Adverse event-related costs for systemic metastatic breast cancer treatment among female Medicaid beneficiaries

<p><b>Objective:</b> This retrospective study compared the real-world incidence and costs of systemic treatment-related adverse events (AEs) in patients with metastatic breast cancer in a Medicaid population.</p> <p><b>Methods:</b> Insurance claims data for adult women who received biologic or chemotherapy (± hormonal therapy) for metastatic breast cancer between 2006–2013 were extracted from the Truven Health MarketScan^® Multi-State Medicaid database. Incidence of AEs (per 100 person years) and average monthly AE-related healthcare costs (per-patient-per-month) during each line of therapy (first or later lines) were estimated. The association between AEs and total all-cause healthcare costs was estimated using multivariable regression.</p> <p><b>Results:</b> A total of 729 metastatic breast cancer patients were analyzed. Hematological (202.3 per 100 person years) and constitutional AEs (289.6 per 100 person years) were the most common class of AEs reported. Unadjusted per-patient-per-month AE-related expenditure by class were highest for hematological AEs ($1524), followed by gastrointestinal ($839) and constitutional AEs ($795), with anemia ($942), nausea/vomiting ($699), and leukopenia/neutropenia ($550) having incurred the highest total AE-related costs. Adjusted total all-cause monthly costs increased with the number of AEs ($19,701 for >7 AEs,$16,264 for 4 − 6 AEs, and $13,731 for 1 − 3 AEs) compared to no AEs ($5908) (all <i>p</i> < 0.01).</p> <p><b>Conclusions:</b> Among metastatic breast cancer patients treated with systemic therapy in a Medicaid population, AEs were associated with significant increases in costs, which increased with the number of AEs experienced. Therapies associated with a lower incidence of AEs may reduce cost burden and improve patient outcomes. </p

Average contact frequency (mean number of contacts per individual ± SD) for koalas at St Bees Island, Queensland, Australia during breeding and non-breeding seasons.

<p>*P = 0.004</p

Average encounter duration (± SD) in seconds for koalas at St Bees Island, Queensland, Australia, during breeding (September–December) and non-breeding (May–July) seasons.

<p>*P = 0.007</p

Legislative Documents

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A phase 2 open label randomized study of enobosarm, a novel oral, selective androgen receptor modulator, in androgen receptor-positive, oestrogen receptor-positive, and HER2-negative advanced breast cancer: study G200802

Background The androgen receptor (AR) is a tumour suppressor in oestrogen receptor positive (ER+) breast cancer. This study evaluated the efficacy and safety of enobosarm, an orally bioavailable selective AR modulator, in women with ER+ HER2- and AR+ disease. Methods Previously treated postmenopausal women (≥18 years) with an Eastern Cooperative Oncology Group performance status of 0–2 and ER+, HER2- locally advanced, or metastatic breast cancer were enrolled in a randomized phase 2, open-label, parallel design clinical trial (NCT01616758; trial closed including follow-up). Participants were randomly assigned 1:1 to either 9 or 18 mg enobosarm daily. The primary endpoint was clinical benefit rate at 24 weeks in AR+ cases. Findings Between September 10th, 2015, and January 11th, 2019, 136 of 172 screened patients were deemed eligible and randomized (9mg, n=72; 18mg, n=64). 102 patients had AR+ breast cancers and formed the evaluable cohort (9mg, n=50; 18mg, n=52). Clinical benefit rate at 24 weeks was 32% (95% C.I. 19·5-46·7) in the 9 mg arm and 28·8% (95% C.I. 17·1-43·1) in the 18 mg arm. The proportion of patients with grade 3 or 4 drug related toxicities was six (8%) of 75 and ten (16·4%) of 61 in the 9 and 18 mg arms, respectively. The most common Grade 3 or 4 toxicities in the 9 mg group was increased hepatic transaminases (three (4·2%) of 75) and in the 18 mg group increased hepatic transaminases (two (3·3%) of 61), hypercalcemia (two (3·3%) of 61), and fatigue (two (3·3%) of 61). Seven deaths (three in the 9 mg arm and four in the 18 mg arm) were all unrelated to study drug. Interpretation Enobosarm has anti-tumour activity in ER+, HER2- metastatic breast cancer, demonstrating that activating the AR can result in clinical benefit. Funding Study G200802 was funded by GTx Inc.</p

Additional file 4: of Targeting tumour re-wiring by triple blockade of mTORC1, epidermal growth factor, and oestrogen receptor signalling pathways in endocrine-resistant breast cancer

Figure S4. Anti-proliferative effect combination of RAD001 and neratinib together with endocrine agents (a) 4-OHT and (b) ICI. Endocrine-resistant and -sensitive BC cell lines were treated with a combination of RAD001 and neratinib and increasing concentrations of (a) 4-OHT or (b) ICI for 6 days with media change at day 3. Cell viability was analysed using a cell titer-glo assay. Data are expressed as fold-change relative to vehicle control. Error bars represent mean ± SEM. wt-MCF7 (1.5 nM RAD001; 200 nM neratinib); MCF7-LTED (1.5 nM RAD001; 300 nM neratinib); wt-SUM44 (0.37 nM RAD001; 450 nM neratinib); SUM44-LTED (0.37 nM RAD001; 250 nM neratinib); wt-HCC1428 (1.5 nM RAD001; 500 nM neratinib); HCC1428-LTED (3 nM RAD001; 250 nM neratinib). (PDF 208 kb

Additional file 7: of Targeting tumour re-wiring by triple blockade of mTORC1, epidermal growth factor, and oestrogen receptor signalling pathways in endocrine-resistant breast cancer

Figure S7. Assessment of dynamic changes in expression of cell cycle regulatory genes. (a) Log2 differences in CCNE1, CCNL1, CDK3, CDK7, and CDK9 gene expression following treatment with RAD001, RAD001 + neratinib, and RAD001 + neratinib + fulvestrant (ICI), compared with vehicle. (b) GSEA enrichment plots for 198 genes known to be induced by sustained activation of ERK in response to EGF activity. Plots show the profile of the running Enrichment Score and positions of GeneSet Members on the Rank Ordered List for rank gene lists generated from the comparison of: ICI vs. vehicle; neratinib + ICI vs. ICI; RAD001 + ICI vs. ICI; and RAD001 + neratinib + ICI vs. RAD001 + ICI. (PDF 721 kb

Additional file 2: of Targeting tumour re-wiring by triple blockade of mTORC1, epidermal growth factor, and oestrogen receptor signalling pathways in endocrine-resistant breast cancer

Figure S2. Anti-proliferative effect of RAD001 in combination with endocrine agents (a) 4-OHT and (b) ICI. Endocrine-resistant and -sensitive BC cell lines were treated with a combination of RAD001 (3 nM) and increasing concentrations of (a) 4-OHT or (b) ICI for 6 days with media change at day 3. Cell viability was analysed using a cell titer-glo assay. Data are expressed as fold-change relative to vehicle control. Error bars represent mean ± SEM. (PDF 196 kb

Additional file 6: of Targeting tumour re-wiring by triple blockade of mTORC1, epidermal growth factor, and oestrogen receptor signalling pathways in endocrine-resistant breast cancer

Figure S6. Assessment of dynamic changes in gene expression in response to RAD001, neratinib, or the combinations with fulvestrant. (a) MCF72a cells, which were previously engineered to express aromatase (CYP19) [33] were implanted into ovariectomised mice under androstenedione support. In this setting, MCF72a cells convert androstenedione in to oestrogen to drive proliferation. Once tumours developed, androstenedione was withdrawn. After a lag phase, tumour growth occurred synonymous with ligand independence. Assessment of the MCF72a-LTED showed continued expression of ER and proliferation in the absence of exogenous oestrogen providing a model of AI relapse. (b) Changes to gene expression (log2 difference drug – vehicle) as detected by RNA-seq for five drug combinations (neratinib, RAD001, ICI, neratinib + RAD001, and neratinib + RAD001 + ICI) were mapped to KEGG pathway graphs using Pathview ( https://bioconductor.org/packages/release/bioc/html/pathview.html ). Genes with a fold-change greater than 50% compared with vehicle in any condition were selected in order to expand the list of differentially expressed genes, allowing the identification of subtle changes in gene expression; for example, kinases or transcription factors that might have significant impact on downstream gene expression. A heatmap for each gene in shown. (c) Assessment of expression of E2F target genes in response to neratinib and RAD001. (PDF 1861 kb