Hernandez-Martinez et al. Challenges facing lung cancer immunotherapy of acquired resistance to anti-PD-1 therapy in metastatic melanoma patients.
Resumen. El cáncer de pulmón es una de las principales causas de mortalidad alrededor del mundo. Su historia natural, con la manifestación de síntomas en etapas avanzadas y el retraso en su diagnóstico hacen que una gran proporción de pacientes se diagnostiquen en estadios tardíos de la enfermedad, lo que hace muy complicado el tratamiento exitoso de la misma. De esto deriva la importancia de dar origen a recomendaciones basadas en evidencia para soportar la toma de decisiones clínicas por parte de los grupos interdisicplinarios que se encargan del manejo de este padecimiento. Objetivos. Esta Guía de Práctica Clínica (GPC) contiene recomendaciones clínicas desarrolladas de forma sistematizada para asistir la toma de decisiones de médicos especialistas, pacientes, cuidadores de pacientes y elaboradores de políticas públicas involucrados en el manejo de pacientes con cáncer de pulmón en estadios tempranos, localmente avanzados y metastásicos. Material y métodos. Este documento se desarrolló por parte de la Sociedad Mexicana de Oncología en colaboración con el Centro Nacional de Excelencia Tecnológica de México (Cenetec) a través de la dirección de integración de Guías de Práctica Clínica en cumplimiento a estándares internacionales como los descritos por el Instituto de Medicina de EUA (IOM, por sus siglas en inglés), el Instituto de Excelencia Clínica de Gran Bretaña (NICE, por sus siglas en inglés), la Red Colegiada para el Desarrollo de Guías de Escocia (SIGN, por sus siglas en inglés), la Red Internacional de Guías (G-I-N, por sus siglas en inglés); entre otros. Se integró en representación de la Sociedad Mexicana de Oncología un Grupo de Desarrollo de la Guía (GDG) de manera interdisciplinaria, considerando oncólogos médicos, cirujanos oncólogos, cirujanos de tórax, radio-oncólogos, y metodólogos con experiencia en revisiones sistemáticas de la literatura y guías de práctica clínica. Resultados. Se consensuaron 62 preguntas cllínicas que abarcaron lo establecido previamente por el GDG en el documento de alcances de la Guía. Se identificó la evidencia científica que responde a cada una de estas preguntas clínicas y se evaluó críticamente la misma, antes de ser incorporada en el cuerpo de evidencia de la Guía. El GDG acordó mediante la técnica de consenso formal de expertos Panel Delphi la redacción final de las recomendaciones clínicas. Conclusión. Esta Guía de Práctica Clínica pretende proveer recomendaciones clínicas para el manejo de los distintos estadios de la enfermedad y que asistan en el proceso de toma de decisiones compartida. El GDG espera que esta guía contribuya a mejorar la calidad de la atención clínica en las pacientes con cáncer de pulmón de células no pequeñas.
chemotherapy(HT) for the adjuvant treatment of HER2+ early breast cancer(eBC) significantly improved invasive diseasefree survival(iDFS) versus HT in the intention-to-treat population(ITT) and, particularly, in lymph node-positive(N+) and/or hormone receptor-negative(HR-) patients. We performed a study aimed at determining the cost-utility of PHT versus HT as adjuvant treatment in HER2+ eBC for Spain. Methods: A six-state Markov model (iDFS, local recurrence, iDFS after local recurrence, metastatic-relapse[1L], metastatic-relapse[2L], and death) was adapted considering the Spanish National Healthcare System perspective, over a lifetime horizon. APHINITY 4 year-iDFS data were fitted with a log-logistic distribution for ITT and N+ populations and with an exponential distribution for HR-patients. Transition probabilities and costs (V 2019 and list prices of medicines considered) were obtained from national databases/ literature. Utilities were derived from the APHINITY trial. Model inputs were validated by an expert panel. A 3% annual discount rate was applied to effects and costs. Deterministic and probabilistic sensitivity analyses(SA) were performed to explore uncertainties. Results: PHT provided 0.637 additional quality-adjusted lifeyears(QALYs) and V27,733 cost versus HT in the N+ subgroup (incremental costutility ratio[ICUR] of V43,530/QALY). In this subgroup, ICUR were between V19,000 and V27,000 when applying a 20%-30% reduction in pertuzumab and trastuzumab treatment price. In the HR-subgroup, PHT provided 0.405 QALYs and V39,159 cost (ICUR of V96,630/QALY). ICUR were between V58,000 and V71,000 when applying a 20%-30% reduction in treatment price. The ICUR of PHT versus HT was V102,581/ QALY in the ITT population, and between V60,000 and V74,000 when considering a 20%-30% treatment price decrease. SA confirmed the robustness of the model. Conclusions: Great controversy currently surrounds cost-effectiveness thresholds. Eighteen cycles of PHT would be an efficient therapeutic alternative in HER2+ N+ eBC with a threshold of V43,530/QALY and in HR-patients with a threshold of V96,630/ QALY.
Background: Small cell lung cancer (SCLC) represents 13-15% of all primary lung neoplasms and is characterized by its rapid growth rate and the rapid development of distant metastases. Objectives: The ovjective of the study was to guide and standardize the treatment of extensive disease SCLC in Mexico based on national and international clinical evidence. Material and methods: This document was developed as a collaboration between the National Cancer Institute and the Mexican Society of Oncology in compliance with international standards. An interdisciplinary group was formed, including medical oncologists, oncological surgeons, thoracic surgeons, radiation oncologists, and methodologists with experience in systematic reviews of the literature and clinical practice guidelines. Results: A consensus was reached, both by the Delphi method and in remote meetings, of extensive disease recommendations resulting from work questions. The scientific evidence that answers each of these clinical questions was identified and critically evaluated, before being incorporated into the body of evidence of the Guide. Conclusions: This Clinical Practice Guide provides clinical recommendations for the management of extensive disease of SCLC to contribute to the decision-making process of the clinicians involved with its management in our country, hoping that this will contribute to improving the quality of clinical care in these patients.
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