Nav: Home

Little cost difference between tests to diagnose coronary heart disease

May 23, 2016

1. Little cost difference between CT angiography and stress test for diagnosing heart disease



URL goes live when the embargo lifts

For patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) and functional diagnostic testing strategies have similar costs through 3 years of follow up. Results of this prospective economic study are published in Annals of Internal Medicine.

Chest pain is a common reason for patients to seek medical care and a challenge for doctors who must diagnose the cause. Typically, clinicians rely on health history and noninvasive tests to assess for CAD, such as CTA and functional stress tests. The recent PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial examined the effect of these different diagnostic testing strategies for CAD on patient outcomes and found little difference between them. A planned secondary aim of PROMISE was to conduct an economic analysis to assess cost differences between the approaches.

Researchers analyzed economic data for 9,649 patients enrolled in PROMISE between July 2010 and September 2013. They looked at cost of the initial outpatient testing strategy, hospital-based costs, and physician fees for the first 90 days and then estimated out to 3 years. The data showed that an initial CTA strategy had costs similar to those of a functional stress testing strategy, but patterns of care differed. Patients in the CTA group had less follow-up noninvasive testing and more invasive catheterization and revascularization. After 90 days, the choice of test had little effect on differential costs.

According to the author of an accompanying editorial, the PROMISE economic analysis is disappointing because it lacks data on treatment costs associated with heart disease. Stable ischemic heart disease therapeutic management includes a focus on symptom control, lifestyle modification, and targeted risk factor modifying treatments, which may impart a heavy economic burden on many patients. The author suggests further research to determine the value of symptom-guided treatment without diagnostic testing as a way to eliminate the commonplace finding of "testing begetting more testing."

Note: For an embargoed PDF, please contact Cara Graeff. For an interview with the lead author, Dr. Daniel Mark, please contact Sarah Avery at or 919-660-1306.

2. Novel trial approaches may help to make cancer treatments more precise


URL goes live when the embargo lifts

Newer trial designs may help to personalize cancer treatments based on DNA alterations in tumors, rather than on primary tumor site or stage of disease. The result could be more effective treatments. A summary of three of these novel trial designs is published in Annals of Internal Medicine.

Traditional trial designs in oncology have proceeded along three phases of research. Phase 1 oncology trials seek to find the maximum dose tolerated by the patient's normal tissues among patients with metastatic disease of various primary tumor sites that were resistant to known treatments; phase 2 trials are used to evaluate antitumor drug activity in patients with advanced disease of a given primary tumor site in which other treatments have failed; and phase 3 trials are randomized controlled trials (RCTs) comparing a new treatment to a standard-of-care control in patients who are representative of the general population of patients with a specified primary site and stage of cancer. However, developments in tumor biology and genomics have indicated that tumors of a primary site represent a heterogeneous collection of diseases that differ with regard to DNA drivers. This means that conventional approaches to clinical trial design and analysis may no longer be appropriate as clinicians look to base treatments on molecular phenotypes. This movement is known as precision medicine.

The author describes new clinical trial designs in oncology that may help to advance precision medicine. In phase 2 basket trials, which can be randomized or nonrandomized and include a single drug or multiple individual drugs, patient eligibility is based on a defined genomic alteration rather than on primary tumor site. For example, eligibility may require that the tumor contains a V600E mutation in the BRAF gene in a patient with any type of solid tumor. Phase 3 enrichment designs conducted for regulatory approval have eligibility limited to patients with a single primary site of disease and genomic alteration. Approval of a drug is accompanied by an approval of a companion diagnostic for identifying the patients who have tumors for which the drug is effective. For example, trastuzumab was approved for breast cancer with an assay for amplification of the HER2 gene overexpression of the HER2 protein as the companion diagnostic test. And finally, phase 3 umbrella designs involve several molecularly targeted test drugs and a population of patients with a single primary site of disease. Phase 3 umbrella trials consist of a combination of several enrichment designs conducted with a common genomic alteration testing infrastructure. For example, in the Lung-MAP (Lung Master Protocol-phase II/III Biomarker Driven Master Protocol for Second Line Therapy of Squamous Cell Lung Cancer) study, patients with advanced squamous cell lung cancer who have undergone one previous treatment are screened for genomic alterations in more than 200 genes using a sequencing platform that has been analytically validated for accuracy. As a result of this tumor characterization, patients are recommended for 1 of 5 subtrials with the umbrella framework.

These new trial designs are promising in oncology precision medicine and have may indications in other disease areas, as well, according to the author.

Note: For an embargoed PDF, please contact Cara Graeff. For an interview with the lead author, Dr. Richard Simon, please contact the National Cancer Institute Press Officers at or 301-496-6641.
Also new in this issue:

Transparent Electronic Health Records and Lagging Laws

Bryan S. Lee, MD, JD; Jan Walker, RN, MBA; Tom Delbanco, MD, and Joann G. Elmore, MD, MPG

Ideas and Opinions

American College of Physicians

Related Cancer Articles:

Radiotherapy for invasive breast cancer increases the risk of second primary lung cancer
East Asian female breast cancer patients receiving radiotherapy have a higher risk of developing second primary lung cancer.
Cancer genomics continued: Triple negative breast cancer and cancer immunotherapy
Continuing PLOS Medicine's special issue on cancer genomics, Christos Hatzis of Yale University, New Haven, Conn., USA and colleagues describe a new subtype of triple negative breast cancer that may be more amenable to treatment than other cases of this difficult-to-treat disease.
Metabolite that promotes cancer cell transformation and colorectal cancer spread identified
Osaka University researchers revealed that the metabolite D-2-hydroxyglurate (D-2HG) promotes epithelial-mesenchymal transition of colorectal cancer cells, leading them to develop features of lower adherence to neighboring cells, increased invasiveness, and greater likelihood of metastatic spread.
UH Cancer Center researcher finds new driver of an aggressive form of brain cancer
University of Hawai'i Cancer Center researchers have identified an essential driver of tumor cell invasion in glioblastoma, the most aggressive form of brain cancer that can occur at any age.
UH Cancer Center researchers develop algorithm to find precise cancer treatments
University of Hawai'i Cancer Center researchers developed a computational algorithm to analyze 'Big Data' obtained from tumor samples to better understand and treat cancer.
New analytical technology to quantify anti-cancer drugs inside cancer cells
University of Oklahoma researchers will apply a new analytical technology that could ultimately provide a powerful tool for improved treatment of cancer patients in Oklahoma and beyond.
Radiotherapy for lung cancer patients is linked to increased risk of non-cancer deaths
Researchers have found that treating patients who have early stage non-small cell lung cancer with a type of radiotherapy called stereotactic body radiation therapy is associated with a small but increased risk of death from causes other than cancer.
Cancer expert says public health and prevention measures are key to defeating cancer
Is investment in research to develop new treatments the best approach to controlling cancer?
UI Cancer Center, Governors State to address cancer disparities in south suburbs
The University of Illinois Cancer Center and Governors State University have received a joint four-year, $1.5 million grant from the National Cancer Institute to help both institutions conduct community-based research to reduce cancer-related health disparities in Chicago's south suburbs.
Leading cancer research organizations to host international cancer immunotherapy conference
The Cancer Research Institute, the Association for Cancer Immunotherapy, the European Academy of Tumor Immunology, and the American Association for Cancer Research will join forces to sponsor the first International Cancer Immunotherapy Conference at the Sheraton New York Times Square Hotel in New York, Sept.

Related Cancer Reading:

Best Science Podcasts 2019

We have hand picked the best science podcasts for 2019. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

Digital Manipulation
Technology has reshaped our lives in amazing ways. But at what cost? This hour, TED speakers reveal how what we see, read, believe — even how we vote — can be manipulated by the technology we use. Guests include journalist Carole Cadwalladr, consumer advocate Finn Myrstad, writer and marketing professor Scott Galloway, behavioral designer Nir Eyal, and computer graphics researcher Doug Roble.
Now Playing: Science for the People

#530 Why Aren't We Dead Yet?
We only notice our immune systems when they aren't working properly, or when they're under attack. How does our immune system understand what bits of us are us, and what bits are invading germs and viruses? How different are human immune systems from the immune systems of other creatures? And is the immune system so often the target of sketchy medical advice? Those questions and more, this week in our conversation with author Idan Ben-Barak about his book "Why Aren't We Dead Yet?: The Survivor’s Guide to the Immune System".