ObjectiveWe wanted to examine the incremental cost-effective ratio (ICER) for a variety of Food and Drug Administration (FDA) approved oncology drugs in the adjuvant or curative setting to determine the value provided.DesignWe examined the annualized incremental drug costs of a variety of FDA approved chemotherapeutic drugs used in an adjuvant or curative setting based on National Comprehensive Cancer Network (NCCN) category 1 practice guidelines for melanoma, Her2/neu over-expressive breast cancer, renal cell carcinoma, stage IIIA non-small cell lung cancer, myeloma, B cell lymphoma, and Hodgkin lymphoma. The studies we examined were randomized clinical trials on which the NCCN guidelines are based; we solely examined the incremental cost-effectiveness of the trial drug as we assumed that the costs of the health care provided were equivalent between the two treatment arms. We used a formula to determine the incremental cost-effectiveness ratio (ICER). The ICER compares a new intervention (C new) with its alternate (C alt) divided by the quality-adjusted life-years (QALY) that results from the new intervention (QALY new) versus the alternate (QALY alt) and is expressed as ICER = (C new-C alt)/(QALY new-QALY alt). The QALY’s were derived from what was reported in the study and based on the incremental disease-free survival.ResultsDrugs such as rituximab provide high value in the curative therapy for lymphoma. Drugs such as adjuvant dabrafenib and trametinib provide intermediate value in the treatment of melanoma, and similarly with maintenance lenalidomide in myeloma and adjuvant trastuzumab in breast cancer. Oncologic drugs that provide low value include adjuvant ipilimumab in melanoma, adjuvant sunitinib in renal cell carcinoma, adjuvant neratinib in breast cancer, adjuvant durvalumab in lung cancer, and brentuximab in the curative therapy for Hodgkin’s lymphoma.ConclusionThe ICER needs to be evaluated for newly approved FDA oncology chemotherapeutic drugs before incorporating them into routine clinical practice.
Metastatic carcinomatosis cirrhosis is a pattern of metastasis in which malignancy infiltrates the liver and provokes hepatic fibrosis. It is an especially rare complication of several malignancies, including breast cancer. We report a case of a 61-year-old woman with lobular carcinoma of the breast who presented with confusion and rising serum tumor markers without evidence of disease recurrence on imaging. She subsequently developed clinical evidence of hepatic dysfunction and a liver biopsy revealed diffuse infiltration of the liver by breast carcinoma with surrounding fibrous tissue deposition, consistent with metastatic carcinomatosis cirrhosis. This case highlights a rare and clinically significant pattern of metastasis and is the first to describe lobular carcinoma of the breast causing metastatic carcinomatosis cirrhosis.
Background: The value of next-generation sequencing (NGS) tests is dependent on how it changes clinical management, if at all. There are not any guidelines on when a physician should obtain testing; what certain genetic variations can be clinically, meaningfully intervened on; and if this active drug is financially practical. A NGS test ideally should identify a targetable mutational profile that leads to a treatment that can be obtained and produces lasting responses. We reviewed the NGS testing practices at our community hospital. Methods: Patients in our oncology clinic that underwent NGS testing of their tumor were reviewed. Specifically, the patient’s age, gender, diagnosis, date of diagnosis, previous lines of treatment, date of NGS testing, and reported molecular targets were recorded. Details of the changes in clinical management based on the NGS and survival time after the NGS test was ordered were also analyzed. Results: Forty-three patient cases were reviewed that had NGS testing obtained between the years 2014–2015 and 2017. Eighteen patients were males and 25 were females. Median age was 60 years. Most common tumor type was breast; 3 were triple-negative and 6 were only hormone-receptor positive. Second most common type was colorectal. NGS changed management in 12 cases. Two patients were able to enter a clinical trial and the other 10 had therapeutic changes based on protein or mRNA overexpression. Median time of change in management to survival in these patients was 7 months. Thirty-seven patients died; overall time from ordering of test to death was 7 months. Overall time of ordering test to survival for all patients was 8 months. Conclusions: NGS gathers a significant amount of information of a patient’s cancer, but this information is difficult to interpret in the clinical setting. Twenty-eight percent of our patients had a change in treatment, but this did not translate into lasting responses compared to other patients. Furthermore, the responses that were seen may have not been related to the therapeutic interventions, but intrinsic tumor biology. It is important to be aware of the clinical utility in ordering these tests for both the physician and patient.
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