Post on 27-Jul-2020
Cáncer de pulmón Panorama sobre su impacto, retos y necesidades actuales de atención
Oscar Arrieta MD Unidad Funcional de Oncología Torácica
Instituto Nacional de Cancerología
Noviembre 2015
Diez principales neoplasias en el mundo - GLOBOCAN 2008
Jemal A. Global Cancer Facts &Figures 2008
Pulmón Mama Colorrectal Estómago Próstata Hígado Cérvix Esófago Vejiga Linfomas Otros
n=12,667,500 nuevos casos
12.7%
10.9%
9.73%
7.81%
7.13% 5.9%
Países Desarrollados
Países en desarrollo
Cáncer Pulmonar: PROBLEMA DE SALUD PÚBLICA MUNDIAL
Primera causa de muerte por cáncer
1.6 millones de casos nuevos anualmente
1.2 millones de muertes anuales
~15% viven a 5 años
Muertes diarias: >3,000
Enfermedad avanzada: viven 10-12 meses
From: The Global Burden of Cancer 2013
JAMA Oncol. Published online May 28, 2015. doi:10.1001/jamaoncol.2015.0735
Age-Specific Global Contributions of Cancer Types to Total Cancer Incidence and Mortality, 2013For International Classification of Diseases codes included in the other neoplasms
group, see eTable 15 in the Supplement.
Figure Legend: FFFFFFFFFFFFFiiiiiiiiiiiiiggggggggggguuuuuuuuuuurrrrrrrrrreeeeeeeeee LLLLLLLLLLLLLLLeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeggggggggggggggggggeeeeeeeeeeeeeennnnnnnnnnnnnndddddddddddddddddddddddddddddddddddddddddd::::::::::::::
The Global Burden of Cancer 2013, Jama-oncol
Date of download: 7/2/2015 Copyright © 2015 American Medical Association. All rights reserved.
From: The Global Burden of Cancer 2013
JAMA Oncol. Published online May 28, 2015. doi:10.1001/jamaoncol.2015.0735
Trends in Age-Standardized Incidence Rates for Tracheal, Bronchus, and Lung Cancer, 1990-2013
Figure Legend:
Distribución porcentual de las defunciones por tumores malignos para cada sexo (2006-2007)
Mortalidad
Sobrevida en pacientes tratados con quimioterapia
Median OS: 8 months
N=1007
Lung Cancer Mutation Consortium LCMC
Mutations/gene alterations identified in >60% of cases
Johnson B, et al. ASCO 2013. Abstract 8019.
Mutación + Terapia Blanco (n = 313) Mutación + no terapia blanco (n = 265) Sin mutaciones Tx con QT (n = 361) 100
80
60
40
20
0
Supe
rviv
enci
a G
loba
l (%
)
0 1 2 3 4 5 Años
Beneficios de las terapias blanco: SVG de acuerdo a mutaciones y terapia recibida
The Jackson Laboratory – West UC Davis Cancer Center ••Center for Advanced Preclinical Research, NCI
EGFR Mutation status per ethnicity
Geographical and ethnic frequencies of epidermal growth factor receptor mutations
Frequency Country
19% Korea
32-56% Japan
55-61% Taiwan
18% Italy
6.8-2’% USA
14% Non-Hispanic Whites
2.4% African-Americans
12% Spain
Latin America N= 4,136 Positive 6.09% (252)
Negative 93.91% (3,884)
FISH- ALK in Non-Small Cell Lung Cancer
Colombia 4.1%
(10/242)
Chile 5.2% (5/94)
Argentina 6.1%
(153/2491)
Uruguay 5.3% (2/37)
Panama 4.4%
(5/114)
Mexico 8.3%
(64/769)
Costa Rica 8.7%
(13/137)
Mexico 486/1417 (EGFR (34.3)
Colombia 479/1939 (EGFR (24.7))
Argentina 247/1713 (EGFR 14.4%)
Perú 201/393 (EGFR 51.1%)
Number of patients 5738 Mutation Rate 1491 (26.0%) (95%CI: 25.3-26.7)
Costa Rica 32/102 (31.4)
Panama 47/174 (27.3)
Arrieta et al, J Thorac Oncol. 2011 Nov;6(11):1955-9
The Jackson Laboratory – West UC Davis Cancer Center ••Center for Advanced Preclinical Research, NCI
Figure 2. Clinical and epidemiological differences among NSCLC by gender
NSCLC Mutation EGFR
Sharma SV, et al. Nature Rev Cancer 2007;7;169–181; Ji H, et al. Proc Natl Acad Sci USA 2006;103;7817–7822
180 patients
Mexico Costa Rica Colombia
The impact of common and rare EGFR mutations
uncommon EGFR mutations
APC T cell
Activation (cytokines, lysis, prolif.,
migration)
B7.1 CD28
TCR Signal 1 MHC-Ag
Tumor
INMUNOTERAPIA
r ME et al, Annu Rev Immunol 2008; Pardoll DM, Nat Rev Cancer 20
APC T cell
Activation (cytokines, lysis, prolif.,
migration)
B7.1 CD28
TCR Signal 1 MHC-Ag
Tumor
INMUNOTERAPIA
Tumor PD-L1 PD-1
r ME et al, Annu Rev Immunol 2008; Pardoll DM, Nat Rev Cancer 20
(-) (-) (-)
Inhibition (anergy, exhaustion, death)
APC T cell
Activation(cytokines, lysis, prolif.,
migration)
B7.1 CD28
TCR Signal 1 MHC-Ag
Tumor
INMUNOTERAPIA
Tumor PD-L1 PD-1
r ME et al, Annu Rev Immunol 2008; Pardoll DM, Nat Rev Cancer 20
(-) (-) (-)
Inhibition (anergy, exhaustion, death)
Anti-PD-1
Costos del Tratamiento del Cáncer Pulmonar
Avances en el Tratamiento actual…
¿Y el costo de los
Tratamiento?
Arrieta et al. Tobacco Induced Diseases (2014) 12:25
Lopes et al, Nat Rev Clin Oncol. 2013 Jun;10(6):314-22.
By 2008: 63% global deaths due to noninfectious maladies
Cancer: 7.1 million deaths
80% Low-and Middle-income countries
Main cause of lost life years and productivity
Initiative Benefits Challenges Access to care Universal health-care coverage Pooling of resources
Financial protection Financing through taxation or contrivution in areas with low resources Rising health-care costs and expenditures once enacted Lawsuits against the state or government when drugs are not supplied
Genetic drugs and biosimilars Lower cost of drugs through increased competition Increased Access
Public and health-care worker perception on quality Regulatory pathways for biosimilars are still uncertain in many jurisdictions
Compulsory Licensing Early introduction of generic drug competition
Might lead to trade sanctions and decreased incentives for innovation
Research Participation in clinical trials and research
Access to standard and research medications and treatments that might not be widely available because of high cost
Ethical issues include the adequacy of informed consent, independent review and oversight, ethnic differences and conflicts of interest
Drug development in emerging Lower cost of development might Regulatory scrutiny seems less
Initiative Benefits Challenges New payment methods Price discrimination Companies expand the number of
customers who are able to afford its products Successful distribution of medications in the developing world
Parallel imports can lead to decreased profits in higher paying markets, political backlash because of lower prices in other jurisdictions and perceived inequity
Access Programs Companies expand the number of customers who are able to afford its products
Parallel importing
Risk-sharing agreements Decreases overall costs as no payment is made for patients who do not benefit from drug
Complexity, lack of consensus on end point and definiotion of benefit
Cooperation among stakeholders Health technology assessments Pricing process for a new
medications is objective and attuned to its clinical and economic benefit
Complexity, lack of agreement for universal willingness-to-pay threshold
Public-private partnerships and philantrhopy
Multiple stakeholder involvement and sources of finance
Often haphazard, leading to wasted efforts Sometimes unsustainable in the l t
Investigación independiente vs Industria Estudios clínicos de oncología regristados en clinicaltrials
EUA Brasil México
Registrados 20,749 (100%) 539 (100%) 340 (100%)
Activos 6,743 (32%) 186 (34.5%) 114 (33.5%)
Industria 7,268 (35%) 404 (74.9%) 285 (83.8%)
NIC 8,127 (39%) 118 (21.9%) 48 (14.1%)
Otros 5,327 (25.6%) 19 (3.5%) 8 (2.4%)
The Jackson Laboratory – West UC Davis Cancer Center ••Center for Advanced Preclinical Research, NCI
Importancia de desarrollar investigación independiente
– Mejorar el pronóstico del paciente
– Obtención de recursos para el tratamiento oncológico
– Evaluar objetivamente nuestros resultados
– Obtención de resultados de NUESTRA población
Pacientes en proyectos de investigación No Proyectos de investigación
ECOG 0-2 Estadio IV
INCAN 2002-2012 >900 pacientes
INCAN 2007-2013
Disease Stage II 0.6 (8/1260) IIIa 4.8 (60/1260) IIIb 18.4 (231/1260) IV 76.3 (961/1260) ECOG PS 0-1 73.2 (922/1260) 2-4. 26.8 (338/1260) Histology Adenocarcinoma 76.3 (961/1260) Epidermoid 13.3 (167/1260) Large Cell Carcinoma 3.3 (41/1260) Undifferentiated and others NSCLC 7.2 (91/1260) Carcinoembrionic antigen Mean 154.3 Median CNS metastases at diagnosis No 52.8 (675/1260) Yes 47.2 (585/1260)
EUA 2009
Diferencias en estadiaje Cáncer de pulmón
NLST: Estudio clínico aleatorizado
Tiempo
0 1 2 3 4 5 6 7 8
53,476 Personas alto riesgo
Brazo TAC
Brazo Rx
Aleatorizados
Seguimiento
T0
T1
T2
Oscar Arrieta
Apoyo de la Cámara de Diputados Comisión de Igualdad de Genero
“Programa de Apoyo a Mujeres No Fumadoras con Cáncer de Pulmón”
Trabajo con organizaciones
• Instituto Nacional de Cancerología • Gobierno • ONG
– RESPIRANDO CON VALOR – SOLO POR AYUDAR – SOCIEDAD MEXICANA DE ONCOLOGIA – CIENCIA QUE SE RESPIRA – AYUDA MESOTELIOMA, A.C. – ASOCIACIÓN MEXICANA DE LUCHA CONTRA EL
CÁNCER A.C.
Sobrevida a 1 año
Meses
Sob
revi
da
Supervivencia de 93.6% de
pacientes a 12 meses
Progresión a 1 año
Paci
ente
s (%
)
Progresión de la enfermedad (Meses)
Progresión en sólo 10.6% de pacientes
a 12 meses
Recursos aplicados a pacientes
Feb Mar Abr May Jun Jul Ago Sep Oct Nov Dic Recursos (mill) 17.5 17.1 16.5 16.0 15.3 14.0 12.7 8.0 5.6 2.9 - Pacientes - 11 18 18 25 43 46 54 60 66 74
0
10
20
30
40
50
60
70
80
0
2
4
6
8
10
12
14
16
18
20
Peso
s (m
illon
es)
Costos por paciente
Mar Abr May Jun Jul Ago Sep Total por paciente $36,185 $31,982 $31,755 $30,193 $37,899 $28,045 $28,816 Medicamentos por paciente $21,639 $20,688 $20,084 $22,062 $22,062 $23,159 $24,830 Recursos humanos por paciente $14,545 $11,294 $11,671 $8,132 $5,002 $4,885 $3,986
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
Peso
s
Agradecimiento
• Gracias al apoyo de la comisión de equidad y género de la cámara de diputados otorgado en Enero del 2015 a la Unidad Funcional de Oncología Torácica y Laboratorio de Medicina Personalizada del Instituto Nacional de Cancerología.
The Jackson Laboratory – West UC Davis Cancer Center ••Center for Advanced Preclinical Research, NCI
Victory at all costs, victory in spite of all terror, victory
however long and hard the road may be; for without
victory, there is no survival.
Winston Churchill