Medication overuse in oncology: current trends and future implications for patients and society.

The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.

Alternative payment and care-delivery models in oncology: A systematic review.

Rising US health care costs have led to the creation of alternative payment and care-delivery models designed to maximize outcomes and/or minimize costs through changes in reimbursement and care delivery. The impact of these interventions in cancer care is unclear. This review was undertaken to describe the landscape of new alternative payment and care-delivery models in cancer care. In this systematic review, 22 alternative payment and/or care-delivery models in cancer care were identified. These included 6 bundled payments, 4 accountable care organizations, 9 patient-centered medical homes, and 3 other interventions. Only 12 interventions reported outcomes; the majority (n = 7; 58%) improved value, 4 had no impact, and 1 reduced value, but only initially. Heterogeneity of outcomes precluded a meta-analysis. Despite the growth in alternative payment and delivery models in cancer, there is limited evidence to evaluate their efficacy. Cancer 2018. © 2018 American Cancer Society.

Comparative effectiveness of less commonly used systemic monotherapies and common combination therapies for moderate to severe psoriasis in the clinical setting.

BACKGROUND: The effectiveness of psoriasis therapies in real-world settings remains relatively unknown. OBJECTIVE: We sought to compare the effectiveness of less commonly used systemic therapies and commonly used combination therapies for psoriasis. METHODS: This was a multicenter cross-sectional study of 203 patients with plaque psoriasis receiving less common systemic monotherapy (acitretin, cyclosporine, or infliximab) or common combination therapies (adalimumab, etanercept, or infliximab and methotrexate) compared with 168 patients receiving methotrexate evaluated at 1 of 10 US outpatient dermatology sites participating in the Dermatology Clinical Effectiveness Research Network. RESULTS: In adjusted analyses, patients on acitretin (relative response rate 2.01; 95% confidence interval [CI] 1.18-3.41), infliximab (relative response rate 1.93; 95% CI 1.26-2.98), adalimumab and methotrexate (relative response rate 3.04; 95% CI 2.12-4.36), etanercept and methotrexate (relative response rate 2.22; 95% CI 1.25-3.94), and infliximab and methotrexate (relative response rate 1.72; 95% CI 1.10-2.70) were more likely to have clear or almost clear skin compared with patients on methotrexate. There were no differences among treatments when response rate was defined by health-related quality of life. LIMITATIONS: Single time point assessment may result in overestimation of effectiveness. CONCLUSIONS: The efficacy of therapies in clinical trials may overestimate their effectiveness as used in clinical practice. Although physician-reported relative response rates were different among therapies, absolute differences were small and did not correspond to differences in patient-reported outcomes.

Patient-reported reasons for the discontinuation of commonly used treatments for moderate to severe psoriasis.

BACKGROUND: Despite widespread dissatisfaction and low treatment persistence in moderate to severe psoriasis, patients' reasons behind treatment discontinuation remain poorly understood. OBJECTIVES: We sought to characterize patient-reported reasons for discontinuing commonly used treatments for moderate to severe psoriasis in real-world clinical practice. METHODS: A total of 1095 patients with moderate to severe plaque psoriasis from 10 dermatology practices who received systemic treatments completed a structured interview. Eleven reasons for treatment discontinuation were assessed for all past treatments. RESULTS: A total of 2231 past treatments were reported. Median treatment duration varied by treatment, ranging from 6.0 to 20.5 months (P < .001). The frequency of each cited discontinuation reasons differed by treatment (all P < .01). Patients who received etanercept (odds ratio [OR] 5.19; 95% confidence interval [CI] 3.23-8.33) and adalimumab (OR 2.10; 95% CI 1.20-3.67) were more likely to cite a loss of efficacy than those who received methotrexate. Patients who received etanercept (OR 0.34; 95% CI 0.23-0.49), adalimumab (OR 0.48; 95% CI 0.30-0.75), and ultraviolet B phototherapy (OR 0.21; 95% CI 0.14-0.31) were less likely to cite side effects than those who received methotrexate, whereas those who received acitretin (OR 1.56; 95% CI 1.08-2.25) were more likely to do so. Patients who underwent ultraviolet B phototherapy were more likely to cite an inability to afford treatment (OR 7.03; 95% CI 3.14-15.72). LIMITATIONS: The study is limited by its reliance on patient recall. CONCLUSIONS: Different patterns of treatment discontinuation reasons are important to consider when developing public policy and evidence-based treatment approaches to improve successful long-term psoriasis control.

Progress in the unraveling of the endoplasmic reticulum stress/autophagy pathway and cancer: implications for future therapeutic approaches.

Given the inherent resistance to apoptosis that characterizes cancer, the targeting of alternative pathways is an attractive strategy to improve anti-tumor therapy. Endoplasmic reticulum (ER) stress, which is basally activated in many cancers, and the subsequent activation of autophagy represent novel cancer treatment targets. While these associated pathways are often protective and promote cell survival, when excessive, ER stress results in autophagic cell death. Therefore, depending on the circumstances, either inhibition or activation of ER stress and autophagy can improve cancer therapy. This review provides an update on how ER stress relates to autophagy, and how these associated pathways can serve dual functions to promote survival or cell death in cancer. Furthermore, it lays out a spectrum of potential pharmacological agents and combinatorial approaches that target these pathways to enhance tumor cell kill.

Genomic Alteration in Metastatic Breast Cancer and Its Treatment.

Metastatic breast cancer (mBC) remains responsible for the majority of breast cancer deaths. Whereas clinical outcomes have improved with the development of novel therapies, resistance almost inevitably develops, indicating the need for novel therapeutic approaches for the treatment of mBC. Recent investigations into mBC genomic alterations have revealed novel and potential therapeutic targets. Most notably, therapies against PIK3CA mutation and germline BRCA1/2 mutations have solidified the role of targeted therapy in mBC, with treatments against these alterations now approved by the U.S. Food and Drug Administration (FDA) on the basis of clinical benefit for patients with mBC. Familiarity with relevant genomic alterations in mBC, technologies for mutation detection, methods of interpreting genomic alterations, and an understanding of their clinical impact will aid practicing clinicians in the treatment of mBC as the field of breast oncology moves toward the era of precision medicine.

Practice Patterns for Older Adult Patients With Advanced Cancer: Physician Office Versus Hospital Outpatient Setting.

PURPOSE: A shift in outpatient oncology care from the physician's office to hospital outpatient settings has generated interest in the effect of practice setting on outcomes. Our objective was to examine whether medical oncologists' prescribing of drugs and services for older adult patients with advanced cancer is used more in physicians' offices compared with hospital outpatient departments. METHODS: This was a retrospective comparative study. SEER-Medicare data (2004 to 2011) were used to identify Medicare beneficiaries diagnosed with advanced breast, colon, esophagus, non-small-cell lung, pancreatic, or stomach cancer. Between physicians' offices and hospital outpatient departments, we compared use of selected likely low-value supportive drugs, low-value therapeutic drugs, chemotherapy-related hospitalizations, and hospice. We used hierarchical modeling to assess differences between settings to account for correlation within physicians. RESULTS: Compared with patients treated in a hospital outpatient department, those treated in a physician's office setting were more likely to receive erythropoiesis-stimulating agents (odds ratio, 1.72; 95% CI, 1.53 to 1.94) and granulocyte colony-stimulating factors (odds ratio, 1.28; 95% CI, 1.18 to 1.38). For combination chemotherapy and nanoparticle albumin-bound-paclitaxel in patients with breast cancer, there was a trend toward higher use in physicians' offices, although this was not statistically significant. Chemotherapy-related hospitalizations and hospice did not vary by setting. CONCLUSION: We found somewhat higher use of several drugs for patients with advanced cancer in physicians' office settings compared with hospital outpatient departments. Findings support research to dissect the mechanisms through which setting might influence physicians' behavior.

Next-Generation Alternative Payment Models in Oncology-Will Precision Preclude Participation?

This Viewpoint proposes 3 changes to the Enhancing Oncology Model of the US Centers for Medicare & Medicaid Services.

Extended Adjuvant Aromatase Inhibitor Therapy in Post-Menopausal Women.

PURPOSE OF THE REVIEW: To understand the evidence for extending adjuvant aromatase inhibitor (AI) therapy from 5 to 10 years in post-menopausal women with hormone receptor positive (HR+) breast cancer. RECENT FINDINGS: Multiple large trials have investigated this question. The two trials most representative of the dilemma faced in clinical practice are the MA.17R and NSABP-B42 trials, which both investigated the benefit of continuing versus stopping AI therapy beyond 5 years. Both trials showed that extended AI therapy led to a reduction in new or recurrent breast cancers, but had no effect on survival outcomes when death from any cause was included. SUMMARY: The decision to extend AI therapy beyond 5 years remains a personalized one based on a discussion of the projected risk of recurrence, the expected benefits of prolonged AI treatment, and the patient's ability to tolerate side effects so that quality of life is preserved.

Psoriasis: Pathogenesis, Assessment, and Therapeutic Update.

Psoriasis is a chronic condition that affects more than 7 million Americans. This article explores the pathogenesis and physical signs of psoriasis. Over the past 2 decades enhanced understanding of the immunologic basis of psoriasis has led to the development of new systemic agents that have revolutionized the management of this disease, and these modalities, along with traditional therapies, are described.

Quality of Life, Mood, and Prognostic Understanding in Patients with Metastatic Breast Cancer.

BACKGROUND: Although breast cancer is the second leading cause of cancer-related mortality in women in the United States, few studies focus on the supportive care needs of patients living with metastatic breast cancer (MBC). OBJECTIVE: We studied quality of life (QOL), depression, anxiety, and prognostic understanding of patients with MBC. DESIGN: We conducted a cross-sectional study of 140 patients with MBC, stratified by receipt of endocrine therapy or chemotherapy. MEASUREMENTS: We evaluated anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). We assessed QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B), specifically measuring the FACT-B Trial Outcome Index (TOI), which includes physical and functional well-being and breast cancer-specific symptoms. Higher FACT-B TOI scores represent better QOL. We used a 12-item questionnaire to assess patients' perceptions of their prognosis and goals of therapy. RESULTS: Compared to those taking endocrine therapy (n = 40), patients receiving chemotherapy (n = 100) reported lower scores on the FACT-B TOI (66.1 versus 72.5, p < 0.01) and more depression symptoms (HADS-D >7; 22% versus 7.5%, p = 0.03). Higher scores on the FACT-B TOI were associated with lower depression (ß, -0.16; p < 0.01) and anxiety (ß, -0.11; p < 0.01), and patients who reported frequent prognostic conversations with their oncologists had less depression (ß, -1.28; p < 0.01). Thirty-nine percent (54/140) reported that their cancer was likely curable. CONCLUSION: Patients with MBC, particularly those treated with chemotherapy, may benefit from interventions to address their physical, functional, and breast cancer-related symptoms. Many do not report accurate prognostic understanding, and more frequent prognostic conversations might address this information gap.