A tailored approach to horizon scanning for cancer medicines

BACKGROUND

Horizon scanning (HS) is the systematic identification of emerging therapies to inform policy and decision-makers. We developed an agile and tailored HS methodology that combined multi-criteria decision analysis weighting and Delphi rounds. As secondary objectives, we aimed to identify new medicines in melanoma, non-small cell lung cancer and colorectal cancer most likely to impact the Australian government's pharmaceutical budget by 2025 and to compare clinician and consumer priorities in cancer medicine reimbursement.

METHOD

Three cancer-specific clinician panels (total n = 27) and a consumer panel (n = 7) were formed. Six prioritisation criteria were developed with consumer input. Criteria weightings were elicited using the Analytic Hierarchy Process (AHP). Candidate medicines were identified and filtered from a primary database and validated against secondary and tertiary sources. Clinician panels participated in a three-round Delphi survey to identify and score the top five medicines in each cancer type.

RESULTS

The AHP and Delphi process was completed in eight weeks. Prioritisation criteria focused on toxicity, quality of life (QoL), cost savings, strength of evidence, survival, and unmet need. In both curative and non-curative settings, consumers prioritised toxicity and QoL over survival gains, whereas clinicians prioritised survival. HS results project the ongoing prevalence of high-cost medicines. Since completion in October 2021, the HS has identified 70 % of relevant medicines submitted for Pharmaceutical Benefit Advisory Committee assessment and 60% of the medicines that received a positive recommendation.

CONCLUSION

Tested in the Australian context, our method appears to be an efficient and flexible approach to HS that can be tailored to address specific disease types by using elicited weights to prioritise according to incremental value from both a consumer and clinical perspective.

POLICY SUMMARY

Since HS is of global interest, our example provides a reproducible blueprint for adaptation to other healthcare settings that integrates consumer input and priorities.

Characteristics of immune checkpoint inhibitor-induced encephalitis and comparison with HSV-1 and anti-LGI1 encephalitis: A retrospective multicentre cohort study

AIM

Immune checkpoint inhibitor-induced encephalitis (ICI-iE) is a rare but life-threatening toxicity of immune checkpoint inhibitor treatment. We aim to identify the characteristics of ICI-iE and describe factors that discriminate it from herpes simplex virus (HSV)-1 encephalitis and anti-leucine-rich glioma-inactivated 1 (anti-LGI1) encephalitis, as two alternative entities of encephalitis.

METHODS

In this retrospective multicentre cohort study, we collected patients with ICI-iE reported to the Side Effect Registry Immuno-Oncology from January 2015 to September 2021 and compared their clinical features and outcome with 46 consecutive patients with HSV-1 or anti-LGI1 encephalitis who were treated at a German neurological referral centre.

RESULTS

Thirty cases of ICI-iE, 25 cases of HSV-1 encephalitis and 21 cases of anti-LGI1 encephalitis were included. Clinical presentation of ICI-iE was highly variable and resembled that of HSV-1 encephalitis, while impairment of consciousness (66% vs. 5%, p = .007), confusion (83% vs. 43%; p = .02), disorientation (83% vs. 29%; p = .007) and aphasia (43% vs. 0%; p = .007) were more common in ICI-iE than in anti-LGI1 encephalitis. Antineuronal antibodies (17/18, 94%) and MRI (18/30, 60%) were mostly negative in ICI-iE, but cerebrospinal fluid (CSF) showed pleocytosis and/or elevated protein levels in almost all patients (28/29, 97%). Three patients (10%) died of ICI-iE. Early immunosuppressive treatment was associated with better outcome (r = 0.43).

CONCLUSIONS

ICI-iE is a heterogeneous entity without specific clinical features. CSF analysis has the highest diagnostic value, as it reveals inflammatory changes in most patients and enables the exclusion of infection. Early treatment of ICI-iE is essential to prevent sequelae and death.

Single-agent anti-PD-1 or combined with ipilimumab in patients with mucosal melanoma: an international, retrospective, cohort study

BACKGROUND

Mucosal melanoma (MM) is a rare melanoma subtype with distinct biology and poor prognosis. Data on the efficacy of immune checkpoint inhibitors (ICIs) is limited. We determined the efficacy of ICIs in MM, analysed by primary site and ethnicity/race.

PATIENTS AND METHODS

Retrospective cohort study from 25 cancer centres in Australia, Europe, USA and Asia. Patients with histologically confirmed MM were treated with anti-PD1+/-ipilimumab. Primary endpoints were response rate (RR), progression-free survival (PFS), overall survival (OS) by primary site (naso-oral, urogenital, anorectal, other), ethnicity/race (Caucasian, Asian, Other) and treatment. Univariate and multivariate Cox proportional hazard model analyses were conducted.

RESULTS

In total, 545 patients were included: 331 (63%) Caucasian, 176 (33%) Asian and 20 (4%) Other. Primary sites included 113 (21%) anorectal, 178 (32%) urogenital, 206 (38%) naso-oral and 45 (8%) other. 348 (64%) received anti-PD1 and 197 (36%) anti-PD1/ipilimumab. RR, PFS and OS did not differ by primary site, ethnicity/race or treatment. RR for naso-oral was numerically higher for anti-PD1/ipilimumab (40%, 95% CI 29-54%) compared with anti-PD1 (29%, 95% CI 21-37%). 35% of patients that initially responded progressed. Median duration of response (mDOR) was 26 months (95% CI 18-NR [Not Reached]). Factors associated with short PFS were ECOG PS ≥3 (p<0.01), LDH >ULN (p=0.01), lung metastases (p<0.01) and ≥1 previous treatments (p<0.01). Factors associated with short OS were ECOG PS ≥1 (p<0.01), LDH >ULN (p=0.03), lung metastases (p<0.01) and ≥1 previous treatments (p<0.01).

CONCLUSIONS

MM has poor prognosis. Treatment efficacy of anti-PD1+/-ipilimumab was similar and did not differ by ethnicity/race. Naso-oral primaries had numerically higher response to anti-PD1/ipilimumab, without difference in survival. The addition of ipilimumab did not show greater benefit over anti-PD1 for other primary sites. In responders, mDOR was short and acquired resistance was common. Other factors, including site and number of metastases were associated with survival.

Combined ipilimumab and nivolumab first-line and after BRAF-targeted therapy in advanced melanoma

The combination of ipilimumab and nivolumab is a highly active systemic therapy for metastatic melanoma but can cause significant toxicity. We explore the safety and efficacy of this treatment in routine clinical practice, particularly in the setting of serine/threonine-protein kinase B-Raf (BRAF)-targeted therapy. Consecutive patients with unresectable stage IIIC/IV melanoma commenced on ipilimumab and nivolumab across 10 tertiary melanoma institutions in Australia were identified retrospectively. Data collected included demographics, response and survival outcomes. A total of 152 patients were included for analysis, 39% were treatment-naïve and 22% failed first-line BRAF/MEK inhibitors. Treatment-related adverse events occurred in 67% of patients, grade 3-5 in 38%. The overall objective response rate was 41%, 57% in treatment-naïve and 21% in BRAF/MEK failure patients. Median progression-free survival was 4.0 months (95% CI, 3.0-6.0) in the whole cohort, 11.0 months (95% CI, 6.0-NR) in treatment-naïve and 2.0 months (95% CI, 1.4-4.6) in BRAF/MEK failure patients. The combination of ipilimumab and nivolumab can be used safely and effectively in a real-world population. While first-line efficacy appears comparable to trial populations, BRAF-mutant patients failing prior BRAF/MEK inhibitors show less response.

Assessment of an adverse drug reaction monitoring program in nursing homes

An adverse drug reaction monitoring program was developed in ten geriatric nursing care facilities with a population of 826 patients. Over a two year period, the incidence of moderate to severe adverse reactions was decreased from 27 to 20 percent. Digitalis glycosides, antipsychotics, sedatives and hypnotics, diuretics, and anti-inflammatory agents were responsible for more than three quarters of the reactions. Elderly females receiving large numbers of drugs and patients having a history of a previous reaction were found to be at high risk of experiencing an adverse effect. A substantial reduction in the number of drug-related acute care hospital admissions and a decrease in drug consumption demonstrated the cost effectiveness of the program. The response of other health care professionals to the program was excellent. A Patient Assessment Form was developed to assist in the quarterly review of patient medications. Guidelines for monitoring adverse drug reactions in nursing care facilities are suggested to aid other pharmacists in the implementation of similar clinical services.

Developing an adverse drug reaction program in nursing homes

The study of 826 geriatric nursing home patients was undertaken by a pharmacist to determine the incidence of adverse reactions to drugs. A formalized adverse drug reaction reporting program was used as the basis for the detection of unwanted drug effects. Approximately 27% of patients experienced a moderate to severe adverse effect. Five groups of drugs accounted for three-quarters of the reactions detected. The majority of these reactions were predictable and preventable. Females over the age of 70 on large quantities of drugs were significantly more susceptible to experiencing an adverse reaction. Physicians implemented 76% of pharmacist initiated recommendations for the treatment of adverse effects and were appreciative of increased pharmacy involvement. The implementation of such recommendations was felt to have substantially reduced the incidence of drug-induced acute hospitalizations. Although the information was generated in nursing homes, it may be generalized to other geriatric specialty areas such as medical wards and extended care units. Several recommendations are provided on how other pharmacists can implement similar clinical services in their areas of professional practice.