Pharmacoeconomic and clinical implications of sequential therapy for metastatic renal cell carcinoma patients in Central and Eastern Europe

INTRODUCTION

The incidence and mortality rates of kidney cancer in the Central and Eastern European (CEE) region are among the highest in the world. Access to second and subsequent lines of metastatic renal cell carcinoma (mRCC) therapies is highly varied in the region. Despite the increasing body of evidence supporting the clinical benefit of multiple lines of treatment, access to treatment beyond first line is restricted in many of these countries.

AREAS COVERED

The adoption of targeted therapies for the first-line treatment of mRCC in the region was slow and faced many obstacles. In order to evaluate the current status of treatment beyond the first-line setting in the CEE region, this review examines the availability and reimbursement of mRCC drugs and clinical practice in institutions that treat patients with mRCC.

EXPERT OPINION

This review highlights the need to raise awareness among physicians, payers and regulators on clinical trial and cost-effectiveness data regarding the treatment of mRCC beyond the first line. The obstacles to mRCC drug access highlighted in this review need to be overcome to ensure that patients are receiving the best treatment available.

Insights into cancer surveillance in Central and Eastern Europe, Israel and Turkey

The current cancer landscape within transitional economies in central and Eastern Europe and the Mediterranean area is not particularly optimistic. Current perceptions are often based on extrapolations from other countries and regions; and hence the authors collaborated with the South Eastern Europe Oncology Group (SEEROG) to collect information on cancer registration in Central and Eastern Europe, Israel and Turkey. Healthcare authorities and specialist oncology centres in 21 countries in the region were contacted for information on cancer registries in their countries. Based on this information, the authors believe that the recording and reporting of data on cancer in the region is at an acceptable level. The authors discuss and compare institution- and population-based registries, and present opinions on elements of an 'ideal registry' based on the survey replies and comparisons with other registries. A comparison with the sources used for GLOBOCAN 2008 illustrates the need for consistent data to be communicated, published and utilised throughout the region and the oncology community. The authors conclude by considering the potential value of collaboration between health authorities across the region, as well as between the clinical and epidemiological communities, to ensure that cancer data are consistently collected, verified and made public.

A randomized prospective study of low-dose interleukin-2 (IL-2) in combination with interferon-alpha (IFN) and 5-fluorouracil (5-FU) for metastatic renal cell carcinoma: Final results

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Background: High and intermediate IL-2 regimens are difficult to recommend because of great toxicity. Based on previous activity of combination low-dose cytokines (including 1 MIU IL-2) in metastatic renal cell carcinoma (MRCC) patients (pts) (J Europ Urol, Supp. 2006;5 (2):286), we performed this randomized study. The primary endpoint was response rate. The secondary endpoints were median overall survival (OS) and toxicity in groups. Methods: Eligibility criteria included histopathologically confirmed MRCC, ECOG PS 0- 2, no autoimmune diseases, no brain metastases, and normal organ function. All pts are randomized to IL-2 alone, 1 MIU, iv, t.i.w., weeks 1–3 or IL-2, 1 MIU, iv, t.i.w., weeks 1–3 plus IFN 5 MIU, sc, t.i.w, weeks 1–3 or biochemotherapy group 5-FU, 500 mg/m2, iv, once a week, weeks 1–3 plus IL-2 and IFN. Cycles were repeated every three weeks. Response evaluation was performed according to RECIST every 2 cycles. Results: From Jan 2003 to Jun 2006, 66 pts with any type of MRCC histology were randomized. Median age of the pts was 55.4 years (range 16–74). 43.9% of the patients had been previously treated by chemo- or immunotherapy. 54.5 percent of the pts had poor prognosis by MSKCC criteria. Bone metastases were present in 52.4% pts. Baseline characteristics were well balanced in groups. Pts treated with IL-2+IFN or 5-FU+IL-2+IFN had a statistically longer survival than those treated with IL-2 alone ( Table ). OS and TTP of pts in combined arms were not statistically different. There were no toxicity grade 3 and 4. Conclusions: Low-dose IL-2 alone is not effective. 5- FU does not improve efficacy of the cytokine combination. Low dose IL-2 and IFN demonstrate reasonable efficacy and could be recommend for MRCC pts outside clinical trials and available target therapy. All regiments are well tolerated.

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No significant financial relationships to disclose.

Low molecular weight heparin (LMWH) increases the efficacy of immunotherapy in metastatic renal cell carcinoma patients with abnormal coagulation

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Background: Antitumor effects of LMWH are unclear. Heparin can bind with fibroblast-growth factor, other heparine-binding angiogenic factors, their receptors, and/or impact on coagulation system which induces angiogenesis. We previously revealed hypercoagulation is a frequent symptom in metastatic renal cell carcinoma (MRCC) patients (pts) and clinically correlates with progression of the disease. Methods: Pts with MRCC and high level of fibrinogen, D-dimer or fibrin, antithrombin III and prothrombin were stratified by MSKCC prognostic criteria and included to receive immunotherapy plus LMWH (IL-2, 1 MIU, i.v, 3 tiw + IFN alpha, 5 MU, s.c, 3 tiw ± 5-FU 500 mg/m2, i.v. once a week, and Dalteparin, LMWH, 5000 IU, s.c, every day, for 3 weeks) or immunotherapy alone. Demographic and treatment characteristics were similar between both arms. The primary endpoint was cancer-related overall survival (OS). Results: Flu-like syndrome, hypotension, anorexia were most common side effects (CTC grade 1). There were no bleedings in LMWH group. Conclusions: These results demonstrate that Dalteparin significantly improves cancer specific overall survival and decreases disease progression rate in combination with immunotherapy in MRCC pts with abnormal coagulation. Phase II randomized multicenter open-label discontinuation trial will be conducted.

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No significant financial relationships to disclose.

Rapid detection of regionally clustered germ-line BRCA1 mutations by multiplex heteroduplex analysis. UKCCCR Familial Ovarian Cancer Study Group

Germ-line mutations of the BRCA1 gene are responsible for a substantial proportion of families with multiple cases of early-onset breast and/or ovarian cancer. Since the isolation of BRCA1 last year, >65 distinct mutations scattered throughout the coding region have been detected, making analysis of the gene time consuming and technically challenging. We have developed a multiplex heteroduplex analysis that is designed to analyze one-quarter of the coding sequence in a single-step screening procedure and that will detect approximately 50% of all BRCA1 mutations so far reported in breast/ovarian cancer families. We have used this technique to analyze BRCA1 in 162 families with a history of breast and/or ovarian cancer and identified 12 distinct mutations in 35 families.