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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 402-403

Authors' reply to Agarwal et al. and Venniyoor


1 Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
2 Malabar Cancer Centre, Thalassery, Kerala, India

Date of Submission28-Mar-2020
Date of Decision31-Mar-2020
Date of Acceptance09-Apr-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Avaronnan Manuprasad
Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_98_20

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How to cite this article:
Manuprasad A, Shenoy PK, Jones J, Vinin N V, Dharmaraj A, Muttath G. Authors' reply to Agarwal et al. and Venniyoor. Cancer Res Stat Treat 2020;3:402-3

How to cite this URL:
Manuprasad A, Shenoy PK, Jones J, Vinin N V, Dharmaraj A, Muttath G. Authors' reply to Agarwal et al. and Venniyoor. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Sep 18];3:402-3. Available from: http://www.crstonline.com/text.asp?2020/3/2/402/287284



We thank Venniyoor [1] and Agrawal et al.[2] for their critical comments about our article titled, “Short-course adjuvant trastuzumab in breast cancer: Experience from a tertiary cancer center in rural India” and the accompanying editorial.[3],[4] This was a retrospective study with limitations inherent to these kind of analyses, and we had acknowledged the same in our publication.[3]

Agrawal et al. have pointed out that there has been a significant reduction in the cost of generic trastuzumab. It has to be noted that our study analyzed data from patients who received treatment between 2014 and 2016, when the availability of generic trastuzumab was limited and its cost was significantly higher than that of other drugs used in the adjuvant treatment of cancer. We had mentioned in our article that all our patients had received breast cancer treatment under government support schemes. In addition, a 9-week course of adjuvant trastuzumab was offered to those who were not willing for a 1-year course. We must also remember that breast cancer is not treated with adjuvant trastuzumab alone; the treatment includes surgery, chemotherapy, and/or adjuvant radiotherapy. This, along with mandatory investigations, adds to the cost of treatment of breast cancer. Gupta et al. from their study had concluded that 1-year adjuvant trastuzumab is not as cost-effective at the current price as 9-week adjuvant trastuzumab.[5] They also concluded that a further reduction of 15%–35% in the price of trastuzumab has increased the probability of 1-year trastuzumab use being cost-effective to 90% in India. Their statistical analysis was based on an estimated cost of ₹16,998 for a 440-mg vial of trastuzumab.[5] This is much lower than the price of most generic versions currently available in India.

In the study by Conte et al., it was seen in the subgroup analysis that patients with lower stage and lower nodal burden who received the 9-week schedule fared similar to those who received the 1-year adjuvant trastuzumab. Thus, 9-week adjuvant trastuzumab is an economically viable option, especially for patients with a lower risk of relapse, i.e., small tumors (T1 and T2) with no or low nodal involvement (<3 nodes).[6] We also agree with Agrawal et al.'s comment about the need of a randomized trial for the 9-week schedule of trastuzumab in Indian patients; however, this may be difficult because of multiple reasons.[7] Similarly, as Dr. Venniyoor pointed out, it is not trastuzumab alone but all the drugs together that determine the outcome.[1] We have used the universally accepted chemotherapy regimens, including doxorubicin-cyclophosphamide and weekly paclitaxel, which might have contributed to the favorable outcomes seen in our analysis.[8]

We conclude that short-course trastuzumab (9 weeks) is a feasible alternative and economically a more viable option in a resource-limited setting like India. Therefore, making it available under government schemes may improve the outcomes of patients with Her2-positive breast cancer in our country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Venniyoor A. Trastuzumab is not a one-man show: The sequence matters. Cancer Res Stat Treat 2020;3:399-400.  Back to cited text no. 1
  [Full text]  
2.
Agrawal C, Domadia K, Goyal P. Only 9 weeks or complete 12 months of adjuvant trastuzumab in Indian early-stage breast cancer patients: Is it the practice-changing approach in a resource-constrained setting? Cancer Res Stat Treat 2020;3:401-2.  Back to cited text no. 2
  [Full text]  
3.
Manuprasad A, Shenoy PK, Jones J, Vinin N, Dharmarajan A, Muttath G. Short-course adjuvant trastuzumab in breast cancer: Experience from a tertiary cancer center in rural India. Cancer Res Stat Treat 2020;3:69-73.  Back to cited text no. 3
  [Full text]  
4.
Akram Hussain SM. Molecular-based screening and therapeutics of breast and ovarian cancer in low- and middle-income countries. Cancer Res Stat Treat 2020;3:81-4.  Back to cited text no. 4
  [Full text]  
5.
Gupta N, Verma RK, Gupta S, Prinja S. Cost effectiveness of trastuzumab for management of breast cancer in India. JCO Glob Oncol 2020;6:205-16.  Back to cited text no. 5
    
6.
Conte P, Frassoldati A, Bisagni G, Brandes AA, Donadio M, Garrone O, et al. Nine weeks versus 1 year adjuvant trastuzumab in combination with chemotherapy: Final results of the phase III randomized Short-HER study‡. Ann Oncol 2018;29:2328-33.  Back to cited text no. 6
    
7.
Noronha V. Making a case for cancer research in India. Cancer Res Stat Treat 2018;1:71.  Back to cited text no. 7
  [Full text]  
8.
Sparano JA, Wang M, Martino S, Jones V, Perez EA, Saphner T, et al. Weekly paclitaxel in the adjuvant treatment of breast cancer. N Engl J Med 2008;358:1663-71.  Back to cited text no. 8
    




 

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