Ian F. Tannock

Health systems, oncologists, and patients face a crisis in value of cancer care that has several components: interpretation of meaningful benefit, cost, and affordability that limits access to treatment and effective delivery of evidence-based care. Value in health care has several definitions but can be defined as benefit/cost, which can be explicitly measured using cost-effectiveness analyses and used to shape coverage decisions for health systems. In addition to drug costs, costs can also include physical costs (ie, clinical toxicities and harm), productivity losses (from inability to work because of treatment effects), and time away from family and friends. Low-value treatments include those that offer limited clinical benefit and score poorly on scales such as the European Society of Medical Oncology Magnitude of Clinical Benefit Scale and the overuse, misuse, or underuse of therapies that provide clinical benefit. Opportunity costs are what is given up when one intervention is chosen over another. Opportunity costs of low-value care translate into patient and societal harm and limit access to more effective treatments. Solutions to the value crisis require recognition of low-value care and quality improvement programs to prevent its use and support high-level care. Drug substitution and dose and schedule reduction when supported by evidence can also improve the value of care.

PURPOSE: The Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE)2 trial builds on the foundational STAMPEDE trial, which introduced innovative multiarm treatment protocols for metastatic prostate cancer. This survey assessed Nigeria's readiness for the STAMPEDE2 trial by evaluating current clinical practices, radiotherapy infrastructure, systemic therapy usage, and imaging capabilities across its six geopolitical zones. MATERIALS AND METHODS: We mapped the radiotherapy centers and machines currently available (commissioned) and in the Nigerian pipeline. A structured questionnaire comprising 31 questions in six sections was disseminated to clinical and radiation oncologists via Google Forms. The survey ran from July to September 2024, gathering data on radiotherapy availability, systemic therapies, advanced imaging, and readiness for clinical trial participation. Descriptive statistical analysis was conducted using Microsoft Excel. Responses were aggregated from 14 cancer centers across Nigeria, encompassing both public and private facilities. RESULTS: The survey identified 23 operational radiotherapy machines distributed across 12 centers, with 19 additional facilities in the pipeline. These centers were predominantly located in urban areas such as Lagos and Abuja. Prostate cancer treatment modalities are available; however, access to agents such as abiraterone and enzalutamide was reported in 73% of centers. There is one operational positron emission tomography/computed tomography facility in Nigeria. Clinicians expressed strong interest in participating in trials although some gaps in infrastructure, particularly in rural areas, and limited access to advanced treatments like 177Lu-PSMA-617 were noted. CONCLUSION: The findings underscore Nigeria's potential readiness for the STAMPEDE2 trial, other clinical trials, and collaborative research, bolstered by an expanding radiotherapy infrastructure and clinician enthusiasm for advanced therapeutic approaches. Initiatives like the Cancer Health Fund and the National Cancer Access Partnership represent significant steps toward equitable cancer care.

In November 2024, the Society of Gynecologic Oncology of Canada hosted a 2-day, interdisciplinary Pragmatic Clinical Trials (PCTs) Workshop with the goal of launching an initiative to develop and promote PCTs within the Canadian gynecologic oncology research environment. The programme brought together multiple stakeholders, including patients with ovarian cancer, patient advocates, experts in PCTs, gynecologic oncologists, medical oncologists and clinical fellows. Foundational elements of pragmatism were emphasized in the context of the primary goal of PCTs, showing the real-world effectiveness of interventions in broad patient groups. Examples of how PCT outcomes can inform and influence clinical decision making and health policy were presented in the context of those outcomes that matter most to patients with cancer. The patients and patient advocates had the essential role of helping clinical investigators co-design PCT protocols to answer common, important, and practical questions that focus on outcomes that matter to patients. These endpoints included overall survival, quality of life and promotion of informed patient decision making. Tangible workshop outcomes included the development of several new proposals for PCTs inspirited and directed by the patient voice. Further educational initiatives to engage clinical gynecologic oncology investigators at all stages in their career are being planned.