Treatment Patterns and Clinical Outcomes Among Patients With Metastatic Prostate Cancer Harboring Homologous Recombination Repair Mutations

BACKGROUND

There is currently limited literature assessing the real-world treatment patterns and clinical outcomes of patients with metastatic castration-resistant prostate cancer (mCRPC) and homologous recombination repair (HRR) mutations.

METHODS

Medical charts were abstracted for mCRPC patients with ≥ 1 of 12 HRR somatic gene alterations treated at US oncology centers participating in the American Association for Cancer Research Project Genomics Evidence Neoplasia Information Exchange. Treatment patterns and clinical outcomes were assessed from the initiation of first-line or later (1L+) mCRPC therapy received on or after July 1, 2014.

RESULTS

Among 138 patients included in the study, the most common somatic HRR mutations were CDK12 (47.8%), BRCA2 (22.5%), and ATM (21.0%). Novel hormonal therapy and taxane chemotherapy were most commonly used in 1L; taxane use increased in later lines. Median overall survival (95% confidence interval [CI]) was 36.3 (30.7-47.8) months from initiation of 1L therapy and decreased for subsequent lines. Similarly, there was a trend of decreasing progression-free survival and prostate-specific antigen response from 1L to 4L+ therapy.

CONCLUSIONS

Treatment patterns identified in this study were similar to those among patients with mCRPC regardless of tumor HRR mutation status in the literature.

Real-world treatment patterns and overall survival among men with Metastatic Castration-Resistant Prostate Cancer (mCRPC) in the US Medicare population

BACKGROUND

Real-world treatment patterns and survival in metastatic castration-resistant prostate cancer (mCRPC) have not been characterized for the full fee-for-service Medicare population.

METHODS

Men newly diagnosed with mCRPC were identified in Medicare fee-for-service claims during 1/1/2014-6/30/2019. Men had evidence of mCRPC and continuous insurance coverage ≥1 year before and ≥6 months after diagnosis unless patients died. Treatment patterns after diagnosis were described. Survival from mCRPC diagnosis and from start of first-line (1 L) therapy was modeled using Kaplan-Meier analysis.

RESULTS

Among 14,780 men with mCRPC, mean age was 76 and median follow-up after mCRPC was 17.0 months. 22% received no life-prolonging therapy after mCRPC, 78% received ≥1 line of therapy (LOT), 42% underwent ≥2 LOTs, and 20% had ≥3 LOTs. Median time from start of 1 L to next LOT or end of follow-up was 13.7 months, 10.9 months from 2 L start, and 8.9 months from 3 L start. The most common 1 L to 2 L treatment sequences among men with ≥2 lines were NHT followed by a different NHT (33%), chemotherapy followed by NHT (14%), and NHT followed by chemotherapy (13%). For those initiating 1 L treatment with NHTs, only 28% received subsequent treatment with a different class of therapy. Median survival was 25.6 months after mCRPC and 23.4 months following treatment initiation.

CONCLUSIONS

More than 1 in 5 Medicare patients with mCRPC did not receive any life-prolonging therapy, and less than half received 2 L therapy. NHTs were the most common 1 L and 2 L therapies, with patients treated with NHT as 1 L followed by a different NHT for 2 L as the most common treatment sequence. Median survival from diagnosis for all patients was 25.6 months. These data highlight the dramatic undertreatment that occurs for mCRPC patients, particularly for therapies beyond NHTs as well as the common use of sequential NHTs in real-world data.

Healthcare Costs in Men with Metastatic Castration-Resistant Prostate Cancer: An Analysis of US Medicare Fee-For-Service Claims

INTRODUCTION

To analyze healthcare resource utilization (HRU) and healthcare costs in men with metastatic castration-resistant prostate cancer (mCRPC) in the US Medicare population.

METHODS

A published claims-based algorithm was used to identify men with mCRPC in the fee-for-service Medicare population between January 1, 2014, and December 31, 2019. Unadjusted all-cause HRU (days) and healthcare costs paid by Medicare (medical and pharmacy) per patient per year (PPPY) are described for the periods before mCRPC diagnosis, after diagnosis, and from the start of first-line (1L), second-line (2L), and third-line (3L) therapy with mCRPC life-prolonging treatments to the start of subsequent therapy or end of follow-up/death.

RESULTS

A total of 14,780 men with mCRPC were identified. After mCRPC diagnosis, 11,528 men initiated 1L mCRPC therapy, 6275 initiated 2L, and 2945 initiated 3L. All-cause medical HRU (days PPPY) increased after mCRPC diagnosis and from 1L through 3L treatment, particularly for outpatient care (pre-diagnosis, 10.4; 1L, 16.2; 2L, 18.9; 3L, 22.0) and physician/other visits (pre-diagnosis, 30.1; 1L, 46.5; 2L, 50.2; 3L, 56.9). Similarly, mean all-cause healthcare costs PPPY were $27,468 in the year before mCRPC diagnosis and increased over four fold to $124,379 after mCRPC diagnosis and continued to rise from start of 1L ($148,325) to 2L ($160,118) to 3L ($165,186) therapy.

CONCLUSION

HRU and healthcare costs increased substantially following mCRPC diagnosis, and continued to increase even further through progression from 1L through 3L mCRPC therapy. These findings help to quantify the economic burden of mCRPC and to contextualize the economic value of treatments that delay disease progression.

Real-World Treatment Trends Among Patients with Metastatic Castration-Sensitive Prostate Cancer: Results from an International Study

BACKGROUND

Continuous androgen deprivation therapy ± first-generation non-steroidal antiandrogen was previously the standard-of-care for patients with metastatic castration-sensitive prostate cancer (mCSPC). Treatment intensification with novel hormonal therapy (NHT) or taxane chemotherapy is now approved and guideline-recommended for these patients.

METHODS

Physician-reported data on adult patients with mCSPC from the Adelphi Prostate Cancer Disease Specific Programme were analyzed descriptively. We evaluated real-world treatment trends for patients with mCSPC in 5 European countries (United Kingdom, France, Germany, Spain, and Italy) and the United States (US), looking at differences between patients initiating treatment in 2016-2018 and in 2019-2020. We also investigated treatment trends by ethnicity and insurance status in the US.

RESULTS

This study found that most patients with mCSPC do not receive treatment intensification. However, greater use of treatment intensification with NHT and taxane chemotherapy was observed in 2019-2020 than in 2016-2018 across 5 European countries. In the US, greater use of treatment intensification with NHT in 2019-2020 than in 2016-2018 was observed for all ethnicity groups and those with Medicare and commercial insurance status.

CONCLUSIONS

As the number of patients with mCSPC who receive treatment intensification increases, more patients who progress to metastatic castration-resistant prostate cancer (mCRPC) will have been exposed to intensified treatments. Treatment options for patients with mCSPC and mCRPC overlap, suggesting that an unmet need will emerge for new therapies. Further studies are needed to understand optimal treatment sequencing in mCSPC and mCRPC.

Real-World Treatment Patterns Among Patients With Metastatic Castration-Resistant Prostate Cancer: Results From an International Study

BACKGROUND

There is limited real-world evidence on how increasing use of treatment intensification in metastatic castration-sensitive prostate cancer (mCSPC) has influenced treatment decisions in metastatic castration-resistant prostate cancer (mCRPC). The study objective was to evaluate the impact of novel hormonal therapy (NHT) and docetaxel use in mCSPC on first-line treatment patterns among patients with mCRPC in 5 European countries and the United States (US).

METHODS

Physician-reported data on patients with mCRPC from the Adelphi Prostate Cancer Disease Specific Program were descriptively analyzed.

RESULTS

A total of 215 physicians provided data on 722 patients with mCRPC. Across 5 European countries and the US, 65% and 75% of patients, respectively, received NHT, and 28% and 9% of patients, respectively, received taxane chemotherapy as first-line mCRPC treatment. In Europe, patients who had received NHT in mCSPC (n = 76) mostly received taxane chemotherapy in mCRPC (55%). Patients who had received taxane chemotherapy, or who did not receive taxane chemotherapy or NHT in mCSPC (n = 98 and 434, respectively) mostly received NHT in mCRPC (62% and 73%, respectively). In the US, patients who had received NHT, taxane chemotherapy, or neither in mCSPC (n = 32, 12, and 72, respectively) mostly received NHT in mCRPC (53%, 83%, and 83%, respectively). Two patients in Europe were rechallenged with the same NHT.

CONCLUSIONS

These findings suggest that physicians consider mCSPC treatment history when making first-line treatment decisions in mCRPC. Further studies are needed to better understand optimal treatment sequencing, especially as new treatments emerge.

The impact of race on survival in metastatic prostate cancer: a systematic literature review

BACKGROUND

Prostate cancer (PC) is the second most diagnosed cancer in men worldwide. While racial and ethnic differences exist in incidence and mortality, increasing data suggest outcomes by race among men with newly diagnosed PC are similar. However, outcomes among races beyond Black/White have been poorly studied. Moreover, whether outcomes differ by race among men who all have metastatic PC (mPC) is unclear. This systematic literature review (SLR) provides a comprehensive synthesis of current evidence relating race to survival in mPC.

METHODS

An SLR was conducted and reported in accordance with PRISMA guidelines. MEDLINE®, Embase, and Cochrane Library using the Ovid® interface were searched for real-world studies published from January 2012 to July 2022 investigating the impact of race on overall survival (OS) and prostate cancer-specific mortality (PCSM) in patients with mPC. A supplemental search of key congresses was also conducted. Studies were appraised for risk of bias.

RESULTS

Of 3228 unique records identified, 62 records (47 full-text and 15 conference abstracts), corresponding to 54 unique studies (51 United States and 3 ex-United States) reporting on race and survival were included. While most studies showed no difference between Black vs White patients for OS (n = 21/27) or PCSM (n = 8/9), most showed that Black patients demonstrated improved OS on certain mPC treatments (n = 7/10). Most studies found no survival difference between White patients and Hispanic (OS: n = 6/8; PCSM: n = 5/6) or American Indian/Alaskan Native (AI/AN) (OS: n = 2/3; PCSM: n = 5/5). Most studies found Asian patients had improved OS (n = 3/4) and PCSM (n = 6/6) vs White patients.

CONCLUSIONS

Most studies found Black, Hispanic, and AI/AN patients with mPC had similar survival as White patients, while Black patients on certain therapies and Asian patients showed improved survival. Future studies are needed to understand what aspects of race including social determinants of health are driving these findings.

Patient-reported Outcomes in Men with Metastatic Castration-resistant Prostate Cancer Harboring DNA Damage Response Alterations Treated with Talazoparib: Results from TALAPRO-1

BACKGROUND

Talazoparib has shown antitumor activity with a manageable safety profile in men with metastatic castration-resistant prostate cancer (mCRPC) and DNA damage response (DDR)/homologous recombination repair (HRR) alterations.

OBJECTIVE

To evaluate patient-reported health-related quality of life (HRQoL) and pain in patients who received talazoparib in the TALAPRO-1 study, with a special interest in patients harboring breast cancer susceptibility gene 1 or 2 (BRCA1/2) mutations.

DESIGN, SETTING, AND PARTICIPANTS

TALAPRO-1 is a single-arm, phase 2 study in men with mCRPC DDR alterations either directly or indirectly involved in HRR, who previously received one to two taxane-based chemotherapy regimens for advanced prostate cancer and whose mCRPC progressed on one or more novel hormonal agents.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Men completed the European Quality-of-life Five-dimension Five-level scale (EQ-5D-5L), EQ-5D visual analog scale (VAS), and Brief Pain Inventory-Short Form at predefined time points during the study. The patient-reported outcome (PRO) population included men who completed a baseline and one or more postbaseline assessments before study end. Longitudinal mixed-effect models assuming an unstructured covariance matrix were used to estimate the mean (95% confidence interval [CI]) change from baseline for pain and general health status measurements among all patients and patients with BRCA1/2 mutations.

RESULTS AND LIMITATIONS

In the 97 men in the PRO population treated with talazoparib (BRCA1/2, n = 56), the mean (95% CI) EQ-5D-5L Index improved (all patients, 0.05 [0.01, 0.08]; BRCA1/2 subset, 0.07 [0.03, 0.10]), as did the EQ-5D VAS scores (all patients, 5.42 [2.65, 8.18]; BRCA1/2 subset, 4.74 [1.07, 8.41]). Improvements in the estimated overall change from baseline (95% CI) in the mean worst pain were observed in all patients (-1.08 [-1.52, -0.65]) and the BRCA1/2 subset (-1.15 [-1.67, -0.62]). The probability of not having had experienced deterioration of worst pain by month 12 was 84% for all patients and 83% for the BRCA1/2 subset.

CONCLUSIONS

In heavily pretreated men with mCRPC and DDR/HRR alterations, talazoparib was associated with improved HRQoL in all patients and the BRCA1/2 subset. In both patient groups, worst pain improved from baseline and the probability of not experiencing a deterioration in worst pain with talazoparib was high.

PATIENT SUMMARY

We show that talazoparib was associated at least with no change or improvements in health-related quality of life (HRQoL) and pain burden in men with metastatic castration-resistant prostate cancer and DNA damage response/homologous recombination repair gene alterations in the TALAPRO-1 study. These findings in patient-reported HRQoL and pain complement the antitumor activity and tolerability profile of talazoparib.

Real world (rw) homologous recombination repair (HRR) gene mutation testing trends in patients (pts) with metastatic castrate-resistant prostate cancer (mCRPC) in the United States (US)

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Background: Previous research suggests that HRR mutations may have prognostic value in mCRPC. Additionally, HRR mutations are therapeutically relevant and can inform treatment decisions. Limited information is available on HRR mutation testing rates in the US. This study assessed rw HRR testing patterns in pts with mCRPC in the US and described characteristics associated with HRR testing. Methods: Retrospective data from pts with mCRPC initiating first line (1L) treatment between 2014 – 2021 was obtained from the nationwide Flatiron Health electronic health record-derived de-identified database. Pt demographic and clinical characteristics were summarized descriptively across subgroups by HRR gene testing status (tested vs not tested). A multivariable logistic regression model was used to assess factors associated with receiving HRR testing, and included covariates for demographic, clinical, and treatment characteristics. Results: A total of n=8,166 pts with mCRPC receiving 1L treatment were identified. The mean age of the cohort was 72.9 (standard deviation (SD) 8.1) years. Overall, 2,122/8,166 (26%) were known to have received HRR mutation testing. Pts who did not receive HRR testing were older compared to HRR tested pts (mean age 73.7 (SD 8.5) vs 70.6 (SD 7.5) years). A higher proportion of HRR tested were receiving treatments from an academic medical center vs community practice (14.5% vs. 7.7%). Multivariable logistic regression indicated age > 65 (vs < 65 years), Black race (vs White), being treated in the community (vs academic), and having de novo metastatic disease (vs recurrent) were associated with a statistically significant lower odds of HRR mutation testing. In contrast, a higher socioeconomic status and being diagnosed with mCRPC after 2018 were associated with a statistically significant increased odds of HRR mutation testing. Conclusions: In this rw study, a minority of US pts with mCRPC received HRR mutation testing. Disparities in HRR mutation testing exist, and focused efforts to increase HRR testing should be developed, especially among Black pts, pts with lower socioeconomic status, pts treated in the community setting, and pts > 65 years of age. [Table: see text]

Real-World Study of Regional Differences in Patient Demographics, Clinical Characteristics, and BRCA1/2 Mutation Testing in Patients with Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer in the United States, Europe, and Israel

INTRODUCTION

Genetic mutations in breast cancer susceptibility gene 1 or 2 (BRCA1/2) confer a high risk for developing breast cancer; however, at least 50% of women with BRCA1/2 mutations go undiagnosed. This study evaluated differences in patient demographics, clinical characteristics, and BRCA1/2 mutation testing in the USA, European Union (EU4), and Israel in a real-world population of patients with human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (ABC).

METHODS

This study was a retrospective analysis of data from the Adelphi Real World ABC Disease Specific Programme in the USA, EU4, and Israel. Medical oncologists completed a patient record form, which included detailed questions on demographics, clinical assessments and outcomes, and treatment history. Eligible patients were at least 18 years of age and receiving therapy for stage IIIb-IV ABC.

RESULTS

Among the 2527 study patients, 407 were from the USA, 1926 were from the EU4, and 194 were from Israel; 86% had hormone receptor-positive (HR+)/HER2- ABC and 14% had triple-negative breast cancer (TNBC). Israeli patients had a higher rate of family history of BRCA-related cancer (69%) compared with patients in the EU4 (18%; p < 0.0001) and USA (18%; p < 0.0001). Among patients with HR+/HER2- ABC, the BRCA1/2 testing rate was 99% in Israel, 37% in the EU4, and 68% in the USA (p < 0.0001 vs Israel and the EU4). The age of tested patients was significantly younger in Israel (56 years) compared with the EU4 (59 years; p = 0.016 vs Israel) and USA (64 years; p < 0.0001 vs Israel and the EU4). Among patients with TNBC, the BRCA1/2 testing rate was 100% in Israel, 78% in the EU4 (p < 0.0001 vs Israel), and 93% in the USA (p < 0.002 vs the EU4). Among tested patients, genetic counseling rates were also higher in Israel (98%) compared with the EU4 (40%; p < 0.0001) and USA (38%; p < 0.0001).

CONCLUSIONS

Testing and genetic counseling rates for BRCA1/2 mutations were very high in Israel, potentially due to the high rate of family history of BRCA-related cancer in this population and higher general awareness of genetic testing. In the EU4 and USA, overall rates of testing for BRCA1/2 mutations and genetic counseling were significantly lower compared with Israel. Given the high risk of breast cancer in BRCA1/2 mutation carriers and the efficacy of new therapies in treating ABC with a BRCA1/2 mutation, efforts should be made to improve BRCA1/2 testing rates in Europe and the USA.

Real-world patient-reported outcomes and physician satisfaction with poly (ADP-ribose) polymerase inhibitors versus chemotherapy in patients with germline BRCA1/2-mutated human epidermal growth factor receptor 2-negative advanced breast cancer from the United States, Europe, and Israel

BACKGROUND

In clinical trials, poly (ADP-ribose) polymerase inhibitors (PARPi) versus chemotherapy resulted in significantly improved progression-free survival, manageable adverse event profiles, and favorable patient-reported outcomes (PROs) in patients with human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (ABC) and germline BRCA1/2 mutations (gBRCA1/2mut). The objective of this study was to evaluate PROs and physician satisfaction with treatment in patients with gBRCA1/2mut HER2- ABC receiving PARPi or physician's choice of chemotherapy in a multi-country, real-world setting.

METHODS

This retrospective analysis used data from the Adelphi Real World ABC Disease Specific Programmes in the United States, European Union, and Israel. PROs were assessed at a single timepoint using the EuroQol 5-Dimensions 5-Level (EQ-5D-5L) scale, Cancer Therapy Satisfaction Questionnaire (CTSQ), and European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 30 (EORTC QLQ-C30) and the breast cancer-specific module (QLQ-BR23). Baseline PROs were not assessed. Physician satisfaction with treatment scores was dichotomized to a 0/1 variable (0 = very dissatisfied/dissatisfied/moderately satisfied; 1 = satisfied/very satisfied). Scores were compared using inverse-probability-weighted regression adjustment, controlling for multiple confounding factors.

RESULTS

The study included 96 patients (PARPi, n = 38; platinum/non-platinum-based chemotherapy, n = 58). Patients receiving PARPi versus chemotherapy reported significantly better scores on the EQ-5D-5L Health Utility Index. On the EORTC QLQ-C30 functional scales, patients receiving PARPi reported significantly better scores (mean ± SE) for physical functioning (80.0 ± 2.4 vs 71.9 ± 3.4; p < 0.05) and social functioning (82.0 ± 6.2 vs 63.6 ± 3.7; p < 0.05) and, on the symptom scales, reported significantly better scores for constipation (1.9 ± 1.8 vs 18.7 ± 3.2; p < 0.001), breast symptoms (0.4 ± 3.9 vs 13.3 ± 2.6; p < 0.01), arm symptoms (2.6 ± 1.3 vs 11.4 ± 2.4; p = 0.001), and systemic therapy side effects (13.5 ± 1.8 vs 29.4 ± 2.3; p < 0.001). In contrast, patients receiving chemotherapy scored significantly better on the nausea/vomiting scale (18.3 ± 2.8 vs 34.5 ± 5.1; p < 0.01). Patients receiving PARPi reported numerically better satisfaction scores on the CTSQ scales. Physicians were more likely to be satisfied/very satisfied with PARPi versus chemotherapy (95.4% ± 7.3% vs 40.8% ± 6.2%; p < 0.001).

CONCLUSIONS

The PRO findings in this real-world population of patients with gBRCA1/2mut HER2- ABC complement those from the pivotal clinical trials, providing further support for treatment with PARPi in these patients.

Real-world study of patients with germline BRCA1/2-mutated human epidermal growth factor receptor 2‒Negative advanced breast cancer: Patient demographics, treatment patterns, adverse events, and physician-reported satisfaction in the United States, Europe, and Israel

BACKGROUND

Current guidelines for the treatment of human epidermal growth factor receptor 2‒negative (HER2-) advanced breast cancer (ABC) are informed by tumor characteristics and include platinum- and non-platinum-based chemotherapy, chemotherapy plus immunotherapy, endocrine monotherapy, or endocrine therapy plus a targeted therapy. In addition, poly(adenosine diphosphate-ribose) polymerase inhibitors (PARPi) have recently demonstrated improved clinical and patient-reported outcomes and manageable toxicity profiles compared with chemotherapy in patients with germline breast cancer susceptibility gene 1 or 2 (gBRCA1/2)‒mutated HER2- ABC in clinical trials and are now approved to treat this patient population. This study provides complementary real-world data regarding treatment patterns, adverse events, and physician-reported treatment satisfaction in this population.

METHODS

This retrospective analysis using the Adelphi Real World ABC Disease Specific Programme in the United States, European Union, and Israel included patients aged ≥18 years receiving therapy for stage IIIb or IV gBRCA1/2-mutated HER2- ABC. Oncologists completed a patient record form detailing patient demographics, clinical assessments, and treatment history and a survey regarding their use of and satisfaction with treatments.

RESULTS

Among the 543 patients, mean age was 55 years, 25% were premenopausal, 70% had hormone receptor‒positive (HR+) ABC, and 30% had triple-negative breast cancer (TNBC). PARPi were used in 5%, 11%, and 12% of first-line, second-line, and third-line therapies, respectively, for patients with HR+ ABC; for TNBC, percentages were 18%, 44%, and 36%. Across treatment lines, neutropenia, anemia, and nausea occurred in 16%, 24%, and 32% of patients receiving PARPi, respectively; 22%, 38%, and 33% of patients receiving platinum chemotherapy; and 20%, 20%, and 33% of patients receiving non-platinum-based chemotherapy. Physician satisfaction was highest with PARPi and with chemotherapy plus immunotherapy.

CONCLUSIONS

Findings in this real-world population complement clinical trial observations and provide further support for treatment of patients with PARPi in gBRCA1/2-mutated HER2- ABC.

Real-world treatment patterns among men with metastatic castration-resistant prostate cancer (mCRPC) in the U.S. Medicare population

406

Background: Multiple life-prolonging therapies have been approved for mCRPC, for example novel hormonal therapies (NHT; abiraterone [abi], enzalutamide [enza]), docetaxel (doc), cabazitaxel, sipuleucel-T, and radium-223. This study describes real-world treatment patterns with life-prolonging therapies and sequencing among men with mCRPC in the US Medicare population. Methods: Men newly diagnosed with mCRPC were identified in Medicare fee-for-service claims during 1/1/2014–6/30/2019. Adult men were required to have a diagnosis of prostate cancer, metastasis diagnosis, castration-resistance using a published claims-based algorithm, and continuous insurance coverage for ≥1 year before and ≥6 months after index mCRPC diagnosis unless patients died. Treatment patterns of life-prolonging therapies after mCRPC diagnosis and sequencing were described. Results: Among 14,780 men with mCRPC, median age was 75 years, 10% used NHT in the year prior to mCRPC, and 3% had prior taxane therapy. Median follow-up after mCRPC diagnosis was 17 months. 22% of men received no life-prolonging therapy after mCRPC diagnosis, 78% received ≥1 line of therapy with life-prolonging treatment after mCRPC diagnosis, 42% had ≥2, and 20% had ≥3. The most common first-line (1L) therapies were abi (36%), enza (28%), and doc (16%). The most common second-line (2L) therapies were enza (33%), abi (28%), and doc (15%). The most common third-line (3L) therapies were doc (24%), enza (19%), and abi (17%). Median time from start of 1L to next line of therapy or end of follow-up was 13.7 months, 10.9 months from the start of 2L, and 8.9 months from the start of 3L. The most common 1L to 2L treatment sequences among men with ≥2 lines were NHT followed by a different NHT (33%), chemotherapy followed by NHT (14%), and NHT followed by chemotherapy (13%). There were 5,630 men with ≥2 lines of therapy and ≥1 NHT, of whom 53% had ≥2 NHTs. Conclusions: Substantial proportions of men with mCRPC did not receive a life-prolonging therapy or had only 1L therapy after mCRPC diagnosis, with a 50% fall-off rate after each line of therapy. NHTs were the most common 1L and 2L therapies, and NHT followed by a different NHT was the most common treatment sequence. Further research is needed to understand how treatment patterns change as NHTs and doc are used earlier in the disease continuum and new therapies are introduced and ultimately to identify optimal treatment sequencing.

Health care costs among men with metastatic castration-resistant prostate cancer (mCRPC) in the U.S. Medicare population

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Background: Studies have reported healthcare costs before and after mCRPC diagnosis in commercially insured populations, but no information is available about costs with progression through lines of therapy after mCRPC diagnosis. This study describes healthcare costs among men with mCRPC in the US Medicare population before mCRPC diagnosis, after diagnosis, and with progression through lines of therapy. Methods: Men newly diagnosed with mCRPC were identified in Medicare fee-for-service claims during 1/1/2014–6/30/2019. Adult men were required to have a diagnosis of prostate cancer, metastasis diagnosis, castration-resistance using a published claims-based algorithm, and continuous insurance coverage for ≥1 year before and ≥6 months after index mCRPC diagnosis unless patients died. Unadjusted all-cause healthcare costs (medical and pharmacy) per patient per year (PPPY) to Medicare inflated to 2019 dollars were described for the periods before mCRPC diagnosis, after diagnosis, and from the start of first-line (1L), second-line (2L), and third-line (3L) therapy with mCRPC life-prolonging treatments to the start of subsequent therapy or end of follow up. Results: Among 14,780 men with mCRPC, median age was 75 years, and the mean Quan-Charlson Comorbidity Index was 2.1. Median follow-up after mCRPC diagnosis was 17 months. During the follow up, 3,252 men had no life-prolonging treatment, 11,528 men initiated 1L mCRPC therapy, 6,275 initiated 2L, and 2,945 initiated 3L. Mean all-cause healthcare costs PPPY were $27,468 in the year before mCRPC diagnosis, $124,379 after mCRPC diagnosis, $102,380 among men without life-prolonging treatment after mCRPC diagnosis, $148,325 from the start of 1L to subsequent therapy or end of follow up, $160,118 from the start of 2L therapy, and $165,186 from the start of 3L therapy. Conclusions: Mean healthcare costs increased over 4-fold from before to after mCRPC diagnosis and increased steadily as patients progressed from first through third lines of mCRPC therapy. These findings help quantify the economic burden of mCRPC and contextualize the economic value of treatments that delay disease progression.[Table: see text]

Overall survival by race and ethnicity among men with metastatic castration-resistant prostate cancer (mCRPC) in the U.S. Medicare population

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Background: Previous studies reported mixed findings about racial and ethnic disparities in overall survival (OS) in mCRPC. This study describes OS by race and ethnicity among men with mCRPC in the US Medicare population. Methods: Men newly diagnosed with mCRPC were identified in Medicare fee-for-service claims during 1/1/2014–6/30/2019. Adult men were required to have a diagnosis of prostate cancer, metastasis diagnosis, castration-resistance using a published claims-based algorithm, and continuous insurance coverage for ≥1 year before and ≥6 months after index mCRPC diagnosis unless patients died. OS from mCRPC diagnosis and from start of first-line (1L) therapy for mCRPC for White (W), Black (B), Hispanic (H), and Asian (A) men were estimated using Kaplan-Meier analysis and Cox proportional hazards models adjusting for patient characteristics and 1L mCRPC therapy type or no treatment. Results: Among 14,780 men with mCRPC in this study, 75% were W, 14% were B, 6% were H, 3% were A, and 3% were of other or unknown race. Mean age at mCRPC diagnosis was 76 years among W men; B men had similar age while H and A men were slightly older than W men (Table). B, H, and A men had higher Quan-Charlson Comorbidity Index (CCI) than W men. Median follow-up after mCRPC diagnosis was 17 months. Similar proportions of W, H and A men (78%, 78%, and 79%, respectively) and lower proportion of B men (75%) initiated 1L life-prolonging therapy after mCRPC diagnosis. Among treated men, higher proportions of B, H, and A men (71%, 74%, and 73%, respectively) initiated 1L therapy with novel hormonal therapy than W men (64%). Median OS after mCRPC diagnosis was 26.0, 22.3, 22.9, and 24.2 months among W, B, H, and A men, respectively. Median OS after initiation of 1L mCRPC therapy was 23.8, 21.1, 19.9, and 24.1 months among W, B, H, and A men, respectively. After adjusting for patient characteristics and 1L treatment, OS was not different for B and H men relative to W men, while A men had lower risk of death. (Table). Conclusions: This study found no statistically significant differences in overall survival in mCRPC for B and H men and lower risk of death for A men relative to W men after adjusting for patient characteristics and treatment in the US Medicare population.[Table: see text]

Treatment trends among men with metastatic castration sensitive prostate cancer (mCSPC): Results from the US component of an international study

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Background: Novel hormonal therapies (NHTs) and taxane-based chemotherapy (CT) were initially approved for the treatment of metastatic castration resistant prostate cancer (mCRPC) and are now approved for use in mCSPC. Little is known about the recent uptake of these treatments in mCSPC. This study evaluated mCSPC treatment trends from 2016 to 2020 in the US. Methods: Participating physicians collected information from medical charts for the next consecutive 8 men with advanced prostate cancer (4 men with mCSPC, and 4 men with mCRPC) during January-August 2020. A subset of men with current mCRPC had historical mCSPC treatment information available. Treatments were categorized into 4 mutually exclusive categories: (1) androgen deprivation therapy (ADT) ± first-generation anti-androgen (1st gen AA); treatment intensification with (2) NHT, (3) taxane CT ± NHT, and (4) other treatments (e.g., radium-223, sipuleucel-T, non-taxane CT). To account for the availability of new mCSPC treatments, treatment patterns across all lines of mCSPC therapy were described for men initiating treatment in 2016-2018 and 2019-2020. Results: 239 men with mCSPC were included (146 with mCSPC at data collection; 93 with mCRPC at data collection and who had historical information on mCSPC treatments). Mean age was 69 years; 69% had bone metastases and 30% had visceral metastases. Most patients were managed by oncologists (75%), while 48% were treated at academic/cancer centers. From 2016-2018 to 2019-2020, mCSPC treatment intensification with NHT increased while treatment intensification with taxane CT or other therapies declined. (Table) Conclusions: In this real-world study of adult men with mCSPC, increased use of NHT was observed over time indicating that more men will have been exposed to NHT when they progress to mCRPC. This suggests an unmet need for novel therapies in mCRPC. Funding: Pfizer. [Table: see text]

Treatment (tx) patterns among men with metastatic castration resistant prostate cancer (mCRPC) in the United States (US)

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Background: Novel hormonal therapies (NHTs) and docetaxel were initially approved for the tx of men with mCRPC. Over time, these agents moved earlier in the disease continuum and are now also used in metastatic castration sensitive prostate cancer (mCSPC). Little is known about first-line (1L) mCRPC tx patterns for men with prior taxane-based chemotherapy (CT) or NHT exposure. This study evaluated the impact of taxane CT or NHT use in mCSPC on recent 1L tx patterns among men with mCRPC in the US. Methods: Participating physicians collected information from medical charts for the next consecutive 4 adult men with mCRPC during January-August 2020. A subset of men had prior mCSPC tx information available. 1L mCRPC txs were described overall and stratified by previous tx with taxane CT or NHT during mCSPC. No statistical comparisons were performed. Results: 116 adult men with mCRPC and known mCSPC tx history were included. Mean age was 70 years; 15% had known family history of prostate cancer; 70% had bone metastases and 33% had visceral metastases at data collection. Overall, 10% (12/116) of men had been previously treated with taxane CT and 28% (32/116) were treated with NHT during mCSPC. 1L mCRPC tx was initiated on average 35 days after mCRPC diagnosis. NHT was the most common 1L mCRPC tx regardless of prior taxane CT or NHT use. Men pre-treated with taxane CT were more likely to initiate mCRPC tx with NHT than taxane naïve men. NHT pre-treated men were less likely to initiate 1L mCRPC tx with NHT and more likely to initiate tx with docetaxel than NHT naïve men. 53% of men with prior NHT tx were rechallenged with NHTs in 1L mCRPC. (Table). Conclusions: Findings from this US real-world study among men with mCRPC suggest physicians most commonly initiate 1L mCRPC life-prolonging tx with NHT regardless of prior taxane CT or NHT exposure. Additional studies with larger sample sizes are needed to confirm these findings and better understand optimal tx sequencing, especially as new tx options become available.[Table: see text]

Abstract P2-09-08: Impact of race on clinical outcomes among patients with advanced triple negative breast cancer (TNBC) and Germline BRCA1/2 mutation(s) (gBRCA1/2mut): Results from a US real-world study

Background: Racial disparities among patients with breast cancer in the United States are well documented, with Black patients having a 40% higher mortality than White patients. Socioeconomic status, tumor biology differences, and treatment access are known contributing factors. Additionally, despite having a higher incidence of TNBC, Black patients are substantially less likely to receive gBRCA1/2mut testing than White patients. TNBC is an aggressive subtype, accounting for 15% of all breast cancers diagnosed in the United States. TNBC disproportionately affects BRCA mutation carriers and Black women. With the advent of poly ADP-ribose polymerases inhibitors (PARPi), gBRCA1/2mut are considered actionable biomarkers. Limited data are available on the impact of race on clinical outcomes among patients with gBRCA1/2-mutated advanced TNBC in the United States. Methods: US oncologists retrospectively reviewed patient charts (July 2019-June 2020) of a quasirandom selection of patients aged ≥18 years with gBRCA1/2-mutated advanced TNBC who received ≥1 cytotoxic chemotherapy (CT) regimen for advanced TNBC between Jan 2013-April 2018. Patients were categorized into 2 mutually exclusive cohorts of White and Black (based on self-identification). Descriptive analysis was performed for treatment patterns for the first 2 lines of therapy (LOT). Clinical outcomes (progression-free survival [PFS] by LOT and survival rates) were estimated with the Kaplan-Meier method. A log-rank test was used to assess differences in PFS and survival rates between White and Black patients. Results: Among 182 patients with gBRCA1/2-mutated advanced TNBC, 99.5% were women and 76.4% were White. The median age was 57.2 years (range, 48.7-64.7 years), and 30.2% had no known family history of BRCA-related cancer. Treatments for White patients with advanced TNBC included first-line (n=139) nonplatinum-based CT (61.9%) and platinum-based CT (38.1%) and second-line (n=90) PARPi (40.0%), nonplatinum-based CT (43.3%), platinum-based CT (11.1%), and other (5.6%). Treatments for Black patients with advanced TNBC included first-line (n=43) nonplatinum-based CT (60.5%) and platinum-based CT (39.5%) and second-line (n=19) PARPi (47.4%), nonplatinum-based CT (31.6%), platinum-based CT (10.5%), and other (10.5%). Across treatment types, no significant difference in 2-year survival rates was observed between White and Black patients (73.8% vs 73.2%, P=0.89). Median PFS rates by LOT were not statistically different across White and Black patients (Table 1). Conclusion: In this real-world study, no significant differences in clinical outcomes were observed between White and Black patients with gBRCA1/2-mutated advanced TNBC. This observation may be because this sample reflects a select patient population with a known genetic test result of a gBRCA1/2mut who were treated by oncologists that understood the value of genetic testing, and provided appropriate treatment options. The findings suggest that when all patients are provided with equitable care (inclusive of genetic testing), racial disparities in breast cancer may be minimized. Further trials are needed to validate these findings. Funding: Pfizer Inc

Table 1.PFS (Months) by LOT and Race Among Patients With gBRCA1/2-Mutated Advanced TNBCWhite PatientsBlack PatientsP ValueFirst-line, n 13642PFS, median (95% CI)10.7 (9.3−12.6)15.6 (9.7−NE)0.078Second-line, n 5310PFS, median (95% CI)7.2 (5.9−11.4)9.2 (2.8−NE)0.406NE=not estimatable.

Citation Format: Kristen Whitaker, Rohan Parikh, Elizabeth Esterberg, Bhakti Arondekar, Abigail Hitchens, Lillian Shahied Arruda, Alexander Niyazov, Elias Obeid. Impact of race on clinical outcomes among patients with advanced triple negative breast cancer (TNBC) and Germline BRCA1/2 mutation(s) (gBRCA1/2mut): Results from a US real-world study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-08.

Abstract P2-09-05: Germline BRCA1/2 mutation testing in human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC): A real-world study in the Syapse Learning Health Network (LHN)

Background: Germline (g)BRCA1/2 mutations represent approximately 5% of metastatic breast cancer. Poly ADP-ribose polymerase inhibitors (PARPi) have shown improved clinical outcomes, a manageable toxicity profile, and favorable patient (pt)-reported outcomes versus chemotherapy in pts with gBRCA1/2 mutated HER2- locally advanced or metastatic breast cancer. With the advent of PARPi, clinical guidelines have broadened eligibility criteria for gBRCA1/2 testing. However, limited information is available on the impact of the COVID-19 pandemic on gBRCA1/2 testing rates. We assessed trends and factors associated with gBRCA1/2 testing in pts with HER2- ABC before and during the COVID-19 pandemic. Methods: This retrospective study included pts from the Syapse LHN, a longitudinal database of pts with cancer cared for in community-based, integrated care delivery networks in 25 states in the United States. Pts were eligible for gBRCA1/2 testing from initial ABC diagnosis until death or date of last contact with the participating health system. Information on gBRCA1/2 testing was obtained from scaled sources and further curated by Certified Tumor Registrars. Logistic regression evaluated the associations between age at diagnosis, family history of relevant cancer, race/ethnicity, median household income, health system, and diagnosis year with gBRCA1/2 testing among HER2- ABCs; models included hormone receptor status. Results: The study population included 1769 pts with HER2- ABC, including 577 pts with triple negative ABC initially diagnosed from 2010: 96% were women, 69% were non-Hispanic White, and 94% had an estimated median household income &gt;$30,000 USD; median age at initial diagnosis was 61 years. The percentage of pts ever gBRCA1/2-tested among those eligible increased over time: 26%, 28%, and 31% by end of 2018, 2019, and 2020, respectively. Similarly, the percentages of new testing among eligible but not previously tested pts increased from 2018-March 2020, decreased from April-September 2020, and trended upwards thereafter (Table 1). In logistic regression models combining data from pre- and post-COVID-19 periods, family history of relevant cancer (odds ratio [OR]=1.9; 95% CI, 1.5-2.4), younger age at diagnosis (&gt;65 reference; &lt;45: OR=12.8, 95% CI, 8.9-18.3; 45-54: OR=6.7, 95% CI, 4.9-9.3; 55-64: OR=2.0, 95% CI, 1.5-2.8), and diagnosis year of 2013 or later (OR=1.9, 95% CI, 1.4-2.6) were significantly associated with increased odds of gBRCA1/2 testing. Positive hormone receptor status (OR=0.5; 95% CI, 0.4-0.6) and Hispanic ethnicity (OR=0.5; 95% CI, 0.3-0.9) were significantly associated with reduced odds; associations with non-Hispanic Black ethnicity did not reach statistical significance (OR=0.8; 95% CI, 0.6-1.1). Conclusion: Following the expanded eligibility criteria for gBRCA1/2 testing, testing rates increased from 2018 to 2019 and decreased only slightly during the national COVID-19 lockdown. Age at diagnosis, family history, diagnosis year, ethnicity, and hormone receptor status impacted the odds of testing. Given that gBRCA1/2 mutations are actionable, focused efforts should be developed to resume the pre-pandemic trajectory of gBRCA1/2 mutation testing. Funding: Pfizer Inc

Table 1.Percentages of Newly gBRCA1/2-Tested Pts with HER2- ABC Who Were Eligible for Testing Anytime During the Time Period and Not Previously TestedTime Period2018, % (n/N)2019, % (n/N)2020, % (n/NJanuary-March2.3 (10/427)2.7 (14/512)4.3 (23/537)April-June2.9 (13/447)3.4 (18/536)2.8 (14/495)July-September4.3 (20/468)4.7 (27/569)2.5 (13/517)October-December1.9 (9/478)3.1 (17/548)3.5 (16/456)Total8.4 (52/622)10.0 (76/757)8.8 (66/747)A pt diagnosed in February and tested in April of 2018 would be included in the denominator (N) for January-March and April-June of 2018 and in the numerator (n) for April-June of 2018.

Citation Format: Alexander Niyazov, Monika Izano, Colden Johanson, Sheetal Walters, Anna Berry, Bhakti Arondekar, A. Douglas Laird, Lillian Shahied Arruda, Henry Kaplan. Germline BRCA1/2 mutation testing in human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC): A real-world study in the Syapse Learning Health Network (LHN) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-05.

Real-World Evidence in Support of Oncology Product Registration: A Systematic Review of New Drug Application and Biologics License Application Approvals from 2015-2020

Real-world evidence (RWE) has garnered great interest to support registration of new therapies and label expansions by the United States Food and Drug Administration (FDA). Currently, practical insights on the design and analysis of regulatory-grade RWE are lacking. This study aimed to analyze attributes of real-world studies in FDA's decision-making and characteristics of full versus accelerated approvals through a systematic review of oncology product approvals. Oncology approvals from 2015 to 2020 were reviewed from FDA.gov. Applications were screened for inclusion of RWE, and variables related to regulatory designations of the application, pivotal clinical trial, and real-world studies were extracted. FDA feedback was reviewed to identify takeaways and best practices for adequate RWE. Among 133 original and 573 supplemental approvals for oncology, 11 and 2, respectively, included RWE; none predated 2017. All real-world studies were retrospective in nature; the most common data source was chart review, and the most common primary endpoint was overall response rate, as in the pivotal trial. The FDA critiqued the lack of the following: a prespecified study protocol, inclusion/exclusion criteria matching to the trial, comparability of endpoint definitions, methods to minimize confounding and address unmeasured confounding, and plans to handle missing data. All full (versus accelerated) approvals shared the following characteristics: high magnitude of efficacy in the pivotal trial; designations of orphan disease, breakthrough therapy, and priority review; and no advisory committee meeting held. This study found that findings from external control real-world studies complemented efficacy data from single-arm trials in successful oncology product approvals.

Payer perceptions on the use of patient-reported outcomes in oncology decision making

BACKGROUND: In oncology, especially with accelerated regulatory approvals and niche populations, US payers appreciate all evidence that can help support formulary decision making, including evidence beyond traditional safety and efficacy data from clinical trials. Research suggests payers incorporate patient-reported outcome (PRO) evidence in their decision making and expect the importance of PRO evidence to grow. Greater understanding on payers' use of PRO information in oncology is needed. OBJECTIVE: To assess US payer perceptions regarding the use of PRO evidence in informing oncology formulary decision making. METHODS: A multidisciplinary steering committee involving a measurement specialist, health economics and outcomes research experts, and payers developed a survey containing single-answer, multiple-answer, and free-response questions. The pilot survey was tested at a mini-advisory board with 5 US payers and revised based on feedback. In February 2020, the survey was distributed to 221 US payers through the AMCP Market Insights program and 10 additional payer panelists who were invited to discuss and contextualize the survey results. Results were presented primarily as frequencies of responses and evaluated by plan size, type of health plan, and geography (regional vs national). Differences in categorical data responses were compared using Pearson chi-square or Fisher exact tests. Two-tailed values are reported and a P value less than or equal to 0.05 was used to indicate statistical significance. RESULTS: Overall, 106 of 231 payers (45.9%) completed the survey; 45.5% represented small plans (< 1 million lives), and 54.5% represented large plans (≥ 1 million lives). Respondents were largely pharmacists (89.9%), with 55.6% of all respondents indicating their job was pharmacy administrator. The majority of payers (60.0% of small health plans and 57.8% of large plans) felt PRO evidence from clinical trials is useful. Similarly, the majority of payers (57.8% of small plans and 51.9% of large plans) felt PRO evidence from real-world studies is useful. Almost half (47.1%) suggested formulary review would be influenced by a lack of PRO evidence from oncology clinical trials either somewhat, much, or a great deal. Most payers (78.2%) thought PRO evidence is useful for providing additional context for safety of oncology therapies. More than one-third of payers (34.3%) valued PRO evidence when comparing 2 similar therapies, and 51.5% felt PRO evidence may help in measuring value for value-based agreements. Panelists indicated PRO evidence can be useful for developing treatment pathways for addressing health-related quality of life, informing provider-patient dialogues, and defining progression-free survival length and quality. CONCLUSIONS: US payers view PRO evidence from both clinical trials and real-world studies as useful for supplementing traditional clinical trial data when making oncology formulary decisions and for refining treatment pathways and care delivery models. Manufacturers of oncology therapies should collect and consider leveraging PRO evidence from both settings when engaging with US payers. DISCLOSURES: Pfizer provided funding for this research, and employees of Pfizer contributed to the development of the survey instrument, were involved in the interpretation of the data, and contributed to the discussion and output as authors. Biskupiak, Oderda, and Brixner are managers of Millcreek Outcomes Group and were paid as consultants on this project. Burgoyne was a consultant for Pfizer on this project. Arondekar, Deal, and Niyazov are employees of Pfizer and own Pfizer stock. Qwek was an employee of Pfizer at the time of this project and owns Pfizer stock.

Payer perceptions on the use of economic models in oncology decision making

BACKGROUND: To support oncology formulary decisions, especially with accelerated regulatory approvals and niche populations, payers desire data beyond what regulators review. Economic models showing financial impact of treatments may help, but data on payers' use of economic models in oncology are limited. OBJECTIVE: To assess payer perceptions regarding use of economic models in informing oncology formulary decisions. METHODS: A multidisciplinary steering committee involving health economists and payers developed a survey containing singleanswer, multiple-answer, and free-response questions. The pilot survey was tested at a mini-advisory board with 5 US payers and revised based on feedback. In February 2020, the survey was distributed to 221 US payers through the AMCP Market Insights program and 10 additional payer panelists, who were invited to discuss survey results. Results were presented primarily as frequencies of responses and evaluated by plan size, type of health plan, and geography (regional vs national). Differences in categorical data responses were compared using Pearson chi-square or Fisher's exact tests. Two-tailed values were reported and an alpha level of 0.05 or less was used to indicate statistical significance. RESULTS: Overall, 106 of 231 payers completed the survey (45.9%); 45.5% represented small plans (< 1 million lives), and 54.5% represented large plans (≥ 1 million lives). Respondents were largely pharmacists (89.9%), and 55.6% indicated that their job was pharmacy administrator. Payers indicated moderate/most interest in cost-effectiveness models (CEMs; 85.3%) and budget impact models (BIMs; 80.4%). Overall, 51.6% of respondents claimed oncology expertise on their pharmacy and therapeutics committees. Large plans were more likely to have expertise in reviewing oncology economic models than small plans (55.6% vs 31.1%, P = 0.015). The most common reasons for not reviewing economic models included "not available at time of review" (44.1%) and "potential bias" (38.2%). Overall, 43.1% of payers conduct analyses using their own data after reviewing a manufacturer-sponsored economic model. To inform formulary decisions, 62.7% of payers use BIMs and 66.7% use CEMs sometimes, often, or always. When comparing therapies with similar safety/efficacy profiles, 68.6% of payers reported economic models as helpful a moderate amount, a lot, or a great deal. Over one-third of payers (37.3%) were willing to partner with manufacturers on economic models using their plans' data. Payers valued preapproval information, data on total cost of care, and early access to models. Concerns remained regarding model transparency and assumptions. CONCLUSIONS: Most US payers reported interest in using economic models to inform oncology formulary decision making. Opportunities exist to educate payers in assessing economic models, especially among small health plans. Ensuring model availability at launch, transparency in model assumptions, and payer-manufacturer partnership in model development may increase the utility of oncology economic models among US payers. DISCLOSURES: Pfizer provided funding for this research, and Pfizer employees led the development of the survey instrument, were involved in the analysis and interpretation of the data, and contributed to the manuscript as authors. Arondekar and Niyazov are employed by Pfizer. Biskupiak, Oderda, and Brixner are managers of Millcreek Outcomes Group and were paid as consultants on this project. Burgoyne was a consultant for Pfizer on this project.

Payer perceptions of the use of real-world evidence in oncology-based decision making

BACKGROUND: Randomized controlled trials (RCTs), the gold standard of safety and efficacy evidence, are conducted in select patients that may not mirror real-world populations. As a result, healthcare decision makers may have limited information when making formulary decisions, especially in oncology, given accelerated regulatory approvals and niche patient populations. Real-world evidence (RWE) studies may help address these knowledge gaps and help inform oncology formulary decision making. OBJECTIVE: To assess US payer perceptions regarding the use and relevance of RWE in informing oncology formulary decisionmaking. METHODS: A national survey containing single-answer, multiple-answer, and free-response questions evaluated 4 key areas: (1) the value of RWE, (2) barriers to RWE, (3) sources of RWE, and (4) use of RWE in outcomes-based contracting. The survey was distributed to 221 US payers through the Academy of Managed Care Pharmacy (AMCP) Market Insights program in February 2020. Ten additional respondents were invited to discuss the survey results. The survey results were presented primarily as frequencies of responses and were evaluated by the respondent's plan size, type, and geography (regional vs national). Differences in responses for categorical data were compared using a Pearson Chi-Square or a Fisher's Exact test. Two-tailed values are reported and a level of ≤ 0.05 was used to indicate statistical significance. RESULTS: The national survey had a 45.9% response rate, with 106 payers responding. Most were from managed care organizations (MCOs; 47.5%) and pharmacy benefit managers (PBMs; 37.4%), with 54.5% from large plans (≥ 1 million lives) and 45.5% from small plans (< 1 million lives). Respondents were largely pharmacists (89.9%), with 55.6% overall indicating their job was a pharmacy administrator. Most (84.9%) used RWE to inform formulary decisions in oncology to support comparative effectiveness in the absence of head-to-head clinical trials (4.1 on a scale of 1 = Not At All Useful to 5 = Extremely Useful) and validation of National Comprehensive Cancer Network (NCCN) recommendations (4.0). Almost half (41.5%) used RWE results to inform off-label usage decisions. Payers valued RWE pre-launch to inform formulary and contracting decisions and desired real-world comparative effectiveness data post-launch to validate coverage decisions. However, the majority of payers (54.7%) did not conduct their own real-world studies. Commonly considered RWE sources included claims data (79.2%), medical records (68.9%), prospective cohort studies (60.4%), patient registries (36.8%), and patient outcome surveys (33.0%). Barriers to conducting internal RWE studies included the lack of resources and personnel, analytic capabilities, appropriate in-house data, and perceived value in conducting analyses. Payers expressed interest in using outcomes-based contracting in oncology; few have direct experience, and operationalizing through value measurement is challenging. CONCLUSIONS: RWE providing comparative treatment data, validation of NCCN treatment recommendations, and information on off-label usage are appreciated pre launch with post launch validation. DISCLOSURES: Pfizer provided funding for this research, and employees of Pfizer led the development of the survey and contributed to the manuscript as authors. Arondekar and Niyazov are employees of Pfizer; Oderda, Biskupiak, and Brixner are managers of Millcreek Outcomes Group and were paid as consultants on this project. Burgoyne was a consultant for Pfizer on this project. Malone was paid by Millcreek Outcomes as a consultant on this project.

The value of new drugs for advanced prostate cancer

BACKGROUND

The US Food and Drug Administration has recently approved a number of new cancer drugs. The clinical trials that serve as the basis for new cancer drug approvals may not reflect how the drugs will perform in routine practice and do not measure the impact of the drugs on spending. The authors sought to evaluate the real-world effectiveness and value of drugs recently approved for advanced prostate cancer.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, the authors identified fee-for-service Medicare beneficiaries aged 65 years or older who began treatment with a drug approved for metastatic castration-resistant prostate cancer in 2007-2009, when only 1 drug was approved for metastatic castration-resistant prostate cancer, and in 2014-2016, when 5 additional drugs were approved. They calculated life expectancy and lifetime medical costs (ie, Medicare reimbursements) for each group.

RESULTS

Between 2007-2009 and 2014-2016, life expectancy increased by 12.6 months. Lifetime medical costs increased by $87,000. The incremental cost per life-year gained was $83,000.

CONCLUSION

The release of 5 new drugs coincided with increases in survival rates and spending. This study's estimates indicate that the new drugs collectively were cost-effective.

Impact of race on biomarker testing among HER2- advanced breast cancer (ABC) patients (pts) in the United States: Results from a real-world study

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Background: African Americans (AA) have the highest breast cancer (BC) mortality rate. Access to treatment is a known contributing factor. In the past 4 years, several targeted therapies for HER2- BC have become available which require testing for specific biomarkers. This study assessed the impact of race on biomarker testing rates in HER2- ABC pts receiving treatment in the US. Methods: Oncologists were recruited to abstract data from medical charts for the next 8-10 pts receiving treatment with HER2- ABC during Sept 2019-Apr 2020. Pts records were stratified by race and categorized into 3 mutually exclusive cohorts [White/Caucasian (White), AA, Other]. The other race cohort was excluded from this analysis due to small sample size. Differences in pt demographics/clinical characteristics were analyzed via Fisher’s exact tests. Testing rates for actionable biomarkers (i.e. BRCA1/2, PIK3CA, PD-L1) were compared between White and AA pts utilizing logistic regressions controlling for age, known family history of a BRCA-related cancer, hormone receptor (HR) status and practice setting (academic vs. community). Further analyses by age will be presented. Results: This analysis included 378 pts records, provided by 40 oncologists. Mean age was 64 years; 77% had HR+/HER2- ABC; 20% had advanced triple negative breast cancer (TNBC), 3% had ABC with an unknown HR status. Compared to White pts, AA pts were significantly more likely to have advanced TNBC (27% vs. 18%, p<0.05). Compared to White pts, AA pts had significantly lower BRCA1/2 mutation (mut) testing rates (Table). Numerically lower rates of PIK3CAmut and PD-L1 testing were observed among AA pts (Table). BRCA1/2mut positivity rate (germline [g] and/or somatic [s]) was higher among AA vs. White pts (30% vs. 22%). Positivity rate for PIK3CAmut was lower for AA vs. White pts (8% vs. 11%). Conclusions: A higher than expected BRCA1/2mut positivity rate was observed than previously reported in the literature. This is likely because this analysis included s BRCA1/2mut and represented a high risk pt population. Across all biomarkers assessed, AA pts had lower testing rates than White pts. This suggests racial disparities in testing rates of actionable biomarkers. Consistent with guidelines, and with the increased availability of targeted therapies, focused efforts should be developed to increase biomarker testing in AA pts. Funding: Pfizer Biomarker Testing Rates by Race.[Table: see text]

Abstract PS10-53: Treatment Patterns and Clinical Outcomes Among Patients with germline BRCA1/2 mutated (gBRCA1/2mut) HER2+ Advanced Breast Cancer (ABC): Results from a US Real-world Study

Background: gBRCA1/2mut ABC represents ~5% of all breast cancer (BC), although a fair estimate of gBRCA1/2mut HER2+ BC remains to be determined. HER2-targeted therapy is the current standard of care for these patients with HER2+ BC. While PARP inhibitors (PARPi) are approved for the treatment of gBRCA1/2mut HER2- ABC, recently, NCCN updated its guidelines (v6.2020) to additionally consider the use of PARPi in patients with gBRCA1/2mut HER2+ metastatic BC. However, clinical trials have not evaluated the efficacy of PARPi among patients with gBRCA1/2mut HER2+ metastatic BC. In order to establish a baseline reference point, we assessed real-world treatment patterns and clinical outcomes among patients with gBRCA1/2mut HER2+ ABC.

Methods: US Oncologists retrospectively reviewed charts (July 2019-June 2020) of randomly selected patients ≥18 y, with gBRCA1/2mut ABC who received ≥1 cytotoxic chemotherapy (CT) regimen(s) for ABC between Jan 2013-April 2018. A descriptive analysis was performed for the HER2+ patients including 1st line ABC treatment patterns. Clinical outcomes (1st line ABC PFS rates) were estimated using the Kaplan-Meier method. PARPi clinical outcomes data were immature given its recent launch. Additional analyses evaluating outcomes in patients receiving PARPi are planned.

Results: Of the 387 patients with gBRCA1/2mut ABC included in the study, 82 (21%) female patients had HER2+ disease. Of the gBRCA1/2mut HER2+ patients, median age was 56y, 72% were white. Clinical characteristics: 62% HR+/HER2+, 37% HR-/HER2+, and 1% had unknown HR/HER2+ ABC. Treatments in the 1st line setting for HR+/HER2+ ABC patients (n=51) included CT (55%) and CT + HER2-targeted therapy (43%). First-line treatments used for HR-/HER2+ ABC patients (n=30) included CT + HER2-targeted therapy (77%) and CT (20%). 12-month PFS rate for 1st line HR+/HER2+ patients was 77% and for HR-/HER2+ patients was 64%. Later line treatments will be presented.

Conclusion: In this analysis of HER2+ patients with gBRCA1/2mut ABC, unexpectedly low rates of HER2-targeted therapy were observed in patients with HR+/HER2+ disease. Appropriately high rates of HER2-targeted therapy with CT was observed among gBRCA1/2mut HR-/HER2+ patients. Treatment patterns among patients with non-gBRCA1/2mut HER2+ ABC in a real-world setting need to be evaluated. Clinical outcome findings from this study demonstrate the need to better understand best treatment strategies for this patient population. As PARPi are not yet approved for patients with gBRCA1/2mut HER2+ ABC, studies assessing efficacy of PARPi +/- HER2-targeted therapy are warranted.

Funding: Pfizer

Citation Format: Elias Obeid, Rohan C Parikh, Elizabeth Esterberg, Bhakti Arondekar, Abigail Hitchens, Lillian Shahied Arruda, Alexander Niyazov. Treatment Patterns and Clinical Outcomes Among Patients with germline BRCA1/2 mutated (gBRCA1/2mut) HER2+ Advanced Breast Cancer (ABC): Results from a US Real-world Study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-53.

Abstract PS11-42: Treatment patterns and clinical outcomes among patients (pts) with HER2- advanced breast cancer (ABC) and germline BRCA1/2 mutation(s) (gBRCA1/2mut): results from a US real-world study

Background: gBRCA1/2mut represents~5% of ABC. Recently poly ADP-ribose polymerases inhibitors (PARPi) have demonstrated improved clinical outcomes, advantageous side effect profile, and favorable patient reported outcomes vs. chemotherapy(CT) in gBRCA1/2mut HER2- ABC patients. Optimal treatment sequencing has not been established. We assessed real-world treatment patterns and clinical outcomes by line of treatment (LOT) among adult patients with gBRCA1/2mut HER2- ABC.

Methods: US Oncologists retrospectively reviewed charts (July 2019-June 2020) of quasi-random selected patients ≥18 y, with gBRCA1/2mut HER2- ABC who received ≥1 cytotoxic chemotherapy (CT)regimen(s) for ABC between Jan 2013-April 2018. Descriptive analyses were performed for treatment patterns for the first 3 LOTs. Clinical outcomes (PFS by LOT and survival rates) were estimated using the Kaplan-Meier method. PARPi clinical outcomes data was immature given its recent launch. Additional analyses evaluating outcomes in patients receiving PARPi are planned.

Results: 305 HER2- gBRCA ABC patients were included: 99.7% were women, 76.4% were white, 11.5% were of Ashkenazi Jewish descent. Median age was 57.3 yrs, 36.4% had hormone receptor (HR)+/HER2-ABC, and 63.6% had advanced triple-negative BC (TNBC). Treatments for HR+/HER2-included: 1st line - CT (78.4%),endocrine based therapy (EBT) (19.8%), PARPi (0.9%), other (0.9%); 2ndline - EBT (51.2%), CT (31.0%), PARPi (13.1%),other (4.8%); 3rd line - CT (50.0%), EBT (27.8%), PARPi (19.4%). Across treatment types, 77.0% of patients were alive at 2 years after 1stCT. Treatment for TNBC included: 1st line - non-platinum based CT(60.8%), platinum based CT (39.2%), non-platinum based CT (60.8%); 2ndline - PARPi (42.0%), non-platinum based CT (40.2%), platinum-based CT (10.7%),other (7.1%); 3rd line - PARPi (43.5%), non-platinum based CT (39.1%), platinum-based CT (6.5%). Across treatment types, 73.9% of patients were alive at 2 years after 1stCT. Median PFS for HR+/HER2- and TNBC are reported in Table 1.

Conclusion: CT was frequently used among both HR+ and HR- gBRCA1/2mut HER2-ABC. Recent clinical trials have demonstrated use of chemotherapy-sparing disease specific targeted treatments (e.g., PARPi) improved clinical, and patient reported outcomes, and had a manageable side effect profile. Such disease specific targeted therapies should possibly be considered in earlier LOTs in this patient population and is an area that could benefit from well-designed studies, particularly addressing this important research question. Therefore, future studies assessing treatment sequencing and the associated clinical outcomes including targeted treatments (i.e. PARPi) in patients with gBRCA1/2mut are warranted. Funding: Pfizer

Table 1. PFS (months) by LOT and HR status among gBRCA1/2mut HER2- ABC patients.HR+/HER2-TNBC1st line (n)110190PFS, median no. (95% CI)12.1 (9.1-14.3)11.6 (9.9-13.6)2nd line (n)6864PFS, median no. (95% CI)14.2 (10.7-29.5)9.0 (6.2-11.4)3rd line (n)2926PFS, median no. (95% CI)6.5 (4.4-9.3)5.9 (3.5-not estimable)

Citation Format: Elias Obeid, Rohan C Parikh, Elizabeth Esterberg, Bhakti Arondekar, Abigail Hitchens, Lillian Shahied Arruda, Alexander Niyazov. Treatment patterns and clinical outcomes among patients (pts) with HER2- advanced breast cancer (ABC) and germline BRCA1/2 mutation(s) (gBRCA1/2mut): results from a US real-world study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS11-42.

Abstract PS10-47: Physician and patient satisfaction with poly(ADP-ribose) polymerase inhibitors (PARPi) versus chemotherapy in adult patients with germline BRCA1/2 mutated (gBRCA1/2mut) HER2- advanced breast cancer (ABC): Results from a multi-country real-world (RW) study

Background: Within the past 3 years, PARPi have demonstrated improved progression-free survival and favorable PROs compared with chemotherapy in randomized clinical trials in patients with gBRCA1/2mut HER2- ABC. These agents are now available in multiple countries for the treatment of gBRCA1/2mut HER2- locally advanced and/or metastatic breast cancer. Limited information is available on physician/patient satisfaction with PARPi from the RW. We assessed RW physician/patient treatment satisfaction among adult patients with gBRCA1/2mut HER2- ABC in Germany, France, Italy, Spain (EU4), US, and Israel.

Methods: Oncologist were recruited to abstract data from medical records (2019/2020) for patients with gBRCA1/2mut HER2- ABC. Physicians were asked to rank (1=very dissatisfied to 5=very satisfied) their satisfaction with their patient’s current ABC treatment. The scores were dichotomized to a 0/1 variable (0=very dissatisfied/ dissatisfied/moderately satisfied; 1=satisfied/very satisfied). A subset of patients completed the Cancer Treatment Satisfaction Questionnaire, a validated instrument that was used to measure patient’s satisfaction with their current therapy. The physician and patient sample were matched. Physician/patient satisfaction scores were compared between chemotherapy and PARPi monotherapy utilizing inverse probability weighted regression adjustment controlling for age at therapy initiation, Charlson Comorbidity Index at time of data collection, baseline symptoms, hormone receptor (HR) status, ECOG score at therapy initiation, stage of therapy initiation (locally advanced breast cancer or metastatic breast cancer) and number of lines of ABC treatment.

Results: Overall 96 adult female patients participated; mean age was 51 years. Tumor characteristics were: 34.4% HR+/HER2-, 65.6% triple negative breast cancer. Chemotherapy (n=58) was received among 60.4% of pts [n=29 (50.0%) platinum based, n=29 (50.0%) non-platinum based], and PARPi monotherapy (n=38) was received among 39.6% of pts. Physicians were significantly more likely to be satisfied or very satisfied with PARPi in comparison with chemotherapy (95.4% vs. 40.8%, p&lt;0.001). Mean patient satisfactions scores were numerically higher with PARPi vs. chemotherapy: expectation of therapy 81.3 vs. 72.0 (p=0.13), feelings about side effects 55.7 vs. 51.4 (p=0.30), satisfaction with therapy 74.0 vs. 68.5 (p=0.13).

Conclusions: PARPi have demonstrated superior efficacy and favorable PROs vs. chemotherapy in randomized controlled trials. In this RW study, physicians reported significantly higher satisfaction with PARPi vs. chemotherapy; patients reported numerically higher satisfaction scores with PARPi vs. chemotherapy across all domains. These findings further support the value of PARPi in patients with gBRCA1/2mut HER2- ABC. Additional studies to validate these findings are planned.

Funding: Pfizer

Citation Format: Michael Patrick Lux, Alexander Niyazov, Katie Lewis, James Pike, Alex Rider, Bhakti Arondekar, Reshma Mahtani. Physician and patient satisfaction with poly(ADP-ribose) polymerase inhibitors (PARPi) versus chemotherapy in adult patients with germline BRCA1/2 mutated (gBRCA1/2mut) HER2- advanced breast cancer (ABC): Results from a multi-country real-world (RW) study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-47.

Abstract PS10-36: Treatment patterns and clinical outcomes among patients (pts) with HER2- advanced breast cancer (ABC) and somatic BRCA1/2 mutation(s) (sBRCA1/2mut): Results from a US real-world study

Background: Recently, somatic genetic information is being increasingly usedin clinical decisions for treatment of metastatic diseases, including breastcancer. Somatic mutations in the BRCA1/2 genes are not frequently seen.The poly ADP-ribose polymerases inhibitors (PARPi) have been approved astreatments for patients with germline (gBRCA1/2mut) HER2- ABC. Real-world practice shows that these agents arealso being utilized for patients who have sBRCA1/2mut. While we await data from large clinicaltrials such as MATVH and TAPUR, currently, limited information is available onthe effectiveness of these agents in patients with sBRCA1/2mut andestablishing a reference point is necessary to assess the unknown potentialclinical benefit. We assessed real-world treatment patterns and clinicaloutcomes among patients with HER2- sBRCA1/2mut without associatedgermline mutation and who had received treatment for ABC. Methods: US oncologists retrospectivelyreviewed charts (July 2019-June 2020) of quasi-randomly selected patients ≥18y, who received ≥1 cytotoxic chemotherapy (CT) regimen(s) for ABC between Jan2013-April 2018. Descriptive analyses were performed for patients with sBRCA1/2mut(without associated germline mutation), which included evaluation of treatment patternsand safety events for the first 3 lines of therapy. Clinical outcomes(progression free survival [PFS] and overall survival rates) were estimatedusing the Kaplan-Meier method for 1st line of therapy. Given therelatively recent launch of PARPi, clinical outcomes for these agents wereimmature. Results: 32 patients were included who only had sBRCA1/2mut: 96.9%were female, 68.8% were white, and 28.1% were black. Median age was 53.0 yrs. Advanced triplenegative breast cancer was observed in 40.6% of patients and 59.4% had hormonereceptor (HR)+/HER2- ABC. Common treatments for HR+/HER2- sBRCA1/2mutdisease included: 1st line (n=19), cyclophosphamide + doxorubicin (10.5%);2nd line (n=17), docetaxel (11.8%), PARPi monotherapy (11.8%), CDK4/6i + letrozole (11.8%); 3rd line- (n=7), eribulin (42.9%). Treatments for triplenegative sBRCA1/2mut breast cancer included: 1st line (n=13), cyclophosphamide + doxorubicin (30.8%);2nd line (n=9), PARPi (22.2%); 3rd line (n=7),atezolizumab based (71.4%). Median PFS across both subtypes was 10.8 months,95% CI 8.5 - 15.0. Overall, 78.9% of patients were alive at 2 years after 1stCT. Safety data will be presented. Conclusion: In this analysis of sBRCA1/2mut HER2- ABC, an individualapproach to select treatment regimens such as CT was frequently used, withoutadequate knowledge on best sequential therapy to include tumor genetic directedintervention. Poor clinical outcomes highlight the need for more efficacioustreatment options. Further studies assessingclinical outcomes among patients with sBRCA1/2mut ABC receivingPARPi are warranted.

Citation Format: Elias Obeid, Rohan C Parikh, Elizabeth Esterberg, Bhakti Arondekar, Abigail Hitchens, Lillian Shahied Arruda, Alexander Niyazov. Treatment patterns and clinical outcomes among patients (pts) with HER2- advanced breast cancer (ABC) and somatic BRCA1/2 mutation(s) (sBRCA1/2mut): Results from a US real-world study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-36.

Abstract PS10-32: Patient reported outcomes (PROs) with poly(ADP-ribose) polymerase inhibitors (PARPi) versus chemotherapy (CTX) in patients (pts) with germline BRCA1/2 mutated (gBRCA1/2mut) HER2- advanced breast cancer (ABC): Results from a multi-country real-world (RW) study

Background: In ABC, where treatment is palliative, an important goal is the maintenance or improvement of quality of life (QoL). In the past 3 years, PARPi have demonstrated improved progression-free survival and favorable PROs compared with CTX in randomized clinical trials (RCTs) in pts with ABC and a gBRCA1/2mut. These agents are now available in multiple countries for the treatment of gBRCA1/2mut HER2- locally advanced and/or metastatic breast cancer. Limited information is available on the PRO benefit of these agents in the RW setting. We assessed RW cancer-related and breast-cancer specific PROs among adult pts with gBRCA1/2mut HER2- ABC in Germany, France, Italy, Spain (EU4), US, and Israel.

Methods: Oncologists were recruited to abstract data from medical records (2019/2020) for pts with gBRCA1/2mut HER2- ABC. A subset of pts completed the European Organisation for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30) and the breast cancer module QLQ-BR23. PROs were compared between CTX and PARPi monotherapy utilizing inverse probability weighted regression adjustment (IPWRA) controlling for age at therapy initiation, Charlson Comorbidity Index at time of data collection, baseline symptoms, hormone receptor (HR) status, ECOG score at therapy initiation, stage of therapy initiation (locally advanced breast cancer or metastatic breast cancer) and number of lines of ABC treatment.

Results: Overall 96 female pts participated; mean age was 51 years. Tumor characteristics were: 34.4% HR+/HER2-, 65.6% triple negative breast cancer. CTX (n=58) was received among 60.4% of pts [n=29 (50.0%) platinum based, n=29 (50.0%) non-platinum based], and PARPi monotherapy (n=38) was received among 39.6% of pts. Compared to pts receiving CTX, pts receiving PARPi reported significantly better scores in physical and social functioning (Table 1). Pts receiving PARPi reported significantly better symptoms scores vs. CTX in constipation, breast symptoms, arm symptoms and systemic therapy side effects (Table 1). Pts receiving PARPi reported significantly worse scores vs. CTX in nausea/vomiting (Table 1). Global health status (GHS)/QoL scores were numerically better among pts receiving PARPi vs. CTX (Table 1).

Conclusions: PARPi have demonstrated superior efficacy and favorable PROs vs. CTX in RCTs in pts with gBRCA1/2mut HER2- ABC. In this RW study, the PRO benefits reported with PARPi were consistent with what has been observed in RCTs, further supporting the value of PARPi. Additional studies to validate these findings are planned.

Funding: Pfizer

EORTC QLQ-BR23 categories sexual enjoyment and upset by hair loss were excluded from the analysis due to low sample size

Table 1. IPWRA Analysis for the EORTC QLQ-C30 and QLQ BR-23a scoresCTX (n=58)PARPi Monotherapy (n=38)P valueEORTC QLQ-C30 GHS/QoL and functional scalesGHS/QoL56.5665.240.10Physical71.9079.980.045Role64.5568.060.55Emotional61.2464.580.61Cognitive78.2078.840.89Social63.5781.950.01EORTC QLQ-BR23 Functional scalesSexual12.3717.230.31Future perspective46.6844.530.81Body Image53.2265.360.13EORTC QLQ-C30 Symptoms scalesFatigue40.6739.620.87Nausea/vomiting18.2834.510.005Pain34.2638.880.42Dyspnea22.1523.290.82Insomnia30.7832.400.82Appetite loss24.8531.990.29Constipation18.751.85&lt;.001Diarrhea16.2614.570.81Financial difficulties16.2616.830.92EORTC QLQ-BR23 Symptoms ScalesBreast symptoms13.280.350.008Arm symptoms11.392.600.001Systemic therapy side effects29.3913.48&lt;.001

Citation Format: Reshma Mahtani, Alexander Niyazov, Katie Lewis, James Pike, Alex Rider, Bhakti Arondekar, Michael Patrick Lux. Patient reported outcomes (PROs) with poly(ADP-ribose) polymerase inhibitors (PARPi) versus chemotherapy (CTX) in patients (pts) with germline BRCA1/2 mutated (gBRCA1/2mut) HER2- advanced breast cancer (ABC): Results from a multi-country real-world (RW) study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-32.

Treatment patterns and clinical outcomes in patients with advanced non-small cell lung cancer initiating first-line treatment in the US community oncology setting: a real-world retrospective observational study

Purpose

Treatments for advanced non-small cell lung cancer (NSCLC) have evolved to include targeted and immuno-oncology therapies, which have demonstrated clinical benefits in clinical trials. However, few real-world studies have evaluated these treatments in the first-line setting.

Methods

Adult patients with advanced NSCLC who initiated first-line treatment with chemotherapy, targeted therapies (TT), or immuno-oncology–based regimens in the US Oncology Network (USON) between March 1, 2015, and August 1, 2018, were included and followed up through February 1, 2019. Data were sourced from structured fields of USON electronic health records. Patient and treatment characteristics were assessed descriptively, with Kaplan-Meier methods used to evaluate time-to-event outcomes, including time to treatment discontinuation (TTD) and overall survival (OS). Adjusted Cox regression analyses and inverse probability of treatment weighting (IPTW) were performed to control for covariates that may have affected treatment selection and outcomes.

Results

Of 7746 patients, 75.6% received first-line systemic chemotherapy, 11.7% received immuno-oncology monotherapies, 8.5% received TT, and 4.2% received immuno-oncology combination regimens. Patients who received immuno-oncology monotherapies had the longest median TTD (3.5 months; 95% confidence interval [CI], 2.8–4.2) and OS (19.9 months; 95% CI, 16.6–24.1). On the basis of multivariable Cox regression and IPTW, immuno-oncology monotherapy was associated with reduced risk of death and treatment discontinuation relative to other treatments.

Conclusion

These results suggest that real-world outcomes in this community oncology setting improved with the introduction of immuno-oncology therapies. However, clinical benefits are limited in certain subgroups and tend to be reduced compared with clinical trial observations.

Electronic supplementary material

The online version of this article (10.1007/s00432-020-03414-4) contains supplementary material, which is available to authorized users.

Real-world evidence for U.S. Food and Drug Administration-approved oncology products, 2015 to 2020

280

Background: Since the 21st Century Cures Act, there has been growing interest in using real-world evidence (RWE) to support regulatory filings for new drugs and indications. The goal of this study was to provide a comprehensive source of RWE use cases of U.S. Food and Drug Administration (FDA) approvals for oncology products. Methods: A systematic review of FDA new drug applications (NDAs) and biologics license applications (BLAs) from 1/2015-2/2020 for approved oncology products was performed. Data on the RWE study were extracted (data source, study design, statistical methods, results), and corresponding FDA comments were synthesized to identify patterns of the FDA’s review. Results: We identified 102 NDAs and BLAs, 8 (8%) of which included RWE, all post-Cures Act (see Table). RWE supporting avelumab, axicabtagene ciloleucel, and avapritinib were received positively and used by the FDA in their approval decision. RWE results were used to provide contextualization to the pivotal trial, rather than statistical comparison. Common data sources included Flatiron (38%) and chart reviews (38%). FDA critiques included lack of a priori study protocol, incomparability with the pivotal trial population and endpoints, and uncontrolled confounding. Conclusions: There have been few examples of RWE in oncology submissions, and most served to complement clinical trial results. To meet FDA standards, RWE studies should be clearly designed and discussed with the FDA and include robust methods to minimize bias. [Table: see text]

Role of real-world evidence for oncology product registration in the United States: A review of approvals by the U.S. Food and Drug Administration from 2015 to 2019

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Background: There are few concrete examples of real world evidence (RWE) used to support clinical development in regulatory filings despite growing interest in this field. This study systematically reviewed FDA oncology approvals to identify use cases of RWE. Methods: FDA’s new drug application (NDA) and biologics license application (BLA) approvals for oncology products from 2015-2019 were systematically reviewed. Among cases with RWE, data characterizing the submission and RWE details (data source, study design, FDA comments) were synthesized. Results: 93 approved NDAs and BLAs were identified; 6 included RWE in support of efficacy (see Table), approved on or after 2017, and were largely retrospective studies that contextualized results to pivotal trial, with primary endpoints overall survival (OS), overall response rate (ORR), and time to treatment discontinuation (TTD). Flatiron data were used in 3 of these as database analyses, 1 was an expanded access program (EAP), 1 was a meta-analysis, and 1 was a retrospective chart review. Conclusions: In the past 5 years, few FDA decisions incorporated RWE in oncology drug approvals. When used, RWE has been a complement rather than a supplement for clinical trial data. Early engagement, a priori protocol development, and robust research design (adjusting for bias, comparability to clinical trial population) remain key determinants for successful use of RWE in FDA decision making. [Table: see text]

Treatment patterns and clinical outcomes among patients (pts) with HER2+ advanced breast cancer (ABC) and germline BRCA1/2 mutation(s) (gBRCA1/2mut): Results from a US real-world study

e13076

Background: g BRCA1/2mut ABC represents ~5% of all breast cancer (BC) including pts with HER2+ BC. While HER2-targeted therapy remains an effective tx for those pts, limited information is available on the use and effectiveness of PARP inhibitors (PARPi) for pts with HER2+ g BRCA1/2mut ABC. Recently, NCCN updated its guidelines (v1.2020) to support the use of PARPi in pts with g BRCA1/2mut metastatic BC regardless of subtype. In order to establish a baseline reference point, we assessed real-world tx patterns and clinical outcomes among pts with g BRCA1/2mut HER2+. Methods: Oncologists retrospectively reviewed charts (July-Oct 2019) of randomly selected pts ≥18 y, with g BRCA1/2mut HER2+ABC who received ≥1 cytotoxic chemotherapy (CT) regimen(s) for ABC between Jan 2013-April 2018. Descriptive analysis was performed for 1st line ABC tx patterns. Clinical outcomes (1st line ABC PFS rates) were estimated using the Kaplan-Meier method. PARPi clinical outcomes data was immature given its recent launch. Additional analyses evaluating outcomes in pts receiving PARPi are planned. Results: Of the 225 pts with g BRCA1/2mut ABC included in the study, 48 (21%) female pts had HER2+ disease. Of the g BRCA1/2mut HER2+ pts, 77% were white with a median age of 58 y. Clinical characteristics: 42% HR+/HER2+, 56% HR-/HER2+, 2% had unknown HR/HER2+ ABC. Txs in the 1st line setting for HR+/HER2+ ABC pts (n = 20) included: CT (75%), CT + HER2-targeted therapy (25%) (Table). First-line txs used for HR-/HER2+ ABC pts (n = 27) included: CT + HER2-targeted therapy (78%), CT (15%), other (7%) (Table). 12-month PFS for 1st line HR+/HER2+ pts was 73% and for HR-/HER2+ pts was 69% (Table). Later line tx patterns will be presented. Conclusions: In this analysis of pts with g BRCA1/2mut HR+/HER2+, unexpectedly low rates of HER2-targeted therapy were observed. As expected, high rates of HER2-targeted therapy with CT were observed among g BRCA1/2mut HR-/HER2+ pts. Clinical outcome findings demonstrate the need for more efficacious tx options. Studies assessing clinical outcomes among g BRCA1/2mut HER2+ ABC pts receiving PARPi +/- HER2-targeted tx are warranted. This is a limited sample size; additional data collection including median PFS is ongoing. [Table: see text]

Overall survival of glasdegib in combination with low-dose cytarabine, azacitidine, and decitabine among adult patients with previously untreated AML: comparative effectiveness using simulated treatment comparisons

BACKGROUND

Until recently, treatments for older patients with AML ineligible to receive intensive chemotherapies were limited to hypomethylating agents, low-dose cytarabine (LDAC), or clinical trials. In 2018, the FDA approved combination glasdegib (GLAS) plus LDAC based on Phase II results demonstrating improved overall survival (OS) versus LDAC alone in previously untreated AML. However, no randomized clinical trials have directly compared GLAS + LDAC with other AML treatments.

OBJECTIVE

Using both indirect treatment comparison (ITC) and simulated treatment comparison (STC), which adjusts for baseline differences between trials, the comparative effectiveness of GLAS + LDAC was compared with hypomethylating agent azacitidine (AZA) or decitabine (DEC).

METHODS

A systematic literature review identified published trials of AZA or DEC versus LDAC among older AML patients ineligible for high-intensity chemotherapy. In addition to standard and covariate-adjusted ITC, STC was performed following guidance from the NICE Decision Support Unit (DSU). Using individual patient data from the Phase II GLAS + LDAC study, population-specific OS hazard ratios (HR) for GLAS + LDAC versus AZA or DEC were compared. Furthermore, covariate-adjusted ITC (Cox multivariate models) and STC were repeated using GLAS + LDAC versus LDAC data propensity-weighted for within-trial mean cytogenetic risk. As this initial step was not specified in the DSU, results from this second method were compared to the first STC following DSU guidance only.

RESULTS

Standard ITC and STC both demonstrated significantly improved OS for GLAS + LDAC versus either AZA or DEC. Adjusting for key covariates, STC stepwise exponential models demonstrated GLAS + LDAC superiority to both AZA (HR=0.424; 95% CI: 0.228, 0.789) and DEC (HR=0.505; 95% CI: 0.269, 0.949). These significant results held using full or step-wise approaches, following DSU guidance only or the weighted STC approach.

CONCLUSION

Using ITC and STC, GLAS + LDAC demonstrated superior OS to AZA or DEC in an adult population with previously untreated AML for whom intensive chemotherapy is not an option.

Health-related quality of life in acute myeloid leukemia patients not eligible for intensive chemotherapy: results of a systematic literature review

Background

AML is a rapidly progressing bone marrow cancer, with poor survival rates compared to other types of leukemia. IC and NIC as well as BSC treatment options are available; however, there is scant published literature on the impact of disease and treatment on the HRQoL in patients receiving NIC.

Aim

This study determined the HRQoL among NIC AML patients.

Materials and methods

Embase, Medline, Cochrane database, and conference abstracts were searched using the prespecified PICOS criteria from January 2000 to November 2017 for studies reporting HRQoL and patient preference utilities in NIC AML. Studies on patients with RAEB-t MDS, randomized clinical trials (RCTs), prospective observational studies, and patient surveys were included, while systematic reviews and meta-analyses were used for bibliographic searching.

Results

Thirteen records from 12 original studies were identified. These included five records from four RCTs, three prospective studies, four patient survey studies, and one cost-effectiveness analysis. At baseline, NIC AML patients had poor HRQoL scores especially in fatigue (33) and GHS (50) on a 0–100 scale, with higher scores indicating better health. Low baseline HRQoL scores, especially PF and fatigue (<50) were shown to be significant independent predictors of poor survival. Clinical responders demonstrated meaningful improvements, especially in PF and fatigue, along with other health domains after being treated with NIC agents across several studies.

Conclusion

HRQoL is poor for patients with NIC AML; measures such as fatigue and PF at baseline have been identified as independent prognostic factors for overall survival with several studies showing improvement in both domains with treatment. RCTs should incorporate evaluation of treatment impact on patients’ PF and fatigue as important measures of effectiveness.

Important Group Differences on the Functional Assessment of Cancer Therapy-Kidney Symptom Index Disease-Related Symptoms in Patients with Metastatic Renal Cell Carcinoma

BACKGROUND

The Functional Assessment of Cancer Therapy-Kidney Symptom Index Disease-Related Symptoms (FKSI-DRS) is important to gauge clinical benefit in metastatic renal cell carcinoma (mRCC).

OBJECTIVES

To estimate important difference (ID) in FKSI-DRS scores that is considered to be meaningful when comparing treatment effect between groups, using mRCC trial data.

METHODS

Data were derived from two pivotal phase III mRCC trials comparing sunitinib versus interferon alfa (N = 750) in first-line mRCC, and axitinib versus sorafenib (N = 723) in second-line mRCC. The change from baseline in FKSI-DRS score was examined as a function of a set of anchors using the repeated-measures model. Several anchors were evaluated: FKSI item "I am bothered by side effects of treatment," EuroQol five-dimensional questionnaire utility score, and adverse events.

RESULTS

When the "I am bothered by side effects of treatment" score was used as an anchor, the ID ranged between 1.2 and 1.3 points. When change in the EuroQol five-dimensional questionnaire utility score was used as an anchor, the FKSI-DRS ID ranged between 0.62 and 0.63 points. Selecting the adverse events that corresponded to a maximum worsening in the FKSI-DRS score in either trial, the ID ranged between 0.62 and 0.74 points.

CONCLUSIONS

Among patients undergoing treatment for mRCC, between-group differences in FKSI-DRS scores as low as 1 point might be meaningful.

Systematic literature review and indirect treatment comparisons (ITC) of glasdegib (GLAS) plus low dose ara-c (LDAC) versus a hypomethylating agent (HMA) for previously untreated acute myeloid leukemia (AML) patients ineligible for intensive chemotherapy (NIC)

e18526

Background: In a randomized phase 2 study, GLAS, an oral, smoothened inhibitor, combined with LDAC, showed significantly better overall survival (OS) vs LDAC alone in previously untreated AML NIC patients. HMAs azacitidine (AZA) and decitabine (DEC) are considered current standard of care in this population. An ITC was conducted to compare OS for GLAS+LDAC vs. AZA and DEC, respectively. Methods: Embase, MEDLINE, Cochrane database, and conference abstracts (ASCO, ESMO and ASH) were systematically searched through 12/2016 for relevant RCTs of GLAS, AZA and DEC in AML patients ineligible for IC. Classical frequentist ITC using the Bucher method was used to indirectly compare OS hazards ratios with 95% confidence intervals (CI) using LDAC as the common comparator. Results: Four studies met inclusion criteria: AZA Fenaux 2010, N (treatment/ comparator) = 14/20, AZA Dombret 2015, N = 241/158, DEC: Kantarjian 2012, N = 242/243, and GLAS+LDAC: Cortes 2016, N = 88/44. Upon review of baseline characteristics, Fenaux 2010 was excluded based on major population differences (% bone marrow blasts). Three studies contributed data to ITC based on comparable populations: age, cytogenic risk and OS of comparator were similar among studies: age 75/73/76 years old, poor cytogenic risk 34%/37%/39%, OS of the comparator 6.4/5.0/4.3 months in AZA/DEC/GLAS+LDAC, respectively. In the ITC, GLAS+LDAC showed significantly better OS HR vs. AZA and DEC (0.51 and 0.56 respectively) (Table). Conclusions: Using ITC, treatment with GLAS+LDAC yielded significantly better OS HR than AZA and DEC in previously untreated AML patients ineligible for treatment with IC. Limitations include mixed IC & NIC population for the AZA trial, and mixed comparator arm of both LDAC and BSC for the DEC trial. Analyses using patient-level data matching baseline characteristics across studies may enable more robust ITC. [Table: see text]