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Cost effectiveness of EML4-ALK fusion testing and first-line crizotinib treatment for patients with advanced ALK-positive non-small-cell lung cancer.

https://arctichealth.org/en/permalink/ahliterature104899
Source
J Clin Oncol. 2014 Apr 1;32(10):1012-9
Publication Type
Article
Date
Apr-1-2014
Author
Sandjar Djalalov
Jaclyn Beca
Jeffrey S Hoch
Murray Krahn
Ming-Sound Tsao
Jean-Claude Cutz
Natasha B Leighl
Author Affiliation
Sandjar Djalalov, Jaclyn Beca, and Jeffrey S. Hoch, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital and Cancer Care Ontario; Sandjar Djalalov, Jaclyn Beca, Jeffrey S. Hoch, Murray Krahn, and Natasha B. Leighl, Canadian Centre for Applied Research in Cancer Control; Murray Krahn, Toronto Health Economics and Technology Assessment Collaborative; Ming-Sound Tsao and Natasha B. Leighl, Ontario Cancer Institute and Princess Margaret Cancer Centre, Toronto; and Jean-Claude Cutz, McMaster University, Hamilton, Ontario, Canada.
Source
J Clin Oncol. 2014 Apr 1;32(10):1012-9
Date
Apr-1-2014
Language
English
Publication Type
Article
Keywords
Antineoplastic Agents - economics - therapeutic use
Carcinoma, Non-Small-Cell Lung - chemistry - drug therapy - economics
Cost-Benefit Analysis
Gene Frequency
Humans
Immunohistochemistry - economics
Lung Neoplasms - chemistry - drug therapy - economics
Neoplasm Staging
Oncogene Proteins, Fusion - analysis - genetics
Ontario
Pyrazoles - economics - therapeutic use
Pyridines - economics - therapeutic use
Quality-Adjusted Life Years
Sensitivity and specificity
Tumor Markers, Biological - analysis
Abstract
ALK-targeted therapy with crizotinib offers significant improvement in clinical outcomes for the treatment of EML4-ALK fusion-positive non-small-cell lung cancer (NSCLC). We estimated the cost effectiveness of EML4-ALK fusion testing in combination with targeted first-line crizotinib treatment in Ontario.
A cost-effectiveness analysis was conducted using a Markov model from the Canadian Public health (Ontario) perspective and a lifetime horizon in patients with stage IV NSCLC with nonsquamous histology. Transition probabilities and mortality rates were calculated from the Ontario Cancer Registry and Cancer Care Ontario New Drug Funding Program (CCO NDFP). Costs were obtained from the Ontario Case Costing Initiative, CCO NDFP, University Health Network, and literature.
Molecular testing with first-line targeted crizotinib treatment in the population with advanced nonsquamous NSCLC resulted in a gain of 0.011 quality-adjusted life-years (QALYs) compared with standard care. The incremental cost was Canadian $2,725 per patient, and the incremental cost-effectiveness ratio (ICER) was $255,970 per QALY gained. Among patients with known EML4-ALK-positive advanced NSCLC, first-line crizotinib therapy provided 0.379 additional QALYs, cost an additional $95,043 compared with standard care, and produced an ICER of $250,632 per QALY gained. The major driver of cost effectiveness was drug price.
EML4-ALK fusion testing in stage IV nonsquamous NSCLC with crizotinib treatment for ALK-positive patients is not cost effective in the setting of high drug costs and a low biomarker frequency in the population.
Notes
Comment In: J Clin Oncol. 2014 Apr 1;32(10):983-524567437
PubMed ID
24567430 View in PubMed
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Economic analysis: randomized placebo-controlled clinical trial of erlotinib in advanced non-small cell lung cancer.

https://arctichealth.org/en/permalink/ahliterature145373
Source
J Natl Cancer Inst. 2010 Mar 3;102(5):298-306
Publication Type
Article
Date
Mar-3-2010
Author
Penelope A Bradbury
Dongsheng Tu
Lesley Seymour
Pierre K Isogai
Liting Zhu
Raymond Ng
Nicole Mittmann
Ming-Sound Tsao
William K Evans
Frances A Shepherd
Natasha B Leighl
Author Affiliation
NCIC Clinical Trials Group, Kingston, ON, Canada.
Source
J Natl Cancer Inst. 2010 Mar 3;102(5):298-306
Date
Mar-3-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Angiogenesis Inhibitors - adverse effects - economics - therapeutic use
Canada
Carcinoma, Non-Small-Cell Lung - drug therapy - economics - pathology
Cost-Benefit Analysis
Drug Costs
Female
Hospitalization - statistics & numerical data
Humans
International Cooperation
Lung Neoplasms - drug therapy - economics - pathology
Male
Middle Aged
Multicenter Studies as Topic
Protein Kinase Inhibitors - economics - therapeutic use
Protein-Tyrosine Kinases - antagonists & inhibitors
Quinazolines - adverse effects - economics - therapeutic use
Randomized Controlled Trials as Topic
Receptor, Epidermal Growth Factor - antagonists & inhibitors
Retrospective Studies
Treatment Outcome
Tumor Markers, Biological - analysis
Abstract
The NCIC Clinical Trials Group conducted the BR.21 trial, a randomized placebo-controlled trial of erlotinib (an epidermal growth factor receptor tyrosine kinase inhibitor) in patients with previously treated advanced non-small cell lung cancer. This trial accrued patients between August 14, 2001, and January 31, 2003, and found that overall survival and quality of life were improved in the erlotinib arm than in the placebo arm. However, funding restrictions limit access to erlotinib in many countries. We undertook an economic analysis of erlotinib treatment in this trial and explored different molecular and clinical predictors of outcome to determine the cost-effectiveness of treating various populations with erlotinib.
Resource utilization was determined from individual patient data in the BR.21 trial database. The trial recruited 731 patients (488 in the erlotinib arm and 243 in the placebo arm). Costs arising from erlotinib treatment, diagnostic tests, outpatient visits, acute hospitalization, adverse events, lung cancer-related concomitant medications, transfusions, and radiation therapy were captured. The incremental cost-effectiveness ratio was calculated as the ratio of incremental cost (in 2007 Canadian dollars) to incremental effectiveness (life-years gained). In exploratory analyses, we evaluated the benefits of treatment in selected subgroups to determine the impact on the incremental cost-effectiveness ratio.
The incremental cost-effectiveness ratio for erlotinib treatment in the BR.21 trial population was $94,638 per life-year gained (95% confidence interval = $52,359 to $429,148). The major drivers of cost-effectiveness included the magnitude of survival benefit and erlotinib cost. Subgroup analyses revealed that erlotinib may be more cost-effective in never-smokers or patients with high EGFR gene copy number.
With an incremental cost-effectiveness ratio of $94 638 per life-year gained, erlotinib treatment for patients with previously treated advanced non-small cell lung cancer is marginally cost-effective. The use of molecular predictors of benefit for targeted agents may help identify more or less cost-effective subgroups for treatment.
Notes
Comment In: J Natl Cancer Inst. 2010 Mar 3;102(5):287-820160167
PubMed ID
20160168 View in PubMed
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Lung cancer risk in never-smokers: a population-based case-control study of epidemiologic risk factors.

https://arctichealth.org/en/permalink/ahliterature142873
Source
BMC Cancer. 2010;10:285
Publication Type
Article
Date
2010
Author
Darren R Brenner
Rayjean J Hung
Ming-Sound Tsao
Frances A Shepherd
Michael R Johnston
Steven Narod
Warren Rubenstein
John R McLaughlin
Author Affiliation
Prosserman Centre for Health Research, Samuel Lunenfeld Research Institute, 60 Murray St, Toronto M5T3L9, Canada.
Source
BMC Cancer. 2010;10:285
Date
2010
Language
English
Publication Type
Article
Keywords
Adult
Age of Onset
Aged
Aged, 80 and over
Air Pollution, Indoor - adverse effects
Case-Control Studies
Chi-Square Distribution
Female
Genetic Testing
Humans
Logistic Models
Lung Neoplasms - epidemiology - etiology
Male
Middle Aged
Occupational Exposure
Odds Ratio
Ontario - epidemiology
Pedigree
Respiratory Tract Diseases - complications - epidemiology
Risk assessment
Risk factors
Tobacco Smoke Pollution - adverse effects
Urban health
Young Adult
Abstract
We conducted a case-control study in the greater Toronto area to evaluate potential lung cancer risk factors including environmental tobacco smoke (ETS) exposure, family history of cancer, indoor air pollution, workplace exposures and history of previous respiratory diseases with special consideration given to never smokers.
445 cases (35% of which were never smokers oversampled by design) between the ages of 20-84 were identified through four major tertiary care hospitals in metropolitan Toronto between 1997 and 2002 and were frequency matched on sex and ethnicity with 425 population controls and 523 hospital controls. Unconditional logistic regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the associations between exposures and lung cancer risk.
Any previous exposure to occupational exposures (OR total population 1.6, 95% CI 1.4-2.1, OR never smokers 2.1, 95% CI 1.3-3.3), a previous diagnosis of emphysema in the total population (OR 4.8, 95% CI 2.0-11.1) or a first degree family member with a previous cancer diagnosis before age 50 among never smokers (OR 1.8, 95% CI 1.0-3.2) were associated with increased lung cancer risk.
Occupational exposures and family history of cancer with young onset were important risk factors among never smokers.
Notes
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PubMed ID
20546590 View in PubMed
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Lung cancer screening using low-dose computed tomography in at-risk individuals: the Toronto experience.

https://arctichealth.org/en/permalink/ahliterature151092
Source
Lung Cancer. 2010 Feb;67(2):177-83
Publication Type
Article
Date
Feb-2010
Author
Ravi J Menezes
Heidi C Roberts
Narinder S Paul
Maureen McGregor
Tae Bong Chung
Demetris Patsios
Gordon Weisbrod
Stephen Herman
Andre Pereira
Alexander McGregor
Zhi Dong
Igor Sitartchouk
Scott Boerner
Ming-Sound Tsao
Shaf Keshavjee
Frances A Shepherd
Author Affiliation
Department of Medical Imaging, University Health Network, Toronto, ON, Canada. heidi.roberts@uhn.on.ca
Source
Lung Cancer. 2010 Feb;67(2):177-83
Date
Feb-2010
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Algorithms
Biopsy
Canada - epidemiology
Early Detection of Cancer - methods
Humans
Incidence
Lung Neoplasms - epidemiology - pathology - radiography
Middle Aged
Neoplasm Staging
Prevalence
Risk factors
Sensitivity and specificity
Smoking - adverse effects
Surgery, Computer-Assisted
Tomography, X-Ray Computed - methods
Abstract
The Department of Medical Imaging at the University Health Network in Toronto is performing a lung cancer screening study, utilizing low-dose computed tomography (LDCT) as the modality. Baseline and annual repeat results are reported on the first 3352 participants, enrolled between June 2003 and May 2007.
Enrollment was limited to those aged 50 years or older, with a smoking history of at least 10 pack-years, no previous cancer and general good health. A helical low-dose CT (LDCT) of the chest was performed using 120kVp, 40-60mA, images were reconstructed with 1-1.25mm overlapping slices. The primary objectives were the detection of parenchymal nodules and diagnosis of early stage lung cancer. Baseline LDCTs were termed positive if at least one indeterminate non-calcified nodule 5mm or larger in size, or non-solid nodule 8mm or larger in size was identified. Follow up periods for individuals with a positive baseline LDCT were determined by nodule characteristics.
The median age at baseline was 60 years (range 50-83), with a median of 30 pack-years of cigarette smoking (range 10-189). Baseline CT evaluations were positive in 600 (18%) participants. To date, 2686 (80%) of the participants have returned for at least one annual repeat screening LDCT. Biopsies have been recommended for 82 participants since the study began, and 64 have been diagnosed with screen-detected cancer (62 lung, two plasmacytoma of the rib). A total of 65 lung cancers have been diagnosed (62 screen-detected, 3 interim), 57 are NSCLC (82% with known stage are stage I or II) and the rate of surgical resection was 80%. Sensitivity and specificity of the protocol in successfully diagnosing early stage lung cancers were 87.7% and 99.3%, respectively.
Data indicate that LDCT can identify small lung cancers in an at-risk population. The diagnostic algorithm results in few false-positive invasive procedures. Most cancers are detected at an early stage, where the cancer is resectable with a greater potential for cure. Long-term follow up of lung cancer cases will be carried out to determine survival.
PubMed ID
19427055 View in PubMed
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Molecular predictors of outcome in a phase 3 study of gemcitabine and erlotinib therapy in patients with advanced pancreatic cancer: National Cancer Institute of Canada Clinical Trials Group Study PA.3.

https://arctichealth.org/en/permalink/ahliterature140971
Source
Cancer. 2010 Dec 15;116(24):5599-607
Publication Type
Article
Date
Dec-15-2010
Author
Gilda da Cunha Santos
Neesha Dhani
Dongsheng Tu
Kayu Chin
Olga Ludkovski
Suzanne Kamel-Reid
Jeremy Squire
Wendy Parulekar
Malcolm J Moore
Ming Sound Tsao
Author Affiliation
Department of Pathology, University Health Network, Ontario Cancer Institute, Princess Margaret Hospital, Toronto, Ontario, Canada.
Source
Cancer. 2010 Dec 15;116(24):5599-607
Date
Dec-15-2010
Language
English
Publication Type
Article
Keywords
Antineoplastic Combined Chemotherapy Protocols
Canada
Deoxycytidine - administration & dosage - analogs & derivatives
Disease-Free Survival
Gene Dosage
Humans
Mutation
Pancreatic Neoplasms - drug therapy - mortality
Predictive value of tests
Proto-Oncogene Proteins - analysis - genetics
Quinazolines - administration & dosage
Receptor, Epidermal Growth Factor - antagonists & inhibitors - genetics
Treatment Outcome
Tumor Markers, Biological - analysis
ras Proteins - analysis - genetics
Abstract
National Cancer Institute of Canada Clinical Trials Group PA.3 (NCIC CTG PA.3) was a phase 3 study (n = 569) that demonstrated benefits for overall survival and progression-free survival with the addition of the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) erlotinib to gemcitabine in patients with advanced pancreatic carcinoma (APC). Mutation status of the v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS) and EGFR gene copy number (GCN) were evaluated as predictive markers in 26% of patients who had tumor samples available for analysis.
KRAS mutation status was evaluated by direct sequencing of exon 2, and EGFR GCN was determined by fluorescence in situ hybridization (FISH) analysis. The results were correlated with survival, which was the primary endpoint of the trial.
KRAS analysis was successful in 117 patients, and EGFR FISH analysis was successful in 107 patients. KRAS mutations were identified in 92 patients (78.6%), and EGFR amplification or high polysomy (FISH-positive results) was identified in 50 patients (46.7%). The hazard ratio of death between gemcitabine/erlotinib and gemcitabine/placebo was 0.66 (95% confidence interval [CI], 0.28-1.57) for patients with wild-type KRAS and 1.07 (95% CI, 0.68-1.66) for patients with mutant KRAS (P value for interaction = .38), and the hazard ratio was 0.6 (95% CI, 0.34-1.07) for FISH-negative patients and 0.90 (95% CI, 0.49-1.65) for FISH-positive patients (P value for interaction = .32).
In a molecular subset analysis of patients from NCIC CTG PA.3, EGFR GCN and KRAS mutation status were not identified as markers predictive of a survival benefit from the combination of erlotinib with gemcitabine for the first-line treatment of APC.
PubMed ID
20824720 View in PubMed
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Role of KRAS and EGFR as biomarkers of response to erlotinib in National Cancer Institute of Canada Clinical Trials Group Study BR.21.

https://arctichealth.org/en/permalink/ahliterature156160
Source
J Clin Oncol. 2008 Sep 10;26(26):4268-75
Publication Type
Article
Date
Sep-10-2008
Author
Chang-Qi Zhu
Gilda da Cunha Santos
Keyue Ding
Akira Sakurada
Jean-Claude Cutz
Ni Liu
Tong Zhang
Paula Marrano
Marlo Whitehead
Jeremy A Squire
Suzanne Kamel-Reid
Lesley Seymour
Frances A Shepherd
Ming-Sound Tsao
Author Affiliation
FRCPC, Princess Margaret Hospital, 610 University Ave, Toronto, Ontario, Canada M5G 2M9; Ming.Tsao@uhn.on.ca.
Source
J Clin Oncol. 2008 Sep 10;26(26):4268-75
Date
Sep-10-2008
Language
English
Publication Type
Article
Keywords
Antineoplastic Agents - therapeutic use
Canada
Carcinoma, Non-Small-Cell Lung - drug therapy - genetics - mortality
Female
Genes, erbB-1 - genetics
Genotype
Humans
In Situ Hybridization, Fluorescence
Lung Neoplasms - drug therapy - genetics - mortality
Male
Middle Aged
Mutation
Predictive value of tests
Proto-Oncogene Proteins - genetics
Quinazolines - therapeutic use
Survival Analysis
ras Proteins - genetics
Abstract
To evaluate the effect of KRAS and epidermal growth factor receptor (EGFR) genotype on the response to erlotinib treatment in the BR.21, placebo-controlled trial.
We analyzed 206 tumors for KRAS mutation, 204 tumors for EGFR mutation, and 159 tumors for EGFR gene copy by fluorescent in situ hybridization (FISH). We reanalyzed EGFR deletion/mutation using two highly sensitive techniques that detect abnormalities in samples with 5% to 10% tumor cellularity. KRAS mutation was analyzed by direct sequencing.
Thirty patients (15%) had KRAS mutations, 34 (17%) had EGFR exon 19 deletion or exon 21 L858R mutations, and 61 (38%) had high EGFR gene copy (FISH positive). Response rates were 10% for wild-type and 5% for mutant KRAS (P = .69), 7% for wild-type and 27% for mutant EGFR (P = .03), and 5% for EGFR FISH-negative and 21% for FISH-positive patients (P = .02). Significant survival benefit from erlotinib therapy was observed for patients with wild-type KRAS (hazard ratio [HR] = 0.69, P = .03) and EGFR FISH positivity (HR = 0.43, P = .004) but not for patients with mutant KRAS (HR = 1.67, P = .31), wild-type EGFR (HR = 0.74, P = .09), mutant EGFR (HR = 0.55, P = .12), and EGFR FISH negativity (HR = 0.80, P = .35). In multivariate analysis, only EGFR FISH-positive status was prognostic for poorer survival (P = .025) and predictive of differential survival benefit from erlotinib (P = .005).
EGFR mutations and high copy number are predictive of response to erlotinib. EGFR FISH is the strongest prognostic marker and a significant predictive marker of differential survival benefit from erlotinib.
PubMed ID
18626007 View in PubMed
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A systematic review and Canadian consensus recommendations on the use of biomarkers in the treatment of non-small cell lung cancer.

https://arctichealth.org/en/permalink/ahliterature133382
Source
J Thorac Oncol. 2011 Aug;6(8):1379-91
Publication Type
Article
Date
Aug-2011
Author
Peter M Ellis
Normand Blais
Dennis Soulieres
Diana N Ionescu
Meenakshi Kashyap
Geoff Liu
Barb Melosky
Tony Reiman
Phillippe Romeo
Frances A Shepherd
Ming-Sound Tsao
Natasha B Leighl
Author Affiliation
Juravinski Cancer Centre, Hamilton, Ontario, Canada. peter.ellis@jcc.hhsc.ca
Source
J Thorac Oncol. 2011 Aug;6(8):1379-91
Date
Aug-2011
Language
English
Publication Type
Article
Keywords
Canada
Carcinoma, Non-Small-Cell Lung - diagnosis - therapy
Clinical Trials as Topic
Consensus
Humans
Lung Neoplasms - diagnosis - therapy
Practice Guidelines as Topic
Tumor Markers, Biological - analysis
Abstract
Greater understanding of molecular pathways important in cell growth and proliferation of thoracic malignancies, particularly non-small cell lung cancer (NSCLC), has resulted in intense clinical and translational research. There is now considerable interest in personalizing treatment based on an understanding of tumor histology and molecular abnormalities. However, there is a multiplicity of data, often with discordant results resulting in confusion and uncertainty among clinicians.
We conducted a systematic review and a consensus meeting of Canadian lung cancer oncologists and pathologists to make recommendations on the use of biomarkers in NSCLC. PubMed covering 2005 to March 2010 was searched using MESH terms for NSCLC and randomized trials, plus text words for the biomarkers of interest. Conference proceedings from 2005 to 2009 ASCO, ESMO, IASLC, and USCAP were also searched. The articles were reviewed by pairs of oncologists and pathologists to determine eligibility for inclusion.
Ten oncologists and pathologists reviewed and summarized the literature at a meeting attended by 37 individuals. Draft recommendations were formulated and agreed upon by consensus process. There is some evidence that histology is prognostic for survival. There is evidence from multiple randomized clinical trials to recommend the following: histologic subtype is predictive of treatment efficacy and for some agents toxicity. Immunohistochemistry testing should be performed on NSCLC specimens that cannot be classified accurately with conventional H&E staining. As EGFR mutations are predictive of benefit from tyrosine kinase inhibitors, diagnostic NSCLC samples should be routinely tested for EGFR-activating mutations. Clinical data on K-RAS mutations are inconsistent, therefore testing is not recommended. There is insufficient evidence to recommend other biomarker testing. No biomarkers to date reliably predict improved efficacy for anti-VEGF therapy. Routine assessment for EML4/ALK mutations is not recommended at present, although emerging data suggest that it may become valuable in the near future.
Assessment of NSCLC biomarkers is becoming increasingly important. Therefore, adequate diagnostic material must be obtained for accurate histologic subtyping and relevant molecular biology assays.
Notes
Comment In: J Thorac Oncol. 2012 Apr;7(4):773-4; author reply 77422425934
PubMed ID
21709590 View in PubMed
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7 records – page 1 of 1.