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Dasatinib, nilotinib and standard-dose imatinib for the first line treatment of chronic myeloid leukaemia: Systematic reviews and economic analyses

- Background Nilotinib and dasatinib are now being considered as alternative treatments to imatinib as a first-line treatment of chronic myeloid leukaemia (CML). - Objective This technology assessment reviews the available evidence for the clinical effectiveness and cost-effectiveness of dasatinib, nilotinib and standard-dose imatinib for the first-line treatment of Philadelphia chromosome-positive CML. - Data sources Databases [including MEDLINE (Ovid), EMBASE, Current Controlled Trials, ClinicalTrials.gov, the US Food and Drug Administration website and the European Medicines Agency website] were searched from search end date of the last technology appraisal report on this topic in October 2002 to September 2011. - Review methods A systematic review of clinical effectiveness and cost-effectiveness studies; a review of surrogate relationships with survival; a review and critique of manufacturer submissions; and a model-based economic analysis. - Results Two clinical trials (dasatinib vs imatinib and nilotinib vs imatinib) were included in the effectiveness review. Survival was not significantly different for dasatinib or nilotinib compared with imatinib with the 24-month follow-up data available. The rates of complete cytogenetic response (CCyR) and major molecular response (MMR) were higher for patients receiving dasatinib than for those with imatinib for 12 months' follow-up (CCyR 83% vs 72%, p < 0.001; MMR 46% vs 28%, p < 0.0001). The rates of CCyR and MMR were higher for patients receiving nilotinib than for those receiving imatinib for 12 months' follow-up (CCyR 80% vs 65%, p < 0.001; MMR 44% vs 22%, p < 0.0001). An indirect comparison analysis showed no difference between dasatinib and nilotinib for CCyR or MMR rates for 12 months' follow-up (CCyR, odds ratio 1.09, 95% CI 0.61 to 1.92; MMR, odds ratio 1.28, 95% CI 0.77 to 2.16). There is observational association evidence from imatinib studies supporting the use of CCyR and MMR at 12 months as surrogates for overall all-cause survival and progression-free survival in patients with CML in chronic phase. In the cost-effectiveness modelling scenario, analyses were provided to reflect the extensive structural uncertainty and different approaches to estimating OS. First-line dasatinib is predicted to provide very poor value for money compared with first-line imatinib, with deterministic incremental cost-effectiveness ratios (ICERs) of between £256,000 and £450,000 per quality-adjusted life-year (QALY). Conversely, first-line nilotinib provided favourable ICERs at the willingness-to-pay threshold of £20,000-30,000 per QALY. - Limitations Immaturity of empirical trial data relative to life expectancy, forcing either reliance on surrogate relationships or cumulative survival/treatment duration assumptions. - Conclusions From the two trials available, dasatinib and nilotinib have a statistically significant advantage compared with imatinib as measured by MMR or CCyR. Taking into account the treatment pathways for patients with CML, i.e. assuming the use of second-line nilotinib, first-line nilotinib appears to be more cost-effective than first-line imatinib. Dasatinib was not cost-effective if decision thresholds of £20,000 per QALY or £30,000 per QALY were used, compared with imatinib and nilotinib. Uncertainty in the cost-effectiveness analysis would be substantially reduced with better and more UK-specific data on the incidence and cost of stem cell transplantation in patients with chronic CML. - Funding The Health Technology Assessment Programme of the National Institute for Health Research.

First report of Vialaea minutella in Australia, its association with mango branch dieback and systematic placement of Vialaea in the Xylariales

Vialaea minutella was consistently isolated from infected mango trees showing branch dieback symptoms in northern Queensland. The fungus was identified by morphology and confirmed with molecular sequence data. This is the first report of V. minutella in Australia. The systematic position of Vialaea was confirmed to be in the Xylariales based on reconstructed LSU sequence data.

Complete cytogenetic response and major molecular response as surrogate outcomes for overall survival in first-line treatment of chronic myelogenous leukemia: A case study for technology appraisal on the basis of surrogate outcomes evidence

Objectives In 2012, the National Institute for Health and Care Excellence assessed dasatinib, nilotinib, and standard-dose imatinib as first-line treatment of chronic phase chronic myelogenous leukemia (CML). Licensing of these alternative treatments was based on randomized controlled trials assessing complete cytogenetic response (CCyR) and major molecular response (MMR) at 12 months as primary end points. We use this case study to illustrate the validation of CCyR and MMR as surrogate outcomes for overall survival in CML and how this evidence was used to inform National Institute for Health and Care Excellence’s recommendation on the public funding of these first-line treatments for CML. Methods We undertook a systematic review and meta-analysis to quantify the association between CCyR and MMR at 12 months and overall survival in patients with chronic phase CML. We estimated life expectancy by extrapolating long-term survival from the weighted overall survival stratified according to the achievement of CCyR and MMR. Results Five studies provided data on the observational association between CCyR or MMR and overall survival. Based on the pooled association between CCyR and MMR and overall survival, our modeling showed comparable predicted mean duration of survival (21–23 years) following first-line treatment with imatinib, dasatinib, or nilotinib. Conclusions This case study illustrates the consideration of surrogate outcome evidence in health technology assessment. Although it is often recommended that the acceptance of surrogate outcomes be based on randomized controlled trial data demonstrating an association between the treatment effect on both the surrogate outcome and the final outcome, this case study shows that policymakers may be willing to accept a lower level of evidence (i.e., observational association).

ICPH 2671 – the world's first commercial food legume hybrid

ICRISAT scientists, working with Indian programme counterparts, developed the world's first cytoplasmic-nuclear male sterility (CMS)-based commercial hybrid in a food legume, the pigeonpea [Cajanus cajan (L.) Millsp.]. The CMS, in combination with natural outcrossing of the crop, was used to develop viable hybrid breeding technology. Hybrid ICPH 2671 recorded 47% superiority for grain yield over the control variety ‘Maruti’ in multilocation on-station testing for 4 years. In the on-farm trials conducted in five Indian states, mean yield of this hybrid (1396 kg/ha) was 46.5% greater than that of the popular cv. ‘Maruti’ (953 kg/ha). Hybrid ICPH 2671 also exhibited high levels of resistance to Fusarium wilt and sterility mosaic diseases. The outstanding performance of this hybrid has led to its release for cultivation in India by both a private seed company (as ‘Pushkal’) and a public sector university (as ‘RV ICPH 2671’). Recent developments in hybrid breeding technology and high yield advantages realized in farmers' fields have given hope for a breakthrough in pigeonpea productivity.

First report of Pythiogeton ramosum (Pythiales) in Australia

In 2012, a project was initiated to assess if the soft rot disease of ginger in Australian fields was associated with pathogens other than Pythium myriotylum. Together with nine Pythium spp., ten isolates of a Pythium-like organism were also recovered from ginger with soft rot symptoms. These Pythium-like isolates were identified as Pythiogeton (Py.) ramosum based on its morphology and ITS sequences. In-vitro pathogenicity tests allowed confirmation of pathogenicity of Py. ramosum on excised carrot (Daucus carota), sweet potato (Ipomoea batatas) and potato (Solanum tubersum) tubers, although it was not pathogenic on excised ginger (Zingiber officinale) and radish (Raphanus sativus) rhizome/roots. In addition it was found to be pathogenic on bean (Phaseolus vulgaris), capsicum (Capsicum annuum) and cauliflower (Brassica oleracea var. botrytis) seedlings. This is the first record of Py. ramosum and its pathogenicity in Australia.

First report of Masseeëlla capparis in Australia

The rust fungus Masseeëlla capparis is reported for the first time in Australia on Flueggea virosa (Phyllanthaceae). This is the first species of Masseeëlla found in Australia. The rust is described and illustrated from Australian specimens. A discussion on species of Masseeëlla is provided. A reconstructed phylogeny with the Large Subunit region of ribosomal DNA indicated that Masseeëlla has an affinity with the Phakopsoraceae.

Miraculous Survival 1939-1982

Description of war years in France and Spain, including experiences in internment camps, life in hiding, etc.; emigration to USA.

Study of Structural Stability and Electronic Structure of Nonstoichiometric CdS Nano Clusters from First Principles

Structural stability of small sized nonstoichiometric CdS nano clusters between zincblende and wurtzite structures has been investigated using first-principles density functional calculations. Our study shows that the relative stability of these two structures depends sensitively on whether the surface is S-terminated or Cd-terminated. The associated band gap also exhibits non-monotonic behavior as a function of cluster size. Our findings may shed light on contradictory reports of experimentally observed structures of CdS nano clusters found in the literature.

First Coin Set with 5 New Sheqalim Coin

6 coin set. 1 Agora; 5 Agorot; 10 Agorot; 1/2 New Sheqel; 1 New Sheqel; 5 New Sheqel. The motifs are inspired by ancient Hebrew coins and seals with biblical emblems, and by ornaments from the Holy Temple.

First Fruiting Intergeneric Hybrids between Citrus and Citropsis

Fruiting hybrids are reported for the first time between the genera Citrus L. and Citropsis (Engl.) Swing. & M.Kell. Conventional hybridization using the recently described species Citrus wakonai P.I.Forst. & M.W.Sm. and Citropsis gabunensis (Engl.) Swing. & M.Kell. resulted in high rates of fruit set and seed formation. Although seed were only half normal size, over 90% germinated without the need for embryo rescue techniques. Plant losses were high during the first few months but after six months, the 327 surviving hybrids were potted on. These grew vigorously on their own roots and 35 of them flowered within two years of sowing. Plants flowered continuously but all were pollen-sterile and ovaries abscised shortly after petal fall. However, at 25 months, two newly flowering hybrids began setting fruit. The development, identification, morphology, breeding efficiency, and future implications of this unique germplasm are described.

Book Review: "Safe Design and Construction of Machinery – Regulation, Practice and Performance [First edition]"

With Safe Design and Construction of Machinery, the author presents the results of empirical studies into this significant aspect of safety science in a very readable, well-structured format. The book contains 436 references, 17 tables, one figure and a comprehensive index. Liz Bluff addresses a complex and important, but often neglected domain in OHS – the safety of machinery – in a holistic and profound, yet evidence based analysis; with many applied cases from her studies, which make the book accessible and a pleasant lecture. Although research that led to this remarkable publication might have been primarily focused on the regulators, this book can be highly recommended to all OHS academics and practitioners. It provides an important contribution to the body of knowledge in OHS, and establishes one of the few Australian in-depth insights into the significance of machinery producers, rather than machinery users in the wider framework of risk management. The author bases this fresh perspective on the well-established European Machinery Safety guidelines, and grounds her mixed-methods research predominantly in qualitative analysis of motivation and knowledge, which eventually leads to specific safety outcomes. It should be noted that both European and Australian legal aspects are investigated and considered, as both equally apply to many machinery exporters. A detailed description of the research design and methods can be found in an appendix. Overall, the unique combination of quantitative safety performance data and qualitative analysis of safety behaviours form a valuable addition to the understanding of machinery safety. The author must be congratulated on making these complex relationships transparent to the reader through her meticulous inquiry.