Reliability, validity, and change thresholds of the NCCN/FACT Bladder Symptom Index (NFBlSI-18) in patients with advanced urothelial cancer

BACKGROUND

The NCCN/FACT Bladder Symptom Index-18 (NFBlSI-18) is a bladder cancer-specific instrument. We aimed to psychometrically evaluate the reliability and validity of NFBlSI-18 and estimate change thresholds for total, disease-related symptoms-physical (DRS-P), DRS-emotional (DRS-E), and function/well-being (F/WB) scales in patients with locally advanced/metastatic urothelial cancer (la/mUC).

METHODS

JAVELIN Bladder 100 trial data were analyzed. Anchors to evaluate validity included: 5-level EuroQoL-5D utility index (EQ-5D-5L UI), visual analog scale (VAS), Eastern Cooperative Oncology Group (ECOG) performance status, and number of symptoms. Responsiveness to change was tested by anchoring to time to tumor progression (TTP), best overall response (BOR), and differences in means between ECOG categories to estimate meaningful between-group differences. Meaningful within-group change thresholds were estimated using receiver operating characteristic curve analysis, anchoring to change in EQ-5D-5L UI. Significant within-individual patient change thresholds were estimated with reliable and likely change indexes.

RESULTS

Correlations with EQ-5D-5L UI and VAS ranged from 0.53 to 0.73. Standardized effect sizes were >0.20. Compared with patients with TTP of ≥6 months, patients with TTP of >0-2 and 3-5 months had larger declines; results for BOR were similar. Thresholds (points) for meaningful between-group differences were: total, 6-11; DRS-P, 3-6; and DRS-E and F/WB, 1. Thresholds (points) for meaningful within-group worsening were: total, 4; and DRS-P, 3, and for significant individual change they were: total, 3-9; DRS-P, 2-6; DRS-E, 1-3; and F/WB, 2-4.

CONCLUSIONS

NFBlSI-18 exhibited evidence of reliability, validity, and responsiveness to assess quality of life in studies of la/mUC, and change thresholds are established for future studies.

PLAIN LANGUAGE SUMMARY

The NCCN/FACT Bladder Symptom Index-18 (NFBlSI-18) is a questionnaire used to assess quality of life for people with advanced bladder cancer. People with advanced bladder cancer who took part in the JAVELIN Bladder 100 study completed the NFBlSI-18 when they joined the study and after each treatment with avelumab maintenance or best supportive care. This study showed that NFBlSI-18 is suitable for capturing bladder cancer symptoms and is able to detect important changes in a person's quality of life over time. This study also provides thresholds for changes in NFBlSI-18 scores, which will be useful for future studies.

Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints in Cancer Clinical Trials-Innovative Medicines Initiative (SISAQOL-IMI): stakeholder views, objectives, and procedures

Patient-reported outcomes (PROs), such as symptoms, functioning, and other health-related quality-of-life concepts are gaining a more prominent role in the benefit-risk assessment of cancer therapies. However, varying ways of analysing, presenting, and interpreting PRO data could lead to erroneous and inconsistent decisions on the part of stakeholders, adversely affecting patient care and outcomes. The Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints in Cancer Clinical Trials-Innovative Medicines Initiative (SISAQOL-IMI) Consortium builds on the existing SISAQOL work to establish recommendations on design, analysis, presentation, and interpretation for PRO data in cancer clinical trials, with an expanded set of topics, including more in-depth recommendations for randomised controlled trials and single-arm studies, and for defining clinically meaningful change. This Policy Review presents international stakeholder views on the need for SISAQOL-IMI, the agreed on and prioritised set of PRO objectives, and a roadmap to ensure that international consensus recommendations are achieved.

Patient-reported Outcomes from JAVELIN Bladder 100: Avelumab First-line Maintenance Plus Best Supportive Care Versus Best Supportive Care Alone for Advanced Urothelial Carcinoma

BACKGROUND

In JAVELIN Bladder 100, avelumab first-line maintenance plus best supportive care (BSC) significantly prolonged overall survival (OS; primary endpoint) versus BSC alone in patients with advanced urothelial carcinoma (aUC) without disease progression with first-line platinum-containing chemotherapy.

OBJECTIVE

To evaluate patient-reported outcomes (PROs) with avelumab plus BSC versus BSC alone.

DESIGN, SETTING, AND PARTICIPANTS

A randomized phase 3 trial (NCT02603432) was conducted in 700 patients with locally advanced or metastatic urothelial carcinoma that had not progressed with first-line gemcitabine plus cisplatin or carboplatin. PROs were a secondary endpoint.

INTERVENTION

Avelumab plus BSC (n = 350) or BSC alone (n = 350).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

National Comprehensive Cancer Network/Functional Assessment of Cancer Therapy Bladder Symptom Index-18 (FBlSI-18) and EuroQol five-level EQ-5D (EQ-5D-5L) assessments were analyzed using descriptive statistics and mixed-effect models. Time to deterioration (TTD; prespecified definition: a ≥3-point decrease from baseline in the FBlSI-18 disease-related symptoms-physical subscale for two consecutive assessments) was evaluated via Kaplan-Meier analyses.

RESULTS AND LIMITATIONS

Completion rates for scheduled on-treatment PRO assessments were >90% (overall and average per assessment). Results from descriptive analyses and mixed-effect or repeated-measures models of FBlSI-18 and EQ-5D-5L were similar between arms. TTD was also similar, both in the prespecified analysis (hazard ratio 1.26 [95% confidence interval: 0.90, 1.77]) and in the post hoc analyses including off-treatment assessments and different event definitions. Limitations included the open-label design and limited numbers of evaluable patients at later time points.

CONCLUSIONS

Addition of avelumab first-line maintenance to BSC in patients with aUC that had not progressed with first-line platinum-containing chemotherapy prolonged OS, with a relatively minimal effect on quality of life.

PATIENT SUMMARY

In this trial of people with advanced urothelial carcinoma who had benefited from first-line chemotherapy (ie, had stable disease or reduced tumor size), treatment with avelumab maintenance plus best supportive care (BSC) versus BSC alone improved survival significantly, without compromising quality of life, as reported by the patients themselves.

Avelumab first-line (1L) maintenance for advanced urothelial carcinoma (UC): Long-term follow-up from the JAVELIN Bladder 100 trial in subgroups defined by 1L chemotherapy regimen and analysis of overall survival (OS) from start of 1L chemotherapy

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Background: For platinum-eligible patients (pts) with advanced UC, 1L cisplatin- or carboplatin-based chemotherapy regimens followed by avelumab maintenance in pts without progression has become the standard of care. This is based on the results of the phase 3 JAVELIN Bladder 100 trial (NCT02603432), which showed significantly longer OS and progression-free survival (PFS) from start of maintenance (randomization) with avelumab maintenance + best supportive care (BSC) vs BSC alone (median OS, 23.8 vs 15.0 months; HR, 0.76 [95% CI, 0.63-0.91]; p=0.0036). We report post hoc analyses of long-term outcomes by 1L chemotherapy regimen and OS from start of 1L chemotherapy. Methods: Pts with unresectable locally advanced or metastatic UC that did not progress with 4-6 cycles of 1L cisplatin + gemcitabine or carboplatin + gemcitabine were randomized 1:1 to receive avelumab + BSC (n=350) or BSC alone (n=350). The primary endpoint was OS measured from randomization. Secondary endpoints included PFS and safety. Results: At data cutoff (June 4, 2021), median follow-up from randomization was ≥38 months in both arms. In subgroups treated with 1L cisplatin + gemcitabine or carboplatin + gemcitabine, OS and PFS (measured from start of maintenance [randomization]) were longer in the avelumab + BSC arm than in the BSC alone arm (Table). Safety findings were similar in both subgroups. In the overall population, median OS measured from the start of 1L chemotherapy was 29.7 months (95% CI, 25.2-34.0) in the avelumab + BSC arm and 20.5 months (95% CI, 19.0-23.5) in the BSC alone arm (HR, 0.77 [95% CI, 0.635-0.921]). Conclusions: Long-term follow-up from the JAVELIN Bladder 100 trial confirms that avelumab 1L maintenance provides similar OS and PFS benefits in pts with advanced UC who are progression free following standard-of-care 1L cisplatin- or carboplatin-based chemotherapy, with an acceptable safety profile. The median OS measured from start of chemotherapy further supports the use of avelumab 1L maintenance as standard of care in this setting and provides a benchmark for future clinical trials. Clinical trial information: NCT02603432 . [Table: see text]

P-315 The importance of treatment features beyond pain reduction associated with gonadotropin-releasing hormone analogues from the patient perspective

Study question

Beyond reducing pain, how do women with moderate-severe-endometriosis pain prioritize treatment features and outcomes associated with gonadotropin-releasing hormone (GnRH) analogues?

Summary answer

Moderate-severe-endometriosis patients prioritized safe long-term treatment, feeling treatment-effects within a few cycles, being able to maintain employment, reducing fatigue, depression, and headaches, and improving libido.

What is known already

The importance of pain management in endometriosis treatment is well-established. Poor health-related quality of life has been attributed to endometriosis pain, with greater impact as the number of endometriosis symptoms and symptom severity increase. Endometriosis treatment options include analgesics for acute pain episodes and surgery in more severe cases, as well as hormone therapies, including GnRH analogues. The potential risks, benefits, and outcomes associated with currently available GnRH analogues for endometriosis treatment can vary. Data are lacking on the patient perspective with respect to potential treatment features and outcomes beyond just pain reduction.

Study design, size, duration

Treatment-naïve patients with moderate-severe-endometriosis pain (rating scale ≥4 for menstrual pain) in the United States completed a cross-sectional online survey. Best-worst scaling (BWS) was used to assess preferences for key non-pain treatment attributes that were identified based on the literature. Cognitive pre-test interviews were conducted to confirm content validity of the questionnaire. Data collection for this ongoing survey was initiated in December 2021.

Participants/materials, setting, methods

Patients (English-speaking, premenopausal, 18-50 years-old) were recruited via healthcare research panel. Eligible patients self-reported laparoscopy-confirmed-endometriosis, no endometriosis/other gynecological surgery in past 3 months, no osteoporosis/bone disease/uterine fibroids history, and healthcare coverage for previous 3 years. Treatment features in the BWS exercise included dosage flexibility, short treatment onset, reversibility of side effects, reducing fatigue, depression, headache, impact on libido, impact on sleep, ability to maintain employment, duration of treatment, and additional need for contraceptive use.

Main results and the role of chance

Overall, 115 patients (31.1±7.5 years-old) were included in the analyses. On a 0 (no pain) to 10 (pain as bad as you can imagine) scale, the mean worst menstrual and non-menstrual pelvic pain (during past month) were 7.7±1.6 and 5.4±2.7, respectively. The most common endometriosis treatments ever used included over-the-counter pain medications (90.4%) and prescription contraceptives (74.8%).

Of 11 BWS features tested, patients prioritized:

“You can safely take the treatment for a long period of time” (relative importance=11.4%) “Your ability to get or maintain a job” (11.1%) “When starting a treatment, you will begin to feel the treatment’s effects within the first few menstrual cycles” (10.9%) “You will be less depressed” (10.8%) “Your interest in sex will not be affected” (10.7%) “Any side-effects you may experience are resolved quickly after treatment stops” (10.1%) “You will be less fatigued or tired” (9.5%) “You will have fewer headaches or migraines” (8.6%)

Least important to patients were:

“Your sleep will not be affected” (6.8%) “Your doctor offers different options for the dose strength and how often you take it, as appropriate to your needs” (5.9%) “You are not required to take additional contraceptives along with the treatment” (4.0%)

Limitations, reasons for caution

The preferences of patients who participated may differ from those who did not participate, thereby reducing the ability to generalize results. All data were self-reported; diagnosis and treatment could not be independently confirmed. The BWS exercise cannot include all possible attributes and outcomes relevant to patients.

Wider implications of the findings

Beyond pain reduction, patients most highly valued having safe long-term treatment, feeling treatment effects within a few cycles, rapid resolution of side effects, being able to work, maintaining libido, and reducing fatigue, depression, and headaches. These factors can help physicians to better align endometriosis treatment decision-making with patient preferences.

Trial registration number

Not applicable

Impact of tanezumab on health status, non-work activities and work productivity in adults with moderate-to-severe osteoarthritis

BACKGROUND

To evaluate the impact of tanezumab on health status, non-work activities, and work productivity in a pooled analysis of two large phase 3 osteoarthritis (OA) studies.

METHODS

Subcutaneous tanezumab (2.5 mg and 5 mg) was tested in double-blind, placebo-controlled, 16-week (NCT02697773) and 24-week (NCT02709486) clinical trials in patients with moderate-to-severe OA of the hip or knee. At baseline and week 16, all patients completed EQ-5D-5L and the Work Productivity and Activity Impairment-OA (WPAI-OA) activity impairment item. Those currently employed also completed WPAI-OA work time missed, impairment while working, and overall work impairment items. Between-group differences in least squares (LS) mean changes from baseline at week 16 were tested using analysis of covariance.

RESULTS

Of 1545 pooled patients, 576 were employed at baseline. Improvements in EQ-5D-5L index value at week 16 were significantly greater for the tanezumab 2.5-mg group (difference in LS means [95% confidence interval (CI), 0.03 [0.01, 0.05]; p = 0.0083) versus placebo. Percent improvements (95% CI) in activity impairment (- 5.92 [- 8.87, - 2.98]; p < 0.0001), impairment while working (- 7.34 [- 13.01, - 1.68]; p = 0.0112), and overall work impairment (- 7.44 [- 13.22, - 1.67]; p = 0.0116) at week 16 were significantly greater for the tanezumab 2.5-mg group versus placebo. Results for the tanezumab 5-mg group were generally comparable to the tanezumab 2.5-mg group, although, compared with placebo, percent improvement (95% CI) in work time missed was significantly greater for the tanezumab 5-mg group (- 3.40 [- 6.47, - 0.34]; p = 0.0294), but not the tanezumab 2.5-mg group (- 0.66 [- 3.63, 2.32]; p = 0.6637).

CONCLUSIONS

These pooled analyses showed that health status, non-work activities, and work productivity were significantly improved following tanezumab administration, compared with placebo.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02697773, NCT02709486.

Reliability, validity, and clinically important differences (CIDs) on the NCCN/FACT Bladder Symptom Index (NFBISI-18) among individuals with locally advanced or metastatic urothelial cancer (UC)

408

Background: The NFBlSI-18 is a measure of advanced bladder cancer–specific symptoms composed of a total scale and 3 subscales representing physical disease–related symptoms (DRS-P), emotional disease–related symptoms (DRS-E), treatment side effects (TSE), and function/well-being (F/WB). There is evidence for the reliability and content validity of this instrument, but a full psychometric evaluation of the full 18-item format has not been done. In addition, CIDs have not been estimated. Methods: With the exception of test-retest (TRT) analyses, baseline data (n=651) from the JAVELIN Bladder 100 trial (NCT02603432), which compared maintenance treatment with avelumab + best supportive care (BSC) vs BSC alone in patients with unresectable, locally advanced or metastatic UC that did not progress with first-line platinum-containing chemotherapy, were used for this study. Since we focused on baseline, we did not analyze the TSE. We estimated internal consistency reliability (Cronbach coefficient α), tested convergent validity by estimating Spearman ρ correlations with the EQ-5D-5L utility index (UI) and visual analog score (VAS) scales, and estimated known group validity using age (<65, ≥65 years), ECOG performance status rating (PSR), and number of comorbidities/symptoms (1-9, ≥10) as anchors. We estimated TRT reliability using data from treatment cycles 2-3 with intraclass correlation coefficients (ICCs). To estimate and compare CIDs, we calculated differences in means between categories of the known group anchors for which Cohen’s d was >0.2 (ie, at least a small effect). To provide context for the CIDs, we calculated distributional properties of the scales (1/2 standard deviation [SD], 1 standard error of measurement [SEM]). Results: The table shows the reliability, convergent validity, and CID estimates. Reliability estimates often exceeded thresholds for reliability generally considered acceptable. Cohen’s d for NFBlSI-18 scale score differences between known groups ranged between 0.05 and 0.25 (age), 0.35 and 0.6 (ECOG PSR 0 vs 1), and 0.1 and 0.41 (number of comorbidities/symptoms). Conclusions: This analysis demonstrated that the NFBlSI-18 is a reliable and valid instrument to measure symptoms in patients with advanced UC. The CID estimates can help clinicians and researchers to understand what difference in patient symptoms are clinically meaningful, as measured by NFBlSI-18, to inform clinical practice. [Table: see text]

Treatment Sequencing Patterns in Patients with Metastatic Urothelial Cancer Treated in the Community Practice Setting in the United States: SPEAR-Bladder (Study informing treatment Pathway dEcision in bladder cAnceR)

Purpose

Clinical trial evidence has affirmed the role for immuno-oncology (IO) treatment for locally advanced or metastatic urothelial carcinoma (la/mUC). This Study informing treatment Pathway dEcision in bladder cAnceR (SPEAR-Bladder) aimed to provide insight into the optimal sequencing of IO treatments among la/mUC patients treated in the US Oncology Network.

Patients and Methods

This was a retrospective analysis of adult patients with la/mUC who initiated first-line chemotherapy followed by either IO therapy (C-IO subgroup) or chemotherapy (C-C subgroup) between 01/01/2015 and 04/30/2017 and included a potential follow-up period through 06/30/2017. Data were sourced from iKnowMed electronic health records. Patient and treatment characteristics were assessed descriptively, with Kaplan-Meier methods used to evaluate time-to-event outcomes, including overall survival (OS).

Results

A total of 117 patients were included in this analysis (median age 69 years, 74.4% male, 88.0% Caucasian): 79 and 38 patients were in the C-IO and C-C subgroups, respectively. The median OS was 19.2 months among patients who received the C-IO sequence and 11.9 months among those who received the C-C treatment sequence.

Conclusion

These results suggest that patients who received the C-IO treatment sequence had notable improvement in OS compared with those who received the C-C sequence. In light of the rapidly evolving therapeutic landscape, further investigation will be required to determine how best to select the optimal therapeutic regimen and sequencing for patients with la/mUC.

Updated efficacy results from the JAVELIN Renal 101 trial: first-line avelumab plus axitinib versus sunitinib in patients with advanced renal cell carcinoma

BACKGROUND

The phase 3 JAVELIN Renal 101 trial (NCT02684006) demonstrated significantly improved progression-free survival (PFS) with first-line avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma (aRCC). We report updated efficacy data from the second interim analysis.

PATIENTS AND METHODS

Treatment-naive patients with aRCC were randomized (1 : 1) to receive avelumab (10 mg/kg) intravenously every 2 weeks plus axitinib (5 mg) orally twice daily or sunitinib (50 mg) orally once daily for 4 weeks (6-week cycle). The two independent primary end points were PFS and overall survival (OS) among patients with programmed death ligand 1-positive (PD-L1+) tumors. Key secondary end points were OS and PFS in the overall population.

RESULTS

Of 886 patients, 442 were randomized to the avelumab plus axitinib arm and 444 to the sunitinib arm; 270 and 290 had PD-L1+ tumors, respectively. After a minimum follow-up of 13 months (data cut-off 28 January 2019), PFS was significantly longer in the avelumab plus axitinib arm than in the sunitinib arm {PD-L1+ population: hazard ratio (HR) 0.62 [95% confidence interval (CI) 0.490-0.777]}; one-sided P < 0.0001; median 13.8 (95% CI 10.1-20.7) versus 7.0 months (95% CI 5.7-9.6); overall population: HR 0.69 (95% CI 0.574-0.825); one-sided P < 0.0001; median 13.3 (95% CI 11.1-15.3) versus 8.0 months (95% CI 6.7-9.8)]. OS data were immature [PD-L1+ population: HR 0.828 (95% CI 0.596-1.151); one-sided P = 0.1301; overall population: HR 0.796 (95% CI 0.616-1.027); one-sided P = 0.0392].

CONCLUSION

Among patients with previously untreated aRCC, treatment with avelumab plus axitinib continued to result in a statistically significant improvement in PFS versus sunitinib; OS data were still immature.

CLINICAL TRIAL NUMBER

NCT02684006.

Effect of radium-223 dichloride (Ra-223) on hospitalisation: An analysis from the phase 3 randomised Alpharadin in Symptomatic Prostate Cancer Patients (ALSYMPCA) trial

Symptomatic skeletal events (SSEs) commonly occur in patients with bone metastases, often leading to hospitalisations and decreased quality-of-life. In the ALSYMPCA trial, radium-223 significantly improved overall survival (hazard ratio 0.70, 95% confidence interval [CI] 0.58-0.83, P < 0.001) and prolonged time to first SSE (hazard ratio 0.66, 95% CI 0.52-0.83, P = 0.00037) and subsequent SSE (hazard ratio 0.65, 95% CI 0.51-0.83, P = 0.00039) versus placebo in patients with castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastases. Health care resource use (HCRU), including hospitalisation events and days, were prospectively collected in ALSYMPCA. We assessed health care resource use for the first 12 months post-randomisation. Significantly fewer radium-223 (218/589; 37.0%) versus placebo patients (133/292; 45.5%) had at least one hospitalisation event (P = 0.016). However, mean number of hospitalisation events per patient was similar (radium-223 0.69 versus placebo 0.79, P = 0.226), likely due to the significantly longer follow-up time for radium-223 (7.82 months versus 6.92 months for placebo; P < 0.001). There were significantly fewer hospitalisation days per patient for radium-223 (4.44 versus 6.68, respectively, P = 0.004). The reduction in hospitalisation days with radium-223 was observed both before first SSE (2.35 days versus 3.36 days, respectively) and after SSE (7.74 days versus 9.19 days, respectively). Our data suggest that this reduced hospital days along with the survival benefit and reduction in time to SSEs with radium-223 treatment may contribute to improvements in health-related quality-of-life in patients with castration-resistant prostate cancer with symptomatic bone metastases (ALSYMPCA ClinicalTrials.gov number, NCT00699751.).

Patient-reported quality-of-life analysis of radium-223 dichloride from the phase III ALSYMPCA study

BACKGROUND

Radium-223 dichloride (radium-223), a first-in-class α-emitting radiopharmaceutical, is recommended in both pre- and post-docetaxel settings in patients with castration-resistant prostate cancer (CRPC) and symptomatic bone metastases based on overall survival benefit demonstrated in the phase III ALSYMPCA study. ALSYMPCA included prospective measurements of health-related quality of life (QOL) using two validated instruments: the general EuroQoL 5D (EQ-5D) and the disease-specific Functional Assessment of Cancer Therapy-Prostate (FACT-P).

PATIENTS AND METHODS

Analyses were conducted to determine treatment effects of radium-223 plus standard of care (SOC) versus placebo plus SOC on QOL using FACT-P and EQ-5D. Outcomes assessed were percentage of patients experiencing improvement, percentage of patients experiencing worsening, and mean QOL scores during the study.

RESULTS

Analyses were carried out on the intent-to-treat population of patients randomized to receive radium-223 (n = 614) or placebo (n = 307). The mean baseline EQ-5D utility and FACT-P total scores were similar between treatment groups. A significantly higher percentage of patients receiving radium-223 experienced meaningful improvement in EQ-5D utility score on treatment versus placebo {29.2% versus 18.5%, respectively; P = 0.004; odds ratio (OR) = 1.82 [95% confidence interval (CI) 1.21-2.74]}. Findings were similar for FACT-P total score [24.6% versus 16.1%, respectively; P = 0.020; OR = 1.70 (95% CI 1.08-2.65)]. A lower percentage of patients receiving radium-223 experienced meaningful worsening versus placebo measured by EQ-5D utility score and FACT-P total score. Prior docetaxel use and current bisphosphonate use did not affect these findings. Treatment was a significant predictor of EQ-5D utility score, with radium-223 associated with higher scores versus placebo (0.56 versus 0.50, respectively; P = 0.002). Findings were similar for FACT-P total score (99.08 versus 95.22, respectively; P = 0.004).

CONCLUSIONS

QOL data from ALSYMPCA demonstrated that improved survival with radium-223 is accompanied by significant QOL benefits, including a higher percentage of patients with meaningful QOL improvement and a slower decline in QOL over time in patients with CRPC.

Effect of radium-223 dichloride (Ra-223) on pain from US EAP

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Background: Ra-223, a first-in-class alpha-emitting radiopharmaceutical, has shown pain palliation in phase 2 trials (Parker 2013; Nilsson 2012). Here we present the results of Ra-223 effect on pain from US EAP. Methods: Pain was assessed at baseline, during treatment (trt) , and follow up (up to 6 mos after last trt visit) using the Brief Pain Inventory (BPI-SF) Questionnaire. The pain severity assessment was based on the worst pain item from the BPI-SF. The analysis was restricted to those not on opioids at baseline due to missing data for those on opioids. Hypotheses tests were based on changes from baseline. A meaningful change in score was defined as >2 points from baseline (Atkinson 2010). Results: Of 177 treated patients (pts) with baseline pain scores, 109 were not on opioids at baseline (6% had a score of 0 [no pain], 46% had 1-4 [mild pain], 34% had 5-7 [moderate pain], 14% had 8-10 [severe pain]). A significant decrease in mean pain severity from baseline (P<0.05) was observed at all trt visits. Among 97 pts who could have pain improvement (baseline score ≥2), 57 (59%) experienced a reduction in pain during at least one on-trt visit. Among all pts not on opioids at baseline and had baseline pain assessment, 46/109 (42%) had improved pain without worsening (decrease of ≥2 points), 20/109 (18%) had stable pain (no change of ≥2 points), 30/109 (28%) had worsening of pain (increase of ≥2 points or initiation of opioids) at some point and never had improvement, 11/109 (10%) had improvement and worsening at different times during trt, and 2/109 (2%) had no post baseline data. (Table presents data at each trt visit). Conclusions: Radium-223 was associated with meaningful pain relief in 42% of pts, whereas 28% had worse pain and 18% no change. The confounding effect of change in opioids after initiation prevents adequate interpretation of this finding for pts on opioids at baseline. Clinical trial information: NCT01516762. [Table: see text]

Effect of radium-223 dichloride (Ra-223) on risk for and duration of hospitalization in ALSYMPCA by docetaxel (D) subgroup

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Background: In ALSYMPCA, the first-in-class alpha-emitting radiopharmaceutical Ra-223 significantly improved overall survival vs placebo (pbo) and was well tolerated in patients (pts) with castration-resistant prostate cancer (CRPC) with symptomatic bone metastases and no visceral metastases regardless of prior D use. To understand whether treatment (tx) benefit in prior and no prior D subgroups relates to differences in health care resource utilization, hospitalization and other resource use were evaluated. Methods: Hospitalization, nursing home visit, home health care and adult day care services use, and physician visit data were captured. To account for differences in observation time due to differing survival, resource use was annualized for each pt. Mean number and duration of encounters/year were compared using t-tests. To compare tx groups based on rate of use/year, incidence rates and ratios were calculated using a generalized estimating equation regression model with covariates. Results: For prior D pts, hospitalization incidence rates for Ra-223 vs pbo were 1.18 vs 1.70 (incidence rate ratio = 0.69; 95% CI, 0.53-0.90; P = 0.006) and mean hospitalization days/year were 8.53 vs 16.51 (P = 0.001). Among prior D pts with ≥1 hospitalization, mean hospitalization days/year for Ra-223 vs pbo were 19.65 vs 33.02 (P = 0.003). For no prior D pts, hospitalization incidence rates for Ra-223 vs pbo were 1.02 vs 1.10 (incidence rate ratio = 0.92; 95% CI, 0.66-1.29; P = 0.643) and mean hospitalization days/year were 7.53 vs 12.11 (P = 0.027). Among no prior D pts with ≥1 hospitalization, mean hospitalization days/year for Ra-223 vs pbo pts were 19.12 vs 26.61 (P = 0.063). The only other tx differences were nursing home days/year and day care services/year in the no prior D subgroup, but t-test and regression results were inconsistent. Conclusions: In the prior D subgroup, Ra-223 pts experienced 8.0 fewer hospitalization days/pt/year, driven by a 31% reduction in hospitalization and shorter duration among pts hospitalized. In the no prior D subgroup, Ra-223 pts experienced 4.6 fewer hospitalization days/pt/year, primarily driven by a shorter duration among pts hospitalized. Clinical trial information: NCT00699751.

Effects of radium-223 dichloride (Ra-223) on risk for hospitalization and health care resource use in the phase 3 ALSYMPCA trial

21

Background: Ra-223 is a first-in-class alpha-emitter approved for treatment (tx) of patients (pts) with castration-resistant prostate cancer and symptomatic bone metastases. In ALSYMPCA, Ra-223 significantly improved overall survival by 3.6 months vs placebo (pbo) (HR = 0.70; 95% CI, 0.58-0.83; P < 0.001) and was well tolerated. To understand whether the tx benefit corresponds to differences in utilization, hospitalization and other types of health care resource use were evaluated. Methods: Data on hospitalization, nursing home visits, home health care and adult day care services use, and physician visits were captured for each pt. Tx groups were compared, based on percentage needing each type of health care resource, using Fisher’s exact test. To account for differences in each pt resource use in ALSYMPCA, the number of encounters (eg, office visits) and duration of encounters (eg, days hospitalized) were divided by observation time. The mean number and duration of encounters were compared using analysis of variance. To compare tx groups based on the rate of use per year, incidence rates and ratios were calculated using a generalized estimating equation (GEE) regression model. Results: The mean follow-up time in months for Ra-223 vs pbo was 10.0 vs 8.6. The incidence rate for Ra-223 vs pbo was 1.1 vs 1.4 (incidence rate ratio = 0.77; 95% CI, 0.62-0.95; P = 0.013). The mean number of hospitalizations and hospitalization days per year for Ra-223 vs pbo were 1.3 vs 1.7 (P = 0.020) and 8.1 vs 14.6 (P < 0.001), respectively. The percentage of pts that required hospitalization was nominally lower for Ra-223 vs pbo (42.3% vs 49.0%, P = 0.062). Among pts who experienced at least one hospitalization, the mean number of hospitalization days per year for Ra-223 vs pbo pts was 19.4 vs 30.4 (P < 0.001). No significant differences were found between tx groups in terms of visits or durations of time in nursing homes per year, amount of adult day care and home health care services utilized per year, and number of physician visits per year. Conclusions: Compared with pbo, Ra-223 tx resulted in a 23% reduction in incidence of hospitalizations per year and about 6.5 fewer hospitalization days per pt per year. Clinical trial information: NCT00699751.

An economic analysis of axitinib and sorafenib for second-line treatment of cytokine-refractory patients with advanced renal cell carcinoma in the United States (US)

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Background: Cytokines are a first-line treatment option for a subset of advanced RCC patients in the US. After progression on cytokines, NCCN guidelines recommend targeted agents, such as axitinib and sorafenib. Subgroup analysis of post-cytokine patients in the phase III AXIS trial found that axitinib increased median progression free survival (PFS) compared with sorafenib (12.0 vs. 6.6 months, p<0.0001), while overall survival (OS) showed no difference (29.4 vs. 27.8 months, p=0.144). An economic analysis for this subgroup was conducted from a US healthcare payer perspective. Methods: A cohort partition model with monthly cycles was constructed to estimate direct medical costs and health outcomes, discounted at 3.0% per annum, over cohort lifetime. Patients were apportioned into 3 health states (progression-free, progressed and dead) based on OS and PFS Kaplan-Meier curves for the post-cytokine subgroup in the AXIS trial. Active treatment was applied until progression, followed by best supportive care (BSC) alone thereafter. The wholesale acquisition costs were based from RedBook. Adverse event (AE) management costs were obtained from published studies. AE rates and utility values were informed by the AXIS trial. Administrative claims data from MarketScan Database were analyzed to estimate costs for BSC and routine care of second-line advanced RCC patients. Results: The total per-patient lifetime costs were estimated to be $242,750 for axitinib and $168,880 for sorafenib and most of the cost difference (84%) was due to the higher total medication cost of axitinib. The cost difference was sensitive to dose intensity and length of treatment. The difference in quality-adjusted life-years (QALY) for axitinib versus sorafenib was minor (1.3 versus 1.2) and the incremental cost-effectiveness ratio (ICER) for axitinib compared with sorafenib was $683,209/QALY. Conclusions: For cytokine-refractory advanced RCC patients, axitinib resulted in an ICER > $650,000/QALY versus sorafenib due to high drug costs and lack of OS benefit, indicating that axitinib may not present good value for money as 2nd line treatment when compared to sorafenib in the US.

Human risk of infection with Borrelia burgdorferi, the Lyme disease agent, in eastern United States

The geographic pattern of human risk for infection with Borrelia burgdorferi sensu stricto, the tick-borne pathogen that causes Lyme disease, was mapped for the eastern United States. The map is based on standardized field sampling in 304 sites of the density of Ixodes scapularis host-seeking nymphs infected with B. burgdorferi, which is closely associated with human infection risk. Risk factors for the presence and density of infected nymphs were used to model a continuous 8 km×8 km resolution predictive surface of human risk, including confidence intervals for each pixel. Discontinuous Lyme disease risk foci were identified in the Northeast and upper Midwest, with a transitional zone including sites with uninfected I. scapularis populations. Given frequent under- and over-diagnoses of Lyme disease, this map could act as a tool to guide surveillance, control, and prevention efforts and act as a baseline for studies tracking the spread of infection.