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Chemotherapy trumps BSC in improving survival, QoL of patients with gastric cancer

Tristan Manalac
12 Sep 2017
Health DG: Many new drugs are less cost effective, and not included in the latest formulary

Chemotherapy improves the survival and quality of life of gastric cancer patients better than best supportive care (BSC) alone, according to a new meta-analysis. Moreover, first-line combination chemotherapy results in better survival compared to 5-fluorouracil (5-FU) alone.

Analysis of pooled data from three randomized controlled trials (RCTs) corresponding to 184 participants showed that overall survival (OS) improved by an estimated 6.7 months in those that received chemotherapy than in those who received BSC only (hazard ratio [HR], 0.3; 95 percent CI, 0.24 to 0.55). [Cochrane Database Syst Rev 2017;doi:10.1002/14651858.CD004064.pub4]

Similarly, after analysing pooled data from 23 studies (n=4,447) OS was found to be marginally better in patients who received combination chemotherapy than in those who had single-agent chemotherapy only (HR, 0.84; 0.79 to 0.89). This is offset by the drawback of increased toxicity in combination chemotherapy.

“The pooled results of [the involved] studies represent a generalized estimate of the effectiveness of the combination chemotherapy regimens used in the last 25 years,” said researchers.

“Therefore, the benefit of a modern two-drug combination, such as 5-FU/irinotecan or 5-FU/oxaliplatin over a single-agent, usually fluoropyrimidine-based chemotherapy regimen is likely to exceed this global result,” they added.

Investigators also compared the efficacies of specific chemotherapeutic agents. Five studies (n=732) that compared capecitabine with 5-FU yielded an HR for OS of 0.94 (0.79 to 1.11) in moderate favour of capecitabine. The corresponding median survivals were 10.8 and 10.9 months. The results did not reach statistical significance.

Capecitabine also showed nonsignificant advantages over 5-FU in terms of tumour response (odds ratio [OR], 0.85; 0.41 to 1.79) and time to progression (HR, 0.72; 0.47 to 1.12).

Similarly, S-1 also showed a borderline statistically significant advantage over 5-FU in terms of OS (HR, 0.91; 0.83 to 1.00), according to four randomized studies (n=1,793). The pooled median survival durations were 9.6 and 9.1 months, respectively.

“Taking [these drug] comparisons together, we find that S-1 yields a modest advantage over 5-FU in terms of survival, whereas capecitabine was neither superior nor inferior as a replacement for 5-FU,” according to Nicholas Syn, one of the authors of the study and a researcher at the National University Health System in Singapore.

These drugs, all fluoropyrimidines, have thus far been considered as roughly equivalent to each other in terms of efficacy, he explained. The choice to administer one drug over the other often boils down to cost, in which cases S-1 has the advantage because it is cheaper, or institutional preference, in which cases capecitabine has the advantage in Western countries.

The current meta-analysis, while not explicitly concerned with cost-effectiveness, has provided evidence suggesting “that S-1 might just be a more cost-effective substitute for 5-FU than capecitabine,” Syn said.

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