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.

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).

Targeting resource investments to achieve sediment reduction and improved Great Barrier Reef health

Concerns about excessive sediment loads entering the Great Barrier Reef (GBR) lagoon in Australia have led to a focus on improving ground cover in grazing lands. Ground cover has been identified as an important factor in reducing sediment loads, but improving ground cover has been difficult for reef stakeholders in major catchments of the GBR. To provide better information an optimising linear programming model based on paddock scale information in conjunction with land type mapping was developed for the Fitzroy, the largest of the GBR catchments. This identifies at a catchment scale which land types allow the most sediment reduction to be achieved at least cost. The results suggest that from the five land types modelled, the lower productivity land types present the cheapest option for sediment reductions. The study allows more informed decision making for natural resource management organisations to target investments. The analysis highlights the importance of efficient allocation of natural resource management funds in achieving sediment reductions through targeted land type investments. © 2012.

Improved chemical control of Conyza bonariensis in wheat limits problems in the following fallow

Conyza bonariensis is a major weed infesting zero-tilled cropping systems in subtropical Australia, particularly in wheat and winter fallows. Uncontrolled C.bonariensis survives to become a problem weed in the following crops or fallows. As no herbicide has been registered for C.bonariensis in wheat, the effectiveness of 11 herbicides, currently registered for other broad-leaved weeds in wheat, was evaluated in two pot and two field experiments. As previous research showed that the age of C.bonariensis, and to a lesser extent, the soil moisture at spraying affected herbicide efficacy, these factors also were investigated. The efficacy of the majority of herbicide treatments was reduced when large rosettes (5-15cm diameter) were treated, compared with small rosettes (<5cm diameter). However, for the majority of herbicide treatments, the soil moisture did not affect the herbicide efficacy in the pot experiments. In the field, a delay in herbicide treatment of 2 weeks reduced the herbicide efficacy consistently across herbicide treatments, which was related to weed age but not to soil moisture differences. Across all the experiments, four herbicides controlled C.bonariensis in wheat consistently (83-100%): 2,4-D; aminopyralid + fluroxypyr; picloram + MCPA + metsulfuron; and picloram + high rates of 2,4-D. Thus, this problem weed can be effectively and consistently controlled in wheat, particularly when small rosettes are treated, and therefore C.bonariensis will have a less adverse impact on the following fallow or crop.

Improved estimation of size-transition matrices using tag-recapture data

We derive a new method for determining size-transition matrices (STMs) that eliminates probabilities of negative growth and accounts for individual variability. STMs are an important part of size-structured models, which are used in the stock assessment of aquatic species. The elements of STMs represent the probability of growth from one size class to another, given a time step. The growth increment over this time step can be modelled with a variety of methods, but when a population construct is assumed for the underlying growth model, the resulting STM may contain entries that predict negative growth. To solve this problem, we use a maximum likelihood method that incorporates individual variability in the asymptotic length, relative age at tagging, and measurement error to obtain von Bertalanffy growth model parameter estimates. The statistical moments for the future length given an individual’s previous length measurement and time at liberty are then derived. We moment match the true conditional distributions with skewed-normal distributions and use these to accurately estimate the elements of the STMs. The method is investigated with simulated tag–recapture data and tag–recapture data gathered from the Australian eastern king prawn (Melicertus plebejus).

Surviving the effects of barotrauma: assessing treatment options and a ‘natural’ remedy to enhance the release survival of line caught pink snapper (Pagrus auratus)

A new technique to ameliorate the effects of barotrauma was tested based on observations of pink snapper, Pagrus auratus (Forster), inadvertently piercing their everted stomach with their teeth and releasing trapped swim bladder gases. This technique was termed buccal venting and involved piercing the everted stomach protruding into the buccal cavity or out of the mouth with a 16-gauge hypodermic needle (a practice previously not encouraged). Short-term (~3 days) survival of buccal-vented fish was not significantly different from laterally vented fish nor untreated controls. Both buccal and lateral venting techniques were shown to cause no harm and allowed fish to return to depth. The short-term (1–3 days) post-release survival of line caught snapper was 88% with no significant difference in survival across three depth ranges tested (37–50, 51–100 and 101–180 m). Survival of sublegal pink snapper (<35 cm TL) was not significantly different (P > 0.05) from that of legal-sized fish (≥35 cm TL). Healing of the swim bladder was observed in 27% of pink snapper dissected after ≤3 days in captivity, and healing of stomachs was observed in 64% of pink snapper that had been buccal vented. Relatively high post-release survival rates of line caught pink snapper may offer some protection for snapper stocks where high fishing pressure and legal size restrictions result in the majority of the catch having to be released.

An improved real-time PCR assay for the detection of Old World screwworm flies

The Old World screwworm (OWS) fly, Chrysomya bezziana, is a serious pest of livestock, wildlife and humans in tropical Africa, parts of the Middle East, the Indian subcontinent, south-east Asia and Papua New Guinea. Although to date Australia remains free of OWS flies, an incursion would have serious economic and animal welfare implications. For these reasons Australia has an OWS fly preparedness plan including OWS fly surveillance with fly traps. The recent development of an improved OWS fly trap and synthetic attractant and a specific and sensitive real-time PCR molecular assay for the detection of OWS flies in trap catches has improved Australia's OWS fly surveillance capabilities. Because all Australian trap samples gave negative results in the PCR assay, it was deemed necessary to include a positive control mechanism to ensure that fly DNA was being successfully extracted and amplified and to guard against false negative results. A new non-competitive internal amplification control (IAC) has been developed that can be used in conjunction with the OWS fly PCR assay in a multiplexed single-tube reaction. The multiplexed assay provides an indicator of the performance of DNA extraction and amplification without greatly increasing labour or reagent costs. The fly IAC targets a region of the ribosomal 16S mitochondrial DNA which is conserved across at least six genera of commonly trapped flies. Compared to the OWS fly assay alone, the multiplexed OWS fly and fly IAC assay displayed no loss in sensitivity or specificity for OWS fly detection. The multiplexed OWS fly and fly IAC assay provides greater confidence for trap catch samples returning negative OWS fly results. © 2014 International Atomic Energy Agency.

AC conductivity of a quantum Hall line junction

We present a microscopic model for calculating the AC conductivity of a finite length line junction made up of two counter-or co-propagating single mode quantum Hall edges with possibly different filling fractions. The effect of density-density interactions and a local tunneling conductance (sigma) between the two edges is considered. Assuming that sigma is independent of the frequency omega, we derive expressions for the AC conductivity as a function of omega, the length of the line junction and other parameters of the system. We reproduce the results of Sen and Agarwal (2008 Phys. Rev. B 78 085430) in the DC limit (omega -> 0), and generalize those results for an interacting system. As a function of omega, the AC conductivity shows significant oscillations if sigma is small; the oscillations become less prominent as sigma increases. A renormalization group analysis shows that the system may be in a metallic or an insulating phase depending on the strength of the interactions. We discuss the experimental implications of this for the behavior of the AC conductivity at low temperatures.

Quantitative effects of in-line operations on Campylobacter and Escherichia coli through two Australian broiler processing plants

Campylobacter is an important food borne pathogen, mainly associated with poultry. A lack of through-chain quantitative Campylobacter data has been highlighted within quantitative risk assessments. The aim of this study was to quantitatively and qualitatively measure Campylobacter and Escherichia coli concentration on chicken carcasses through poultry slaughter. Chickens (n = 240) were sampled from each of four flocks along the processing chain, before scald, after scald, before chill, after chill, after packaging and from individual caeca. The overall prevalence of Campylobacter after packaging was 83% with a median concentration of 0.8 log10 CFU/mL. The processing points of scalding and chilling had significant mean reductions of both Campylobacter (1.8 and 2.9 log10 CFU/carcase) and E. coli (1.3 and 2.5 log10 CFU/carcase). The concentration of E. coli and Campylobacter was significantly correlated throughout processing indicating that E. coli may be a useful indicator organism for reductions in Campylobacter concentration. The carriage of species varied between flocks, with two flocks dominated by Campylobacter coli and two flocks dominated by Campylobacter jejuni. Current processing practices can lead to significant reductions in the concentration of Campylobacter on carcasses. Further understanding of the variable effect of processing on Campylobacter and the survival of specific genotypes may enable more targeted interventions to reduce the concentration of this poultry associated pathogen.

Improved optical character recognition by matched filtering

The effectiveness of linear matched filters for improved character discrimination in presence of random noise and poorly defined characters has been investigated. We have found that although the performance of the filter in presence of random noise is reasonably good (16 dB gain in signal-to-noise-ratio) its performance is poor when the unknown character is distorted (linear shift and rotation).

Improved management of key northern region weeds: diverse problems, diverse solutions

The cropping region of northern Australia has a diverse range of cropping systems and weed flora. A fallow phase is commonly required between crops to enable the accumulation of stored soil water in these farming systems dominated by reduced tillage. During the fallow phase, weed control is important and is heavily reliant on herbicides. The most commonly used herbicide has been glyphosate. As a result of over-reliance on glyphosate, there are now seven confirmed glyphosate-resistant weeds and several glyphosate-tolerant species common in the region. As a result, the control of summer fallow weeds is become more complex. This paper outlines project work investigating improved weed control for summer fallows in the northern cropping region. Areas of research include weed ecology, chemical and non-chemical tactics, glyphosate resistance and resistance surveys. The project also has an economic and extension component. As a result of our research we have a better understanding of the ecology of major northern weeds and spread of glyphosate resistance in the region. We have identified and defined alternative herbicide and non-chemical approaches for the effective control of summer fallow weeds and have extended our research effectively to industry.

Construction of Stability Multipliers with Prescribed Phase Characteristics: an Improved Value for $\sigma

For a feedback system consisting of a transfer function $G(s)$ in the forward path and a time-varying gain $n(t)(0 \leqq n(t) \leqq k)$ in the feedback loop, a stability multiplier $Z(s)$ has been constructed (and used to prove stability) by Freedman [2] such that $Z(s)(G(s) + {1 / K})$ and $Z(s - \sigma )(0 < \sigma < \sigma _ * )$ are strictly positive real, where $\sigma _ * $ can be computed from a knowledge of the phase-angle characteristic of $G(i\omega ) + {1 / k}$ and the time-varying gain $n(t)$ is restricted by $\sigma _ * $ by means of an integral inequality. In this note it is shown that an improved value for $\sigma _ * $ is possible by making some modifications in his derivation. ©1973 Society for Industrial and Applied Mathematics.