Cost-effectiveness of ivosidenib versus chemotherapy for previously treated IDH1-mutant advanced intrahepatic cholangiocarcinoma in Taiwan.

BACKGROUND: International guidelines recommend ivosidenib followed by modified FOLFOX (mFOLFOX) for advanced intrahepatic cholangiocarcinoma (ICC) with isocitrate dehydrogenase 1 (IDH1) mutations. Taiwan National Health Insurance covers only fluorouracil/leucovorin (5-FU/LV) chemotherapy for this ICC group, and there has been no prior economic evaluation of ivosidenib. Therefore, we aimed to assess ivosidenib's cost-effectiveness in previously treated, advanced ICC-presenting IDH1 mutations compared with mFOLFOX or 5-FU/LV. METHODS: A 3-state partitioned survival model was employed to assess ivosidenib's cost-effectiveness over a 10-year horizon with a 3% discount rate, setting the willingness-to-pay threshold at 3 times the 2022 GDP per capita. Efficacy data for Ivosidenib, mFOLFOX, and 5-FU/LV were sourced from the ClarIDHy, ABC06, and NIFTY trials, respectively. Ivosidenib's cost was assumed to be NT$10,402/500 mg. Primary outcomes included incremental cost-effectiveness ratios (ICERs) and net monetary benefit. Deterministic sensitivity analyses (DSA) and probabilistic sensitivity analyses (PSA) were employed to evaluate uncertainty and explore price reduction scenarios. RESULTS: Ivosidenib exhibited ICERs of NT$6,268,528 and NT$5,670,555 compared with mFOLFOX and 5-FU/LV, respectively, both exceeding the established threshold. PSA revealed that ivosidenib was unlikely to be cost-effective, except when it was reduced to NT$4,161 and NT$5,201/500 mg when compared with mFOLFOX and 5-FU/LV, respectively. DSA underscored the significant influence of ivosidenib's cost and utility values on estimate uncertainty. CONCLUSIONS: At NT$10,402/500 mg, ivosidenib was not cost-effective for IDH1-mutant ICC patients compared with mFOLFOX or 5-FU/LV, indicating that a 50-60% price reduction is necessary for ivosidenib to be cost-effective in this patient group.

Transpulmonary chemoembolization and microwave ablation for recurrent or advanced non-small cell Lung Cancer.

To verify the treatment effect of the combination of transpulmonary chemoembolization (TPCE) and microwave ablation (MWA), targeting the treatment of recurrent or advanced non-small cell lung cancer (NSCLC). A total of 53 patients were studied and grouped according to the diameter of the largest pulmonary nodule, defined as index tumor size (ITS). Patients with an ITS > 3 cm (n = 20) were treated with TPCE and MWA. Patients with an ITS ≤ 3 cm were treated either with a combination therapy (n = 24) or MWA alone (n = 9). The treatment response, including complications and survival outcome, was then analyzed. After TPCE, there was an average ITS reduction of 0.91 cm, and 25% of patients in ITS > 3 cm were downgraded to ITS ≤ 3 cm. After TPCE, there were 12 patients (27%) with PR status and 32 (73%) with SD status. No PD patient in our case series was noted before MWA.The complication rate of MWA was significantly higher in ITS ≤ 3 cm than in ITS > 3 cm (p = 0.013). The median survival time (MST) was 26.7 months, and the time to progression was 13.2 months. The patients in the ITS ≤ 3 cm had longer MST than the others (31.6 vs. 15.8 months, p = 0.003). The significant prognostic factor was ITS > 3 cm (HR: 1.18, p = 0.02). A combination of TPCE and MWA might be feasible to control non-operable, recurrent, or advanced NSCLC.

Safety and feasibility comparison between three different CT-guided localization techniques under systemic approach algorithm.

INTRODUCTION: In the era of lung cancer screening, more and more sub-centimeter indeterminate lung lesions are being identified. It is difficult to approach these lesions and obtain tissue to confirm diagnosis. CT-guided navigation followed by surgical resection is the best way to overcome this difficulty. The aim of this study is to compare the safety and feasibility of wire and dye-tattoo CT-guided localization techniques. MATERIALS AND METHODS: From September 2019 to August 2021, 418 patients who presented with single lung lesion and received single CT-guided localization were included in this study. Procedure details, navigation results, and related complications were compared. RESULTS: For patients who received wire localization, majority (98.3 %) had perihilar lesions. In addition, 68 (57.1 %) patients received tangential approach because of lesions were blocked by bony or vital structure, abutting major fissure, or previous approach failure. The characteristics of lesion location was quite different than dye-tattooing technique (p = 0.033). As regards persistence of the target lesion localization, the interval between localization and surgery using ICG tattooing was 829.0 ± 552.9 min; much longer than the other two navigation techniques (p < 0.0001). As regards safety, patients who received wire localization had a higher rate of pneumothorax (p = 0.042) and pulmonary hemorrhage (p < 0.001) than the dye-tattooing techniques. DISCUSSION: CT-guided navigation techniques are safe and feasible. Wire localization is suitable for centrally located lesions but the wire needs to be fixed properly and symptomatic pneumothorax monitored for. Dye-tattooing is more suitable for peripheral lesions, while ICG localization persists longer than other techniques.

Similar efficacy and safety between lenvatinib versus atezolizumab plus bevacizumab as the first-line treatment for unresectable hepatocellular carcinoma.

BACKGROUND: Lenvatinib and atezolizumab plus bevacizumab(A + B) have been used for unresectable hepatocellular carcinoma (HCC) as first-line therapy. Real-world studies comparison of efficacy and safety in these two regimens are limited, we therefore conduct this study to investigate these issues. METHODS: We retrospectively reviewed patients received lenvatinib (n = 46) and A + B (n = 46) as first-line systemic therapy for unresectable HCC in a tertiary medical center. Objective response rate (ORR), progression free survival (PFS), and overall survival (OS) were evaluated according to modified Response Evaluation Criteria in Solid Tumors (mRECIST). Inverse probability weighting (IPW) was performed for baseline clinical features balance. RESULTS: A total of 92 patients with median age of 63.8 year-old, 78.3% male, 85.9% viral hepatitis infected, 67.4% BCLC stage C were enrolled. The median treatment and follow-up duration were 4.7 months and 9.4 months, respectively. There was no significant difference in ORR (26.1% vs. 41.3%, p = 0.1226), PFS (5.9 vs. 5.3 months, p = 0.4066), and OS (not reached vs. not reached, p = 0.7128) between the lenvatinib and A + B groups. After IPW, the results of survival and response rate were also compared. Subgroup analysis suggested that using lenvatinib was not inferior to A + B in regards of PFS, including those with elder, Child-Pugh class B, beyond up-to-seven, or portal vein invasion VP4 patients. Among the lenvatinib treated patients, multivariate analysis showed patients elder than 65-year-old was an independent predictor associated with shorter PFS (adjust HR: 2.085[0.914-4.753], p = 0.0213). The incidence rates of adverse events were similar between two groups (76 vs. 63%, p = 0.1740). Both of two regimens had similarly few impact on liver function by comparison of baseline, third month, and sixth month albumin-bilirubin index and Child-Pugh score. CONCLUSIONS: The efficacy and safety of lenvatinib are similar to A + B as a first-line systemic therapy for unresectable HCC.

Patient Involvement in the Health Technology Assessment Process in Taiwan.

The COVID-19 pandemic initially had a smaller impact on Taiwan than on most other industrialized countries. However, an outbreak in late April 2021 led to a sharp surge in cases from mid-May 2021. Patient involvement in the health technology assessment (HTA) process, however, was not much affected by this; virtual meetings were implemented. This descriptive paper presents an overview of patient involvement in the HTA process in Taiwan via the National Health Insurance Administration (NHIA) online submission platform, participation in appraisal committees, education programs, and cooperation with patients' organizations, and outlines its progress and challenges. The National Health Insurance Act, amended in 2013, protects patients' rights and invites them to voice their opinions, which are then presented to the relevant authority. Based on this act, various mechanisms have been developed to involve patients, caregivers, and patient organizations in both the HTA and the reimbursement process. Prior to the Pharmaceutical Benefit and Reimbursement Scheme (PBRS) Joint Committee meeting, the NHIA built an online platform that allows patients to submit their opinions, which are then incorporated into the HTA reports. The results are also discussed with patient representatives, following which the related documents are published on the NHIA website. From May 2015 to December 2020, 30 patients' insights were published before the PBRS Joint Committee meetings. Of these, 19 (63%) were related to oncology cases. In Taiwan, approaches to fostering patient engagement include the use of a platform for patients' and patients groups' input, among others. Although patient engagement is important for understanding the needs of the target patient population, challenges in ensuring timely patient engagement and provision of relevant resources remain. In addition, further efforts are needed to implement and improve the visibility of patient input in the HTA process.

Efficacy and Safety of Preoperative vs. Intraoperative Computed Tomography-Guided Lung Tumor Localization: A Randomized Controlled Trial.

Background: Thoracoscopic removal of small pulmonary nodules is traditionally accomplished through a two-step approach-with lesion localization in a CT suite as the first step followed by lesion removal in an operating room as the second step. While the advent of hybrid operating rooms (HORs) has fostered our ability to offer a more patient-tailored approach that allows simultaneous localization and removal of small pulmonary nodules within a single-step, randomized controlled trials (RCTs) that compared the two techniques (two- vs. single-step) are still lacking. Methods: This is a RCT conducted in an academic hospital in Taiwan between October 2018 and December 2019. To compare the outcomes of traditional two-step preoperative CT-guided small pulmonary nodule localization followed by lesion removal vs. single-step intraoperative CT-guided lesion localization with simultaneous removal performed by a dedicated team of thoracic surgeons. The analysis was conducted in an intention-to-treat fashion. The primary study endpoint was the time required for lesion localization. Secondary endpoints included radiation doses, other procedural time indices, and complication rates. Results: A total of 24 and 25 patients who received the single- and two-step approach, respectively, were included in the final analysis. The time required for lesion localization was significantly shorter for patients who underwent the single-step procedure (median: 13 min) compared with the two step-procedure (median: 32 min, p < 0.001). Similarly, the radiation dose was significantly lower for the former than the latter (median: 5.64 vs. 10.65 mSv, respectively, p = 0.001). Conclusions: The single-step procedure performed in a hybrid operating room resulted in a simultaneous reduction of both localization procedural time and radiation exposure.