Reimbursement recommendations for cancer drugs supported by phase II evidence in Canada

Background

Phase ii data are increasingly being used as primary evidence for public reimbursement for oncologic drugs. We compared the frequency of reimbursement recommendations for phase ii and phase iii submissions and assessed for variables associated with a positive or conditional recommendation.

Methods

We identified submissions made to the pan-Canadian Oncology Drug Review's Expert Review Committee (perc), of the Canadian Agency for Drugs and Technologies in Health, July 2011 to July 2019, that were supported only by phase ii data. We identified variables within the perc's deliberative framework, including clinical and economic factors, associated with the final reimbursement recommendation. We conducted a multivariable analysis with logistic regression for these variables: feasibility of phase iii study, hematologic indication, and unmet need.

Results

We identified 139 submissions with a perc final recommendation. In 27 instances (19%), the submission had only phase ii evidence, and a positive recommendation was issued for 63% of them (the positive recommendation rate was 82% for submissions with phase iii evidence). Clinical benefit (p < 0.001), unmet need (p = 0.047), and patient alignment (p = 0.015) were associated with a positive recommendation. If a future phase iii study was deemed feasible for submissions with only phase ii evidence, then in univariable (p = 0.040) and multivariable analysis (p = 0.024), the perc was less likely to recommend reimbursement (odds ratio: 0.132).

Conclusions

Although more than half the oncologic submissions with phase ii data were recommended for public reimbursement, compared with submissions having phase iii data, they were less likely to be recommended. A positive or conditional recommendation was more likely if clinical benefit and alignment with patient values was demonstrated. The perc was less likely to recommend reimbursement for submissions with phase ii evidence if a phase iii trial was deemed possible.

Size-dependent influence of NOx on the growth rates of organic aerosol particles

Atmospheric new-particle formation (NPF) affects climate by contributing to a large fraction of the cloud condensation nuclei (CCN). Highly oxygenated organic molecules (HOMs) drive the early particle growth and therefore substantially influence the survival of newly formed particles to CCN. Nitrogen oxide (NOx) is known to suppress the NPF driven by HOMs, but the underlying mechanism remains largely unclear. Here, we examine the response of particle growth to the changes of HOM formation caused by NOx. We show that NOx suppresses particle growth in general, but the suppression is rather nonuniform and size dependent, which can be quantitatively explained by the shifted HOM volatility after adding NOx. By illustrating how NOx affects the early growth of new particles, a critical step of CCN formation, our results help provide a refined assessment of the potential climatic effects caused by the diverse changes of NOx level in forest regions around the globe.

Anti-epidermal growth factor receptor (EGFR) monoclonal antibody combined with cisplatin and 5-fluorouracil in patients with metastatic nasopharyngeal carcinoma after radical radiotherapy: a multicentre, open-label, phase II clinical trial

BACKGROUND

We conducted a single-arm phase II trial to evaluate the efficacy and adverse effects (AEs) of an anti-epidermal growth factor receptor monoclonal antibody, nimotuzumab, combined with cisplatin and 5-fluorouracil (PF) as first-line treatment in recurrent metastatic nasopharyngeal carcinoma after radical radiotherapy.

METHODS

Patients who met the eligibility criteria were recruited from ten institutions (ClinicalTrials.gov; NCT01616849). A Simon optimal two-stage design was used to calculate the sample size. All patients received weekly nimotuzumab (200 mg) added to cisplatin (100 mg/m2 D1) and 5-fluorouracil (4 g/m2 continuous infusion D1-4) every 3-weekly for a maximum of six cycles. Primary end point was objective response rate (ORR). Secondary end points included disease control rate (DCR), progression-free survival (PFS), overall survival (OS) and AEs.

RESULTS

A total of 35 patients were enrolled (13 in stage 1 and 22 in stage 2). Overall ORR and DCR were 71.4% (25/35) and 85.7% (30/35), respectively. Median PFS and OS were 7.0 (95% CI 5.8-8.2) months and 16.3 (95% CI 11.4-21.3) months, respectively. Unplanned exploratory analyses suggest that patients who received ≥2400 mg nimotuzumab and ≥4 cycles of PF had superior ORR, PFS and OS than those who did not (88.9% versus 12.5%, P < 0.001; 7.4 versus 2.7 months, P = 0.081; 17.0 versus 8.0 months, P = 0.202). Favourable subgroups included patients with lung metastasis [HROS 0.324 (95% CI 0.146-0.717), P = 0.008] and disease-free interval of >12 months [HROS 0.307 (95% CI 0.131-0.724), P = 0.004], but no difference was observed for metastatic burden. The only major grade 3/4 AE was leukopenia (62.9%).

CONCLUSION

Combination nimotuzumab-PF chemotherapy demonstrates potential efficacy, and is well tolerated as first-line chemotherapy regimen in recurrent metastatic nasopharyngeal carcinoma.

Impact of the pan-Canadian Oncology Drug Review on provincial concordance with respect to cancer drug funding decisions and time to funding

BACKGROUND

The pan-Canadian Oncology Drug Review (pcodr) was implemented in 2011 to address uneven drug coverage and lack of transparency with respect to the various provincial cancer drug review processes in Canada. We evaluated the impact of the pcodr on provincial decision concordance and time from Notice of Compliance (noc) to drug funding.

METHODS

In a retrospective review, Health Canada's Drug Product Database was used to identify new indications for cancer drugs between January 2003 and May 2014, and provincial formulary listings for drug-funding dates and decisions between 1 January 2003 and 31 December 2014 were retrieved. Multiple linear models and quantile regressions were used to evaluate changes in time to decision-making before and after the implementation of the pcodr. Agreement of decisions between provinces was evaluated using kappa statistics.

RESULTS

Data were available from 9 provinces (all Canadian provinces except Quebec), identifying 88 indications that represented 51 unique cancer drugs. Two provinces lacked available data for all 88 indications at the time of data collection. Interprovincial concordance in drug funding decisions significantly increased after the pcodr's implementation (Brennan-Prediger coefficient: 0.54 pre-pcodr vs. 0.78 post-pcodr; p = 0.002). Nationwide, the median number of days from Health Canada's noc date to the date of funding significantly declined (to 393 days from 522 days, p < 0.001). Exploratory analyses excluding provinces with incomplete data did not change the results.

CONCLUSIONS

After the implementation of the pcodr, greater concordance in cancer drug funding decisions between provinces and decreased time to funding decisions were observed.

Clinician participation in CADTH's pan-Canadian Oncology Drug Review: contribution and impact on cancer drug funding recommendations

In any given week, media headlines publicize the benefits of a new “breakthrough” cancer drug, with patients and clinicians subsequently advocating for its use. [...]

[The correlation between cerebral MRI characteristics of posterior reversible encephalopathy syndrome and serum levels of PlGF, sEng in patients with pre-eclampsia]

Objective: To investigate the MRI characteristics of posterior reversible encephalopathy syndrome (PRES) in patients with pre-eclampsia(PE) and its correlation with serum placental growth factor (PlGF), soluble endoglin (sEng) and sEng/PlGF ratio. Methods: 34 patients with PE who were admitted to Guangdong Women and Children Hospital from September 2013 to March 2014 were studied retrospectively.13 cases had PRES and 21 cases had normal cerebral MRI. All patients underwent conventional MRI and DWI scanning. The score of brain edema (SBE) were calculated. PlGF, sEng concentrations were measured with ELISA. The levels of PlGF, sEng and sEng/PlGF were compared between the PRES group and the normal MRI groups. The correlation of sEng/PIGF ratio and SBE were studied as well. Results: The PlGF in the PRSE group was (231.4±66.8) ng/L, and in normal cerebral MRI group was (333.6±37.5) ng/L (t= 5.61, P<0.05). The sEng in the PRSE group was (5 256.2±879.6) ng/L, in normal cerebral MRI group was (3 955.6±537.7) ng/L (t=6.53, P<0.01).The sEng/PlGF in the PRSE group was (26.0±10.0) , and in normal cerebral MRI group was (11.9±1.6; t=8.41, P<0.01) , with the cut-off value of 20.0. The sensitivity was 81.8% and the specificity was 85.0%.There was no statistically significant correlation between PlGF, sEng and SBE (P>0.05).There was a positive correlation between the sEng/PlGF ratio and SBE (P>0.05). Conclusion: The value of sEng/PlGF ratio was correlated with brain edema score in PE. The serum sEng/PlGF ratio may be used as a reference for prediction of PRES.

Abstract P6-06-50: Obesity and the influence on tumor biology as determined by the intermediate risk 21-gene recurrence scores (RS) and the 70-gene breast cancer recurrence signature (70-GS) assay

BACKGROUND

Obesity is an apparent risk factor for postmenopausal breast cancer (BC), estrogen receptor (ER) positive BC, larger tumors, lymph node (LN) involvement, as well as recurrence of BC and BC death despite treatment. However, the specific mechanism of these increased risks remains unclear. Our prior work described the negative influence of metabolic syndrome on BC recurrence in patients assessed by a 21 gene recurrence score (RS) in the low risk and intermediate risk tertiles (Lakhani et al PSABCS 2012). The objective of this study was to analyze the interaction of obesity and BC biology in patients assessed by the 70 gene signature (70-GS) for BC recurrence and the 80 gene molecular subtyping.

METHODS

We studied consecutive patients with newly diagnosed ER positive, LN negative BC treated at Loyola University Medical Center between 2005 -2012 who had an intermediate RS. The 70-GS was done on these same paraffin-embedded tumor blocks for risk level and molecular subtype. Standard descriptive statistics are reported. Wilcoxon rank sum tests were performed for the comparison of BMI by groups defined by RS scores (≤24 vs ≥25) and the 70 gene signature assay (high risk vs low risk). In addition, Chi-squared test, or Fisher's exact test as appropriate, was used to examine the association between BMI tertiles and the 70GS or molecular subtype.

RESULTS

From 102 patients with intermediate RS, the 70-GS was successful in 89 samples. The average age was 61 years (range 41-79). The median body mass index (BMI) was 29 (range 18-53). There was a significant association between BMI and RS (p = 0.0110): median BMI = 28 in patients with RS ≤24; median BMI 33 in patients with RS ≥25. There was a significant association between BMI and the 70-GS (p = 0.0116). Median BMI 27 in low risk group; median BMI 32 in high risk group. There was a significant association between the 70-GS and BMI (p = 0.0190).

Association between the 70-GS and BMI70-GS RiskHealthy (18-25)Overweight (26-30)Obese (&gt;30)TotalHigh (n pts)1292950Low (n pts)15131139

There was a significant association between molecular subtype and BMI tertiles (p = 0.0803).

Association between molecular subtype and BMI tertiles HealthyOverweightObeseTotalLuminal A (n pts)14131239Luminal B (n pts)1392648

CONCLUSION

There is a striking interaction of obesity and BC biology as defined by the RS and 70-GS assays. Our data suggest that BC in obese women may have more aggressive tumor biology and higher risk of recurrence than BC in those with a low BMI. Further molecular characterization of the BC from obese patients may elucidate the role obesity plays in BC development and progression, as well as provide rationale for targeted therapeutic trials. Clinical trials targeting known carcinogenic pathways related to obesity (such as metformin and statins) are ongoing. Several genes in the 70-GS are the same genes expressed in obese patients. Additional studies examining the prognostic and predictive value of the 70-GS need to be conducted for this patient population.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-50.

Toxic effects of copper and cadmium on fertilization potency of gametes of Pacific oyster (Crassostrea gigas)

Not available

Abstract PD10-02: Metabolic syndrome and recurrence within the 21-gene recurrence score assay risk categories in lymph node negative breast cancer

Background: The incidence of the metabolic syndrome (MS) has been increasing in the United States and elsewhere. The interaction of MS with breast cancer (BC) incidence, tumor biology and outcomes are under study. We hypothesized that the presence of MS would predict BC recurrence to a variable degree across the diverse BC biology as defined by the risk categories of the 21-gene recurrence score (RS) assay.

Patients and Methods: We studied consecutive patients (pts) with newly diagnosed, estrogen receptor (ER) positive, lymph node (LN) negative BC treated in our institution between 2006–2011 who had a 21-gene RS assay done on their tumors. All pts were treated with standard systemic and local therapy. The electronic medical record was queried for key diagnoses including MS and its constituent parts. The WHO definition was used to categorize pts as having MS defined as diabetes mellitus (DM) or glucose intolerance, plus at least 2 of the following: hypertension (HTN), dyslipidemia (HL), central obesity and microalbuminemia. Tumor characteristics including Ki67 index, grade, tumor size, HER2/neu status; and pt characteristics including age, race, menopausal status, body mass index were recorded. The association of MS and the tumor and patient characteristics with the RS tertiles of low, intermediate and high risk was analyzed.

Results: We identified 332 pts, median age 62 years, of whom 88 (27%) had MS. There was no significant association between the MS and any of the patient or tumor variables including the 21-gene RS assay, except for race (p = 0.004). Eleven of 21 (52%) African-American women had MS, 68 of 284 (24%) Caucasian women had MS, and 9 of 21 (43%) others including Hispanic and Asian women had MS. However, there was a significant association between recurrence and MS (p = 0.0002) independent of other factors. Of the 21 pts who recurred, 13 (61.9%) had MS. There was an association of recurrence and MS within RS tertiles. For pts with low risk scores, 7/44 (15.9%) with MS vs. 1/126 (0.79%) without MS had recurrence (p = 0.0003). For pts with intermediate risk scores, 5/30 (16.67%) with MS vs. 4/83 (4.82%) without MS had recurrence (p = 0.05). For patients with high risk scores, 1/9 (11.11%) with MS vs. 2/15 (13.33%) without MS had recurrence (p = 1).

Conclusion: MS is an independent risk factor for BC recurrence among women with LN negative, ER positive BC treated with standard adjuvant therapy. There is a striking impact of MS on recurrence in pts with tumor biologies defined by low (and to a lesser degree) intermediate risk 21-gene RS assay scores. However, there is no difference in recurrence risk by MS among those pts with high RS. This implies that interventions directed at modifying MS in newly diagnosed pts with early BC may potentially favorably impact survival in those with specific tumor biologies as defined by multigene assays. Thus, long-term prospective studies should be conducted to further evaluate both the short and long term effects of MS on BC outcomes.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD10-02.

Rapamycin, mycophenolate mofetil, methylprednisolone, and cytotoxic T-lymphocyte-associated antigen 4 immunoglobulin-based conditioning regimen to induce partial tolerance to hind limb allografts without cytoreductive conditioning

BACKGROUND

Composite tissue allograft transplantation may represent the next frontier in the field of reconstructive surgery. However, the main obstacles precluding the routine use of composite tissue allotransplants are rejection and toxicity associated with life-long immunosuppressive therapy. In this study, we investigated a nontoxic immunosuppressant and cytotoxic T-lymphocyte-associated antigen 4 immunoglobulin (CTLA4-Ig)-based protocol to induce donor-specific tolerance to hind limb allografts in rats.

METHODS

Fully mismatched, 4- to 10-week-old Brown Norway (BN, RT1n) and Lewis (RT1) rats were used as cell/organ donors and recipients, respectively. Recipients were treated with CTLA4-Ig (2 mg/kg/d) on days -30, -28, -26, -24, and -22, rapamycin, mycophenolate mofetil, and methylprednisolone (RAPA/MMF/MP) combined therapy (from days -30 to day 100), a single dose of anti-lymphocyte serum (10 mg, on day -30), and donor bone marrow (10 x 10(7) T-cell-depleted cells) transplantation (BMT, on day -30). Thirty days after BMT, chimeric animals received hind limb allotransplantations (on day 0). The RAPA/MMF/MP combined therapy was changed to Cyclosporine (CsA, 8 mg/kg/d) on day 100 and maintained thereafter at this level.

RESULTS

Hematopoietic chimerism of 17.6 +/- 9.5% at day 0, was stable (15.2 +/- 5.6%) at 230 days post-BMT; there was no sign of graft-versus-host disease. Chimeric recipients (Lewis) permanently accepted (>200 days) donor (BN)-specific (RT11, n = 6) hind limbs, yet rapidly rejected (20 +/- 2 days) third-party hind limbs (Wistar Furth [WF]). Lymphocytes of graft-tolerant animals demonstrated hyporesponsiveness in mixed lymphocyte cultures in a donor-specific manner. Tolerant graft histology showed no signs of acute and chronic rejection.

CONCLUSIONS

The immunosuppressant and CTLA4-Ig-based conditioning regimen with donor BMT produced mixed chimerism and induced partial donor-specific tolerance to hind limb allografts.

[Guidelines for the sociomedical assessment of performance in patients suffering from breast cancer]

The following guidelines were developed for the medical assessment services of the German Pension Insurance Federal Institution. Starting from day-to-day practice, criteria and attributes to guide decisions for a systemisation of the sociomedical assessment of performance in breast cancer were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent, e. g., for the assessment of applications for decreased earning capacity benefits. The guidelines summarise typical manifestations of breast cancer and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination, and for diagnostic tests are illustrated. The assessment of the individual's capacity is outlined, taking occupational factors into account. Following the determination of dysfunctions, the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally, inferences are drawn regarding the occupational capacity of the individual.

Comparison of two induction chemotherapy regimens in combination with radiotherapy in patients with advanced nasopharyngeal carcinoma

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Background: Prospective randomized trials failed to show any survival benefits associated with the use of induction chemotherapy in nasopharyngeal carcinoma (NPC). Although cisplatin-based regimens were commonly used in these trials, the impact of cisplatin dose was not clear. Methods: Individual patient data of two published phase III trials using different cisplatin-based induction chemotherapy regimens were pooled together for analysis. A total of 365 patients with stage II-IV NPC received either cisplatin & epirubicin (EP, n = 144) or cisplatin, bleomycin & fluorouracil (PBF, n = 221) followed by radiotherapy between September 1989 and July 1994. The mean total cisplatin dose received by patients ranged from 162 mg/m2 in EP group to 232 mg/m2 in PBF group. Median follow-up time was 59 months. Results: The response rates at the end of induction chemotherapy were 86% in PBF group and 84% in EP group. No significant differences in tumor control and survival were observed between the two groups. Five-year overall survival rates were 63% in PBF group and 62.5% in EP group. Five-year loco-regional failure-free rates were 74% in PBF group and 65% in EP group, the difference being not significant after adjusting for stage grouping. Conclusions: No significant difference in treatment outcome was observed in patients using different cisplatin-based induction chemotherapy. The absence of survival benefits in chemotherapy arms was probably not related to the dose-intensity of cisplatin used, and escalating the total cisplatin dose alone in induction chemotherapy is not likely to improve survival.

No significant financial relationships to disclose.

Investigation of the thermal stability of Ni/C multilayers by X-ray methods

Microstructural properties of Ni/C multilayers prepared by PLD (pulsed laser deposition) have been investigated after heat treatment in vacuum at temperatures in the range of 50 degrees C to 500 degrees C. X-ray diffractometry, X-ray reflectometry, fluorescence EXAFS (extended X-ray absorption fine structure) and HREM (high resolution transmission electron microscopy) have been applied to characterize samples in the initial state and after annealing. The multilayer reflectivity remained unchanged or increased at temperatures below 400 degrees C due to sharpening of the interfaces caused by the formation of alpha-nickel and nickel carbide. The reflectivity decreased at temperatures above 400 degrees C because of the fragmentation of the nickel layers. It can be shown, that both chemical and mechanical driving forces are responsible for the observed modifications of the initial specimen state.

Characterization of ultra smooth interfaces in Mo/Si-multilayers

The interface structure of Mo/Si-multilayers prepared by Pulsed Laser Deposition (PLD) on Si substrates at room temperature has been investigated. Already the in-situ ellipsometer data acquired during film growth indicate a particular behaviour of this material system that is caused by reaction/diffusion processes of the condensing atoms. MoSi(x) interlayers are formed both at the Mo on Si- and at the Si on Mo-interfaces. The results of multilayer characterization carried out by SNMS and RBS show similar concentration profiles for both types of the interlayers. More detailed information about interface structure and morphology can be provided by HREM investigations. In the TEM micrographs of various multilayers prepared for different laser light wavelengths an improvement of layer stack quality, i.e. formation of abrupt interfaces, with increasing photon energy is observed. Layer stacks having almost ideally smooth interfaces were synthesized by UV-photon ablation. HREM micrographs of these multilayers show a pronounced separation of spacer and absorber layers. The roughness sigma(R) of the interfaces between the amorphous Si- and MoSi(x)-layers was determined by image analysis. On the average a level sigma(R) approximately 0.1 nm is found. There is no indication for roughness replication or amplification from interface to interface as it is known from the appropriate products of conventional thin film technologies.

Plasminogen activation in lesional skin of Pemphigus vulgaris type Neumann

Zymographic and immunological studies revealed that primarily tissue-type plasminogen activator and to a lesser extent urokinase-type plasminogen activator were present in fluids of pemphigus vulgaris (type Neumann) skin blisters. Furthermore, plasmin activity was detected in pemphigus blister fluids using chromogenic peptide substrate assays. In pemphigus, but not in control, suction blister fluids plasmin/alpha 2-antiplasmin and plasmin/alpha 2-macroglobulin complexes were found by immunoprecipitation or by testing in immunoassays after fractionation by molecular-sieve chromatography. Plasmin activity, detected by a low molecular weight chromogenic peptide assay, was ascribed to plasmin/alpha 2-macroglobulin complexes. Since formation of plasmin/inhibitor complexes requires active plasmin, the finding indicates previous activation of plasminogen in pemphigus lesions.

Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic, average-risk men

Asymptomatic men (N = 114) 50 years of age or older had screening for colorectal neoplasia with flexible sigmoidoscopy followed by colonoscopy regardless of the sigmoidoscopic result. Our study objective was to determine the prevalence of patients having isolated adenomatous polyps in a proximal colonic segment in the absence of a distal index neoplasm within reach of the sigmoidoscope. Through the combined use of sigmoidoscopy and colonoscopy, adenomatous polyps were detected in 47 of 114 individuals (41%). A total of 88 adenomas was found. Seventeen patients had isolated neoplasms in proximal colonic segments in the absence of distal adenomas. These patients represented 15% of screened subjects (17 of 114) and 20% of individuals who lacked adenomas on sigmoidoscopy (17 of 84). The majority of proximal neoplasms were small (less than 1.0 cm), tubular adenomas. Flexible sigmoidoscopy may be ineffective for screening asymptomatic men for neoplasia. However, it remains to be determined if a 20% miss rate (for those with a normal sigmoidoscopic examination) is significant and whether small proximal adenomas are worth finding.

The epithelial basal lamina of the isolated colonic mucosa: scanning and transmission electron microscopy

The morphology of the rat colonic basement membrane was studied under control conditions and after induction of secretion by distension in the Ussing chamber. The basement membrane was visualized by removing the epithelium with the aid of Ca2+ chelation combined with vibration. Specimens with and without metallic coating were studied with SEM and TEM, respectively. The surface of the basement membrane in the surface region of the epithelium, i.e. between the mouths of the crypts, is rough. In contrast, the deeper parts of the crypts have a rather smooth basal lamina, which is finely pleated. Fenestrations of the basal lamina with a diameter of 0.5-1 microns were found frequently at the surface region, but less frequently in the crypts. Fenestrations with diameters larger than 2 microns were never observed. After the distension experiments and long-time incubation in vitro (5 h), the size of the fenestrations remained unchanged, however, their number increased compared to the controls.

[A contribution to the diagnostic of stress-in-continence (author's transl)]

In 321 women with the symptoms of a stress-incontinence we tried to find out if specific methods can reform the diagnostic. By clinical tests an urinary incontinence could be shown only in 71.1%. The results from urethrocystography (169 patients) and simultane measuring of pressure in urethra and urinary bladder (222 patients) are compared with the results of the clinical examination of urine incontinence. According to the method used, the urethrocystography was corresponding with the positive clinical test between 75.9 and 93.5%, the measuring of the pressure in 87.4%. In negative clinical tests a stress-incontinence could be diagnosed or be excluded by combined radiological, tonometrical and endoscopical examinations. Urethrocystography and simultane measuring of pressure complement one another, they are no competitive methods. Our investigations further showed that the upper urogenital tract is cooperating in stress-incontinence. In the infusion-urogram 19.7% of the patients showed signs of chronic pyelonephritis, 15.3% had no urinary insufficience. 22.6% were suspect to have a chronic pyelonephritis. Finally the worth of diagnostic methods on therapeutic actions is discussed.