authors have disclosed no financial relationships related to this article. Submitted August 22, 2022; accepted in revised form December 22, 2022
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Lin TA, Sherry AD, Ludmir EB. Challenges, Complexities, and Considerations in the Design and Interpretation of Late-Phase Oncology Trials. Semin Radiat Oncol 2023; 33:429-437. [PMID: 37684072 PMCID: PMC10917127 DOI: 10.1016/j.semradonc.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Optimal management of cancer patients relies heavily on late-phase oncology randomized controlled trials. A comprehensive understanding of the key considerations in designing and interpreting late-phase trials is crucial for improving subsequent trial design, execution, and clinical decision-making. In this review, we explore important aspects of late-phase oncology trial design. We begin by examining the selection of primary endpoints, including the advantages and disadvantages of using surrogate endpoints. We address the challenges involved in assessing tumor progression and discuss strategies to mitigate bias. We define informative censoring bias and its impact on trial results, including illustrative examples of scenarios that may lead to informative censoring. We highlight the traditional roles of the log-rank test and hazard ratio in survival analyses, along with their limitations in the presence of nonproportional hazards as well as an introduction to alternative survival estimands, such as restricted mean survival time or MaxCombo. We emphasize the distinctions between the design and interpretation of superiority and noninferiority trials, and compare Bayesian and frequentist statistical approaches. Finally, we discuss appropriate utilization of phase II and phase III trial results in shaping clinical management recommendations and evaluate the inherent risks and benefits associated with relying on phase II data for treatment decisions.
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Affiliation(s)
- Timothy A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexander D Sherry
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.; Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX..
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Cavillon A, Porcher R, Filleron T. Reply to Binghao Zhao, Ruidong Zhang, and Jiaming Wu's Letter to the Editor re: Ana Cavillon, Damien Pouessel, Nadine Houédé, et al. Assessing Long-term Treatment Benefits Using Complementary Statistical Approaches: An In Silico Analysis of the Phase III Keynote-045 and Checkmate-214 Immune Checkpoint Inhibitor Trials. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2023.02.011. Eur Urol 2023; 84:e22-e23. [PMID: 37120335 DOI: 10.1016/j.eururo.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/16/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Ana Cavillon
- Biostatistics & Health Data Science Unit, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France
| | - Raphael Porcher
- CRESS-UMR1153, Centre de Recherche Épidémiologie et Statistiques, Université Paris Cité, Paris, France; Centre d'Épidémiologie Clinique, AP-HP, Paris, France
| | - Thomas Filleron
- Biostatistics & Health Data Science Unit, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France.
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Shao T, Zhao M, Liang L, Shi L, Tang W. Impact of Extrapolation Model Choices on the Structural Uncertainty in Economic Evaluations for Cancer Immunotherapy: A Case Study of Checkmate 067. Pharmacoecon Open 2023; 7:383-392. [PMID: 36757569 PMCID: PMC10169997 DOI: 10.1007/s41669-023-00391-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES The aim of this study was to compare the performance of different extrapolation modeling techniques and analyze their impact on structural uncertainties in the economic evaluations of cancer immunotherapy. METHODS The individual patient data was reconstructed through published Checkmate 067 Kaplan Meier curves. Standard parametric models and six flexible techniques were tested, including fractional polynomial, restricted cubic splines, Royston-Parmar models, generalized additive models, parametric mixture models, and mixture cure models. Mean square errors (MSE) and bias from raw survival plots were used to test the model fitness and extrapolation performance. Variability of estimated incremental cost-effectiveness ratios (ICERs) from different models was used to inform the structural uncertainty in economic evaluations. All indicators were analyzed and compared under cut-offs of 3 years and 6.5 years, respectively, to further discuss model impact under different data maturity. R Codes for reproducing this study can be found on GitHub. RESULTS The flexible techniques in general performed better than standard parametric models with smaller MSE irrespective of the data maturity. Survival outcomes projected by long-term extrapolation using immature data differed from those with mature data. Although a best-performing model was not found because several models had very similar MSE in this case, the variability of modeled ICERs significantly increased when prolonging simulation cycles. CONCLUSIONS Flexible techniques show better performance in the case of Checkmate 067, regardless of data maturity. Model choices affect ICERs of cancer immunotherapy, especially when dealing with immature survival data. When researchers lack evidence to identify the 'right' model, we recommend identifying and revealing the model impacts on structural uncertainty.
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Affiliation(s)
- Taihang Shao
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Mingye Zhao
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Leyi Liang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Lizheng Shi
- Department of Global Health Management and Policy, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, 70118, USA.
| | - Wenxi Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China.
- Department of Public Affairs Management, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China.
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Xu T, Wang C, Chen X, Bai J, Wang E, Sun M. Coexpression of c-Jun in multiple-chain DAP-CAR-engineered T-cells for solid tumor therapy. Immunotherapy 2022; 14:1457-1466. [PMID: 36597720 DOI: 10.2217/imt-2022-0171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aim: This work was designed to explore whether c-Jun overexpression could improve the persistence and antitumor efficacy of DAP chimeric antigen receptor T-cell (CAR-T) cells. Methods: The in vitro and in vivo antitumor effects of mesothelin (MSLN) targeting DAP-CAR-T cells were verified by ELISA, real-time cell analysis and in a xenograft model. Results: c-Jun overexpression did not affect DAP-CAR-T cell expansion while slightly increasing IL-2 secretion. Moreover, c-Jun did not improve the antitumor efficacy of DAP-CAR-T cells in vitro or in vivo, but reduced LAG3 expression and increased the ratio of Tcm and Tn/Tscm cells in vivo. Conclusion: The findings indicate that coexpression with c-Jun in DAP-CAR-T cells slightly improves T-cell exhaustion and central memory phenotype maintenance, which may be useful for DAP-CAR-T cell therapy in solid tumors.
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Affiliation(s)
- Tongpeng Xu
- Department of Oncology, First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Chen Wang
- Nanjing CART Medical Technology Co., Ltd, Nanjing, 210032, China
| | - Xiaomei Chen
- Nanjing CART Medical Technology Co., Ltd, Nanjing, 210032, China
| | - Jian Bai
- Nanjing CART Medical Technology Co., Ltd, Nanjing, 210032, China
| | - Enxiu Wang
- Nanjing CART Medical Technology Co., Ltd, Nanjing, 210032, China.,Department of Pathology, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China.,Clinical Pathological Diagnosis & Research Center, Youjiang Medical University for Nationalities, Baise, 533000, China.,The Key Laboratory of Molecular Pathology (Hepatobiliary Diseases) of Guangxi, Baise, 533000, China
| | - Ming Sun
- Suzhou Cancer Center Core Laboratory, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Baita West Road #16, Suzhou, 215001, China
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Wang H, Wang Y, Li L, Zhou H, Lili S, Li L, Yike S, Aixia M. Economic evaluation of first-line nivolumab plus cabozantinib for advanced renal cell carcinoma in China. Front Public Health 2022; 10:954264. [PMID: 36159269 PMCID: PMC9490003 DOI: 10.3389/fpubh.2022.954264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/18/2022] [Indexed: 01/24/2023] Open
Abstract
Background In the Checkmate9ER trial, first-line treatment with nivolumab combined with cabozantinib (NI + CA) has shown efficacy for advanced renal cell carcinoma. This study aims to evaluate the impact of the health and economic outcomes of NI + CA in China. Methods Clinical efficacy data were derived from pivotal phase III CheckMate 9ER trial. A three-state partitioned survival model was established based on disease progression. Progression-free survival and overall survival of NI + CA vs. sunitinib were fitted with log-logistic and log-normal distributions, respectively. Mixture cure, non-mixture cure, and Royston/Parmar spline models were used to evaluate model robustness. The results derived the computational cost from the Chinese healthcare system perspective. The primary outcomes were quality-adjusted life-years (QALYs), total cost in US dollars, as well as incremental cost-effectiveness ratios (ICERs) at the willingness-to-pay threshold in China. One-way and probabilistic sensitivity analysis were also used to assess the robustness of the model. Results In the base-case analysis result, 0.86 additional QALYs could be obtained in the NI+CA (3.84 QALYs) versus the sunitinib strategy (2.97 QALYs). The ICER of NI+CA compared with the sunitinib strategy was US$292,945 per QALY. The ICER value in the NI+CA strategy was higher than the Chinese willingness-to-pay threshold of US$38,024 per QALY. Although NI+CA can improve long-term patient survival significantly over sunitinib in the treatment of advanced renal cell carcinoma, it is unlikely to be cost-effective due to high cost. The results of the one-way sensitivity analysis showed that drug cost, health utility value at the stage of disease progression, and subsequent treatment proportion had a greater impact on the stability of ICER values. Conclusions Nivolumab combined with cabozantinib can prolong the life of patients with advanced renal cell carcinoma and improve their quality of life, but there is a corresponding increase in medical cost. The NI + CA strategy is unlikely to be considered cost-effective in the treatment of advanced RCC from the perspective of Chinese healthcare system.
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Affiliation(s)
- Hao Wang
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China,Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Ye Wang
- Department of Clinical Pharmacy, School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Li Li
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China,Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Han Zhou
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Shang Lili
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Liao Li
- Department of Clinical Pharmacy, School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Shen Yike
- Department of Clinical Pharmacy, School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ma Aixia
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China,*Correspondence: Ma Aixia
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