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Single Technology Appraisal Padeliporfin for Treating Localised

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Single Technology Appraisal Padeliporfin for Treating Localised Single Technology Appraisal Padeliporfin for treating localised prostate cancer [ID866] Committee Papers © National Institute for Health and Care Excellence 2018. All rights reserved. See Notice of Rights. The content in this publication is owned by multiple parties and may not be re-used without the permission of the relevant copyright owner. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE SINGLE TECHNOLOGY APPRAISAL Padeliporfin for treating localised prostate cancer [ID866] Contents: 1. Pre-Meeting Briefing 2. Final Scope and Final Matrix of Consultees and Commentators 3. Company submission from Steba Biotech 4. Clarification letters NICE request to the company for clarification on their submission Company response to NICE’s request for clarification 5. Patient group, professional group and NHS organisation submission from: British Association of Urological Surgeons 6. Expert statements from: Caroline Moore, clinical expert, nominated by British Association of Urological Surgeons Mark Emberton – clinical expert, nominated by Steba Biotech 7. Evidence Review Group report prepared by Aberdeen HTA Group 8. Evidence Review Group report – addendum Evidence Review Group report – factual accuracy check – the company stated that they did not identify any factual inaccuracies in the ERG report Any information supplied to NICE which has been marked as confidential, has been redacted. All personal information has also been redacted. © National Institute for Health and Care Excellence 2018. All rights reserved. See Notice of Rights. The content in this publication is owned by multiple parties and may not be re-used without the permission of the relevant copyright owner. Pre-meeting briefing Padeliporfin for treating localised prostate cancer [ID866] This slide set is the pre-meeting briefing for this appraisal. It has been prepared by the technical team with input from the committee lead team and the committee chair. It is sent to the appraisal committee before the committee meeting as part of the committee papers. It summarises: • the key evidence and views submitted by the company, the consultees and their nominated clinical experts and patient experts and • the Evidence Review Group (ERG) report It highlights key issues for discussion at the first appraisal committee meeting and should be read with the full supporting documents for this appraisal 1 Key issues for consideration Clinical effectiveness • Treatment pathway and positioning of padeliporfin – relevant comparators (active surveillance or radical treatment)? • Appropriate outcome definition for ‘disease progression’? • No long-term evidence • No evidence of padeliporfin vs radical therapy – potentially delay effective radical therapy → no evidence of long-term impact of padeliporfin on subsequent radical therapy 2 Key issues for consideration Cost effectiveness • Is the company’s assumption that all treatments have the same risk of metastatic progression clinically plausible? • The company adjusted ‘time to metastasis’ and ‘overall survival’ for general population all-cause mortality. Should ‘time to radical therapy’ also be adjusted? • Which extrapolation curve for ‘time to radical therapy’ should be used? • How should adverse events rates be modelled? • Should adjuvant and salvage therapies be included in the model? • What costs should be included for padeliporfin administration? Inpatient or day case? • Innovation and equality issues 3 4 Background • Prostate – small gland near bladder – helps to produce semen • Prostate cancer – most common cancer • 26% of male cancer diagnoses in UK • 17% low risk, 47% intermediate risk* • majority between 65 to 74 years • Risk factors – increasing age – black African-Caribbean family origin Low risk: Prostate-specific antigen (PSA) <10ng/mL & Gleason score ≤6 & Clinical stage T1 to T2a Intermediate risk: PSA 10–20 ng/ml or Gleason score 7 or Clinical stage T2b (NICE CG175) 5 Prostate cancer disease progression Localised disease Metastatic disease Very-low risk Low risk Hormone Intermediate risk sensitive High risk* Hormone resistant^ – no longer hormone sensitive *can be locally advanced disease ^can be hormone resistant and non-metastatic Treatments for localised prostate cancer 6 Routine options are active surveillance and radical therapy Focal therapy available by special arrangements or in trials Radical therapy Active • treats cancer → affects whole prostate surveillance • risk of side effects → affect quality of life • monitors for disease NHS progression • delays radical therapy prostatectomy external beam radiotherapy brachytherapy FOCAL THERAPY •Treats cancer by targeting main lesion → preserve prostate •Reduce risk of side effects •Debate: treating individual cores when disease is multifocal By special arrangements PADELIPORFIN or in trials: •1st focal therapy assessed in trial NICE IPG423 (cryotherapy) • reduce overtreatment by radical therapy NICE IPG424 (high-intensity • intact prostate → future radical therapy focused ultrasound) possible 7 Padeliporfin (Tookad), Steba Biotech Indication population: unilateral, low-risk prostate cancer (not very-low-risk) Administered using Vascular-Targeted Photodynamic (VTP) therapy Mechanism of action Marketing authorisation • administered using Vascular-Targeted monotherapy for adults with Photodynamic (VTP) therapy previously untreated, unilateral, • fibres inserted using hollow tubes into low-risk, adenocarcinoma of the cancer lesions prostate with a life expectancy • padeliporfin is injected ≥10 years: • padeliporfin is activated by laser light → • prostate-specific antigen (PSA) ≤10 kills cancer cells over several days ng/mL & • Gleason score ≤ 6 & Administration and dose • Clinical stage T1c or T2a & • single dose of 3.66 mg/kg of padeliporfin administered intravenously • 3 positive cancer cores (core length no more than 5 mm in any 1 core) or • VTP procedure done under general 1-2 positive cores with ≥50% cancer anaesthetic involvement in any 1 core or a PSA • retreatment of same lobe or treatment of density ≥0.15 ng/mL/cm3 other lobe not recommended Clinical perspective Active surveillance is mainly recommended for low-risk disease • Treatment of localised disease: stop progression outside prostate with few side effects (bowel, urinary and sexual dysfunction) – Active surveillance in low and intermediate risk disease: about 1 in 3 men change to radical therapy by 5 years (mainly disease progression; for minority burden of surveillance) – 8% of men diagnosed with low-risk disease had radical therapy (National Prostate Cancer Audit 2017 report) – Variable access to current focal therapies in the NHS • Treatment response: absence of any ‘clinically significant’ disease on biopsy or MRI – different definitions of ‘clinically significant’: usually at least Gleason 3 + 4 disease (considering maximum cancer core length and grade) • Risk stratification: thresholds between low and intermediate risk disease not well established e.g. low volume Gleason 3 + 4 may have less risk than high volume Gleason 3 + 3 • Padeliporfin has safe side effect profile – option for intermediate risk disease (Gleason 3 + 4 or possibly high volume Gleason 3 + 3) 8 Treatment pathway and positioning of padeliporfin 9 Padeliporfin is an alternative to radical therapy Company’s positioning of padeliporfin NICE CG175 Prostate cancer Low risk: PSA ≤10ng/mL & Gleason (currently being updated) score ≤6 & Clinical stage T1c or T2a & Low risk: PSA <10ng/mL & Gleason unilateral & life expectancy ≥10 years score ≤6 & Clinical stage T1 to T2a NOT alternative to Active surveillance active surveillance in Clinical multi-parametric MRI, PSA testing, digital confirmed, clinically evidence rectal examination, re-biopsy insignificant* disease PCM301: People can move from active padeliporfin vs active progression surveillance to radical therapy IS alternative for surveillance at any time due to person’s people choosing evidence of disease preferences, comorbidities and to have radical no indirect life expectancy therapy comparison: Radical therapy ?with or without padeliporfin surgery (prostatectomy) disease vs radical radiotherapy (external beam radiotherapy, progression brachytherapy) therapy *Index-lesion concept: only dominant lesion drives natural history of disease. Lesions: clinically significant (likely to have an impact on quality and length of life) or clinically insignificant (little to no chance of disease progression in expected lifetime and unlikely to benefit from active treatments) [Valerio 2014] ERG clinical expert comments on positioning of padeliporfin Padeliporfin should be compared with radical therapy Effect of padeliporfin on effectiveness of future radical therapy is unknown • Agree with company that padeliporfin is not an alternative to active surveillance – no place for padeliporfin for low-risk disease – treatment at outset not needed – if treated, may lead to over-treatment • To fit in the current pathway, padeliporfin should: – be compared with radical therapy (cancer and quality of life outcomes) – show better cancer outcomes in people who progress on active surveillance • Padeliporfin delays or avoids need for radical therapy (effective oncologically) → unclear impact of delay on future radical therapy10 effectiveness Decision problem: population and comparators Company only provides clinical evidence of padeliforin compared with active surveillance NICE scope Company submission Population: adults with unilateral, low-risk localised prostate cancer Comparators: • Clinical evidence:
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