JCO Global Oncology最新文献

Purpose: Access to cancer medicines is a function of both availability and affordability. In Nepal, where patients are responsible for procuring and purchasing treatments out of pocket, access is limited by both unavailability of medicines and unaffordability of available medicines. This study aimed to examine the availability, affordability, and price variation of GI cancer medicines in Nepal's public cancer hospitals.

Methods: A cross-sectional survey was conducted among four public cancer hospitals across Nepal between October 2022 and January 2023. Availability, affordability, and price variations of 26 therapeutic regimens for gastroesophageal, colorectal, hepatobiliary, and pancreatic cancers were examined. The maximum and minimum monthly retail prices of each individual available medicine and regimen were compared, and interhospital and intrahospital differences in price were calculated. Affordability was assessed by comparing monthly treatment costs with the monthly national per capita gross domestic product (GDP).

Results: Fourteen of 26 (53.8%) regimens were available in at least one hospital, whereas nine (34.6%) were available in all four public cancer hospitals. We discovered differences as high as 422% in capecitabine pricing within the same hospital, and differences in irinotecan pricing of 997% across hospitals. With the exception of capecitabine monotherapy, and fluorouracil plus cisplatin, all of the remaining available GI cancer treatments have monthly prices that exceed the monthly per capita GDP of Nepal.

Conclusion: GI cancer drug access in Nepal is limited by low availability and significant price variation. Intrahospital and interhospital price disparities may influence patients to seek out different prices across institutions to avoid financial toxicity, adding logistical burden. Price regulation, transparency, and local manufacturing are needed to improve equitable access to cancer medicines.

Purpose: Esophageal squamous cell carcinoma (ESCC) is a prevalent cancer in eastern Africa. Optimal management strategies in eastern Africa have not been well established. This study aimed to evaluate ESCC treatment outcomes at Kamuzu Central Hospital (KCH), a national cancer center in Malawi.

Methods: This prospective, observational, cohort study was conducted as part of a multicenter collaboration within the African Esophageal Cancer Consortium (ClinicalTrials.gov identifier: NCT05177393). Patients who presented to KCH with esophageal cancer (EC) were recruited from June 2021 to December 2022. Data on patient and treatment characteristics were collected using interviews and chart review. Mobile phone outreach was used to assess patient-reported outcomes (PROs). PROs were analyzed using linear mixed modeling. Kaplan-Meier method with log-rank test and Cox proportional hazards regression were used to evaluate overall survival by treatment group.

Results: A total of 148 of 150 eligible patients enrolled. Of 114 with biopsy-proven EC, 97% (n = 111) had ESCC. Most were documented as having localized disease; however, 56% did not complete staging imaging. Forty-seven percent received supportive care, 30% self-expandable metallic stent (SEMS), 20% chemotherapy, and 3% SEMS plus chemotherapy. SEMS was associated with the highest proportion experiencing dysphagia improvement (SEMS 68% v chemotherapy 63% v supportive care 39%). Twelve-month survival rate was the highest in the chemotherapy arm (29% v supportive care 19% v SEMS 6%, log-rank P = .018).

Conclusion: ESCC remains a highly fatal malignancy in Malawi. Most patients at KCH are treated with SEMS or supportive care. Although data must be interpreted with caution given likely confounding, chemotherapy was associated with the highest 12-month survival rate as compared with SEMS and supportive care, whereas SEMS was associated with the highest likelihood of improved dysphagia.

Purpose: There are limited data on presentation and practice patterns, survival, and factors influencing overall survival (OS) in Indian patients with metastatic colorectal cancers (mCRCs).

Patients and methods: The current study evaluated patients from 13 institutions across India diagnosed with mCRC and treated from January 2016 to May 2022. The primary end point of the study was the estimation of median OS by the Kaplan-Meier method.

Results: The data of 3,009 patients were submitted, of whom 2,520 were feasible for analysis. Molecular testing for rat sarcoma virus and/or B-Rapidly Accelerated Fibrosarcoma status via the polymerase chain reaction or next-generation sequencing was conducted in 993 patients (39%). At a median follow-up of 44.6 months (95% CI, 40.8 to 48.3), the median OS for the entire cohort was 18.7 months (95% CI, 18.0 to 19.4). The presence of signet ring (SR) histology (14.65 v 19.15 months, hazard ratio [HR] 1.30 [95% CI, 1.14 to 1.48]; P < .001) and Eastern Cooperative Oncology Group performance status (ECOG PS) 2 versus ECOG PS 0 or 1 (18.0 v 22.87 months, HR 1.37 [95% CI, 1.21 to 1.55]; P < .001) predicted inferior OS, whereas the receipt of monoclonal antibodies (MAbs; 21.81 v 16.92 months, HR 0.79 [95% CI, 0.72 to 0.87]; P < .001) and exposure to greater than two lines of therapy (26.71 v 16.26 months, HR 0.56 [95% CI, 0.50 to 0.62]; P < .001) were associated with improved OS.

Conclusion: The current multi-institutional analysis of more than 2,500 patients with mCRC in India establishes a baseline with regard to clinicopathologic characteristics, molecular testing patterns, and survival. It recognizes the importance of impaired ECOG PS, SR histology, exposure to MAbs, and multiple lines of systemic therapeutic options as factors influencing OS.

Purpose: Lung cancer remains a leading cause of cancer mortality in Brazil, with non-small cell lung cancer (NSCLC) accounting for 85% of cases, with 1.6% carrying epidermal growth factor receptor (EGFR) exon 20 mutations. In the phase I CHRYSALIS trial (ClinicalTrials.gov identifier: NCT02609776), amivantamab demonstrated a median overall survival (OS) of 22.8 months versus 8.3 months with docetaxel, the standard second-line Brazil's Unified Health System (SUS) therapy. Although the Brazilian Health Regulatory Agency approved amivantamab, the National Commission for the Incorporation of Technologies' cost-effectiveness reviews result in an average 10-year delay before SUS incorporation. We aimed to estimate premature deaths and life-years lost attributable to this access gap.

Methods: Using National Institute of Cancer (INCA) data, we estimated SUS-eligible patients, NSCLC prevalence, and EGFR exon 20 frequency. Stage distribution and 5-year recurrence rates identify candidates for amivantamab. A hazard ratio (HR) was derived from the inverse exponential method (ln(2)/OS ratio). Preventable deaths were calculated as: eligible patients × (1 - HR). Life-years gained per patient were estimated as OS difference.

Results: Of the 26,548 new patients with lung cancer, 18,973 are SUS-eligible, 16,127 have NSCLC, and 258 have EGFR exon 20 mutations. Metastatic disease accounts for 114, whereas recurrences occur in 60 (stage III), eight (II), and four (I), totaling 186 candidates annually. With an HR of 0.364, the annual preventable death in the base-case scenario is equal to 186 × (1 - 0.364) × 95% = 112 patients. Over 10 years, 1,120 premature deaths and 1,353 life-years could be avoided.

Conclusion: Delayed SUS incorporation of amivantamab may result in over a 1,000 preventable deaths and life-years lost among Brazilian EGFR exon 20-mutated NSCLC. Urgent real-world studies and cost-effectiveness analyses are needed.

Purpose: About one in three Black Africans carry the African-predominant allele variants CYP2D6*17 and/or CYP2D6*29, which confer a reduced enzymatic activity. CYP2D6 intermediate metabolizers (IM) have a reduced biotransformation rate of tamoxifen compared with its more active metabolite endoxifen.

Methods: A prospective cohort study of Black Zimbabwean patients with hormone receptor-positive breast cancer on tamoxifen therapy was conducted. Patients were genotyped for CYP2D6 and followed up for event-free survival (EFS) on tamoxifen.

Results: In total, 18 CYP2D6 IM and 33 normal metabolizers (NM) were enrolled. At 2 years, the estimated EFS was 40.1% (95% CI, 20.3 to 79.4) for the IM group and 84.0% (95% CI, 72.1 to 97.9) for the NM group (log-rank P = .0021). A Cox proportional hazards model, after adjusting for BMI, stage at diagnosis, and previous breast cancer surgery, estimated about a 5.5-fold higher hazard of recurrence, progression, or death in IM compared with NM.

Conclusion: Individuals with hormone receptor-positive breast cancer who are CYP2D6 NM had better disease recurrence and progression-free survival outcomes compared with IM.

Purpose: Majority of the patients with gastric cancer in resource-restricted country, like Jordan, are diagnosed with advanced-stage disease with poor treatment outcomes. This study explores the state of gastric cancer in Jordan and outlines strategies for disease control.

Materials and methods: Data on disease stage at presentation and treatment outcomes were obtained from the King Hussein Cancer Center registry. Patients were staged according to the US SEER staging system, which classifies gastric cancer into localized, regional and distant. Overall survival (OS) was reported for the whole group and stratified by age at diagnosis, stage, sex, and year of diagnosis, and compared with published data from the United States and Asia.

Results: During the study period, a total of 888 patients were treated and followed up at our institution. The majority (n = 503, 56.6%) were diagnosed with distant metastases); 315 (35.5%) had regional disease and only a minority (n = 70, 7.9%) had localized disease. After a median follow-up of 5.7 (1.3-18.7) years, the 5-year OS for the entire cohort was 18.1% (95% CI, 15.5% to 20.8%), varying by stage; 62.9% (95% CI, 50.7% to 74.3%) for localized disease, 34.1% (95% CI, 28.7% to 39.8%) for regional disease, and only 1.86% (95% CI, 0.80% to 3.36%) for distant metastasis, P < .0001. Patients' age at diagnosis (<40 v ≥40 years), sex, or year at diagnosis (recent years v >10 years ago) had no significant impact on 5-year OS.

Conclusion: Although gastric cancer is relatively uncommon in Jordan, fewer than 10% of patients are diagnosed at an early, localized disease, contributing to persistently poor treatment outcomes with little improvement over time. National initiatives and strategies to improve treatment outcome are urgently needed.

Purpose: Value in health care is a multifaceted concept encompassing patient outcomes, treatment effectiveness, and costs. However, the definition of value can vary between distinct health systems. We compared the perceptions of value in cancer care between providers in high-income countries (HICs) and low- and middle-income countries (LMICs).

Materials and methods: A novel survey assessed the relative importance of health care priorities, including longevity, experience, functional and emotional well-being, costs to patients, and costs to the health system between providers in HICs and LMICs. Kendall's coefficient of concordance assessed agreement between groups.

Results: We received 365 responses: 216 (59.2%) from HICs and 149 (40.8%) from LMICs. HIC providers more frequently rated treatment experience (82.9% v 65.1%) and patient functional independence (72.7% v 59.7%) as extremely important, while fewer rated emotional well-being (65.3% v 78.5%) and costs to the health system (26.4% v 51.7%) as such (all P < .050). With consensus (HIC: W = 35%; P < .001; LMIC: W = 19%; P < .001), both cohorts ranked patient emotional well-being (2.56 ± 1.30 HIC v 2.74 ± 1.58 LMIC; P = .254) as the most important priority. HICs placed higher priority on treatment experience (3.02 ± 1.55 v 3.59 ± 1.47; P < .001) and less on costs to the health system (5.56 ± 1.15 v 4.97 ± 1.44; P < .001), when compared with LMICs.

Conclusion: Although there is consensus on the importance of patient-centered outcomes, the prioritization of treatment experience and costs of care to the health system differ between HICs and LMICs. These findings underscore the importance of developing adaptable value frameworks that are relevant and effective across diverse health care settings.