Stakeholder Insight: Gastric Cancer

Overview 1
Catalyst 1
Summary 1
About Datamonitor healthcare 3
About the oncology pharmaceutical analysis team 3
Executive Summary 4
Scope of the analysis 4
Datamonitor insight into the gastric cancer market 4
Contributing experts 5
Related reports 6
Upcoming reports 6
7
1. Introduction and scope 8
Coverage of the Stakeholder Insight Survey 8
Epidemiology 8
Treatment options 8
Treatment trends 8
Key prescribing influences and brand assessment 8
Improving treatment outcomes 8
Assumptions and caveats 9
2. Country treatment trees 10
Introduction to treatment trees 10
US 11
Japan 18
France 25
Germany 33
Italy 39
Spain 45
UK 51
3. Epidemiology 58
Introduction and background 58
Key points 58
Disease definition and diagnosis criteria 59
Global variation and historical trends 59
Contemporary trends 59
Incidence 59
Prevalence 63
Risk factors 64
Dietary 64
Meat 64
Fruit and vegetables 64
Salt 65
Coffee and tea 65
Helicobacter pylori infection 65
Tobacco smoking 66
Family history 66
Epidemiologic forecasting of gastric cancer 66
Sources of epidemiologic data 66
Cancer registries: age- and sex-specific incidence rates 66
Population denominators 67
Description of methods 67
Statistical analysis 68
Categorization and stratification 68
Results 69
Current incident cases and future trends of gastric cancer 69
Segmentation of incident cases 70
Segmentation by sex 70
Segmentation by age group 71
Segmentation by stage 72
Discussion 72
US 73
Japan 73
Europe 74
Strengths of Datamonitor’s epidemiologic projections 74
Conclusions 74
4. Patient Segmentation 75
Staging of gastric cancer patients 75
Segmentation of the gastric cancer population 75
Gastric adenocarcinoma 76
5. Treatment options and trends 77
Overview of gastric cancer treatment options 78
Surgery has a central role in the management of localized gastric cancer, but controversy remains regarding the extent of surgery 78
Neoadjuvant and adjuvant approaches are employed in localized disease, in an attempt to prevent recurrence 79
The treatment of advanced disease is based on best supportive care (BSC) and palliative chemotherapy 80
Treatment trends in resectable gastric cancer 81
Stage I gastric cancer 82
Treatment options 82
Neoadjuvant therapy alone 84
Adjuvant therapy alone 88
Both neoadjuvant and adjuvant therapy 91
Resectable Stage II gastric cancer 96
Treatment options 96
Neoadjuvant therapy alone 98
Adjuvant therapy alone 103
Neoadjuvant and adjuvant therapy together 109
Resectable Stage III gastric cancer 116
Treatment options 116
Neoadjuvant therapy alone 118
Adjuvant therapy alone 122
Both neoadjuvant and adjuvant therapy 125
Treatment trends in unresectable gastric cancer 131
Unresectable Stage II gastric cancer 131
Treatment options 131
First-line chemotherapy 132
First-line chemoradiotherapy 135
Unresectable Stage III gastric cancer 137
Treatment options 137
First-line chemotherapy 138
First-line chemoradiotherapy 141
Stage IV gastric cancer 142
Treatment options 142
First-line chemotherapy 144
Second-line chemotherapy 152
Further chemotherapy 156
6. Prescribing influences and brand assessment 158
Factors influencing prescribing decisions in gastric cancer 158
Overall survival is the most important prescribing influence for gastric cancer 158
Physician perception of selected branded drugs used in the treatment of gastric cancer 159
Physicians think highly of Taxotere in terms of its clinical efficacy and are familiar with its clinical profile 159
Xeloda scores highly in terms of convenience and physician familiarity 160
Herceptin is perceived as an effective and safe, but costly drug 160
7. Improving treatment outcomes 162
Treatment outcomes 162
Resectable gastric cancer 162
The rate of remission/cure decreases with increasing stage of disease 162
Significantly higher remission/cure rates and lower relapse rates are seen in Japan compared with Western markets 166
Neoadjuvant and/or adjuvant therapy improve survival in resectable disease 167
Unresectable gastric cancer 171
Survival is very poor for patients with unresectable gastric cancer 171
Survival time for metastatic disease appears to be lower in the US 174
Unmet needs 174
The treatment of localized disease needs to be refined 174
More effective therapies are needed for the treatment of advanced disease 175
Research efforts should be directed towards the development of predictive markers and molecular targeted therapy 175
New product development 176
Selected drugs in company-sponsored Phase III development for gastric cancer 176
Afinitor (everolimus; Novartis) 177
Avastin (bevacizumab; Roche/Chugai) 178
Erbitux (cetuximab; Bristol-Myers Squibb/ Eli Lilly/Merck KGaA) 179
Tykerb/Tyverb (lapatinib; GlaxoSmithKline) 180
Ramucirumab (Eli Lilly) 181
Physician perception of pipeline drugs 182
Physicians are optimistic about the future of Herceptin in gastric cancer, but less positive on the uptake of Tykerb 184
Despite the AVAGAST results, there is still optimism for Avastin in gastric cancer 185
Physicians see a higher potential for Erbitux than Afinitor 186
Physicians see limited potential for ramucirumab in gastric cancer 187
Bibliography 188
Journal papers and books 188
Websites 197
APPENDIX A 199
Physician research methodology 199
Physician sample breakdown 199
US 199
Japan 199
France 200
Germany 200
Italy 200
Spain 201
UK 201
Contributing experts 202
APPENDIX B 203
Datamonitor consulting 203
Disclaimer 203
List of Figures
Figure 1: Treatment of Stage I gastric cancer patients in the US (1 of 2), 2010 11
Figure 2: Treatment of Stage I gastric cancer patients in the US (2 of 2), 2010 12
Figure 3: Treatment of resectable Stage II gastric cancer patients in the US (1 of 2), 2010 12
Figure 4: Treatment of resectable Stage II gastric cancer patients in the US (2 of 2), 2010 13
Figure 5: Treatment of resectable Stage III gastric cancer patients in the US (1 of 2), 2010 14
Figure 6: Treatment of resectable Stage III gastric cancer patients in the US (2 of 2), 2010 15
Figure 7: Treatment of unresectable Stage II gastric cancer patients in the US, 2010 16
Figure 8: Treatment of unresectable Stage III gastric cancer patients in the US, 2010 17
Figure 9: Treatment of Stage IV gastric cancer patients in the US, 2010 17
Figure 10: Treatment of Stage I gastric cancer patients in Japan (1 of 2), 2010 18
Figure 11: Treatment of Stage I gastric cancer patients in Japan (2 of 2), 2010 18
Figure 12: Treatment of resectable Stage II gastric cancer patients in Japan (1 of 2), 2010 19
Figure 13: Treatment of resectable Stage II gastric cancer patients in Japan (2 of 2), 2010 20
Figure 14: Treatment of resectable Stage III gastric cancer patients in Japan (1 of 2), 2010 21
Figure 15: Treatment of resectable Stage III gastric cancer patients in Japan (2 of 2), 2010 22
Figure 16: Treatment of unresectable Stage II gastric cancer patients in Japan, 2010 23
Figure 17: Treatment of unresectable Stage III gastric cancer patients in Japan, 2010 24
Figure 18: Treatment of Stage IV gastric cancer patients in Japan, 2010 24
Figure 19: Treatment of Stage I gastric cancer patients in France (1 of 2), 2010 25
Figure 20: Treatment of Stage I gastric cancer patients in France (2 of 2), 2010 26
Figure 21: Treatment of resectable Stage II gastric cancer patients in France (1 of 2), 2010 27
Figure 22: Treatment of resectable Stage II gastric cancer patients in France (2 of 2), 2010 28
Figure 23: Treatment of resectable Stage III gastric cancer patients in France (1 of 2), 2010 29
Figure 24: Treatment of resectable Stage III gastric cancer patients in France (2 of 2), 2010 30
Figure 25: Treatment of unresectable Stage II gastric cancer patients in France, 2010 31
Figure 26: Treatment of unresectable Stage III gastric cancer patients in France, 2010 32
Figure 27: Treatment of Stage IV gastric cancer patients in France, 2010 32
Figure 28: Treatment of Stage I gastric cancer patients in Germany (1 of 2), 2010 33
Figure 29: Treatment of Stage I gastric cancer patients in Germany (2 of 2), 2010 34
Figure 30: Treatment of resectable Stage II gastric cancer patients in Germany (1 of 2), 2010 35
Figure 31: Treatment of resectable Stage II gastric cancer patients in Germany (2 of 2), 2010 35
Figure 32: Treatment of resectable Stage III gastric cancer patients in Germany (1 of 2), 2010 36
Figure 33: Treatment of resectable Stage III gastric cancer patients in Germany (2 of 2), 2010 37
Figure 34: Treatment of unresectable Stage II gastric cancer patients in Germany, 2010 37
Figure 35: Treatment of unresectable Stage III gastric cancer patients in Germany, 2010 38
Figure 36: Treatment of Stage IV gastric cancer patients in Germany, 2010 38
Figure 37: Treatment of Stage I gastric cancer patients in Italy (1 of 2), 2010 39
Figure 38: Treatment of Stage I gastric cancer patients in Italy (2 of 2), 2010 40
Figure 39: Treatment of resectable Stage II gastric cancer patients in Italy (1 of 2), 2010 41
Figure 40: Treatment of resectable Stage II gastric cancer patients in Italy (2 of 2), 2010 41
Figure 41: Treatment of resectable Stage III gastric cancer patients in Italy (1 of 2), 2010 42
Figure 42: Treatment of resectable Stage III gastric cancer patients in Italy (2 of 2), 2010 43
Figure 43: Treatment of unresectable Stage II gastric cancer patients in Italy, 2010 43
Figure 44: Treatment of unresectable Stage III gastric cancer patients in Italy, 2010 44
Figure 45: Treatment of Stage IV gastric cancer patients in Italy, 2010 44
Figure 46: Treatment of Stage I gastric cancer patients in Spain (1 of 2), 2010 45
Figure 47: Treatment of Stage I gastric cancer patients in Spain (2 of 2), 2010 46
Figure 48: Treatment of resectable Stage II gastric cancer patients in Spain (1 of 2), 2010 47
Figure 49: Treatment of resectable Stage II gastric cancer patients in Spain (2 of 2), 2010 47
Figure 50: Treatment of resectable Stage III gastric cancer patients in Spain (1 of 2), 2010 48
Figure 51: Treatment of resectable Stage III gastric cancer patients in Spain (2 of 2), 2010 49
Figure 52: Treatment of unresectable Stage II gastric cancer patients in Spain, 2010 49
Figure 53: Treatment of unresectable Stage III gastric cancer patients in Spain, 2010 50
Figure 54: Treatment of Stage IV gastric cancer patients in Spain, 2010 51
Figure 55: Treatment of Stage I gastric cancer patients in the UK (1 of 2), 2010 51
Figure 56: Treatment of Stage I gastric cancer patients in the UK (2 of 2), 2010 52
Figure 57: Treatment of resectable Stage II gastric cancer patients in the UK (1 of 2), 2010 53
Figure 58: Treatment of resectable Stage II gastric cancer patients in the UK (2 of 2), 2010 53
Figure 59: Treatment of resectable Stage III gastric cancer patients in the UK (1 of 2), 2010 54
Figure 60: Treatment of resectable Stage III gastric cancer patients in the UK (2 of 2), 2010 55
Figure 61: Treatment of unresectable Stage II gastric cancer patients in the UK, 2010 55
Figure 62: Treatment of unresectable Stage III gastric cancer patients in the UK, 2010 56
Figure 63: Treatment of Stage IV gastric cancer patients in the UK, 2010 57
Figure 64: Age-adjusted gastric cancer incidence rates per 100,000 in the seven major pharmaceutical markets, 2008 61
Figure 65: Historical age-adjusted incidence rates in men in the seven major pharmaceutical markets, 1983-2002 62
Figure 66: Historical age-adjusted incidence rates in women in the seven major pharmaceutical markets, 1983-2002 63
Figure 67: Percentage of Stage I gastric cancer patients receiving each type of therapy (neoadjuvant, adjuvant, both neoadjuvant and adjuvant) and surgery alone in the US, five major European markets (5EU) and Japan, 2010 82
Figure 68: Percentage of Stage I gastric cancer patients receiving each type of neoadjuvant therapy in the US, five major European markets (5EU) and Japan, 2010 84
Figure 69: Percentage of Stage I gastric cancer patients receiving each type of adjuvant therapy in the US, five major European markets (5EU) and Japan, 2010 88
Figure 70: Percentage of Stage I gastric cancer patients receiving each type of perioperative therapy in the US, five major European markets (5EU) and Japan, 2010 91
Figure 71: Percentage of Stage II gastric cancer patients treated initially with surgery in the seven major pharmaceutical markets, 2010 96
Figure 72: Percentage of resectable Stage II gastric cancer patients receiving each type of therapy (neoadjuvant, adjuvant, both neoadjuvant and adjuvant) and surgery alone in the US, five major European markets (5EU) and Japan, 2010 97
Figure 73: Percentage of resectable Stage II gastric cancer patients receiving each type of neoadjuvant therapy in the US, five major European markets (5EU) and Japan, 2010 98
Figure 74: Percentage of resectable Stage II gastric cancer patients receiving each type of adjuvant therapy in the US, five major European markets (5EU) and Japan, 2010 103
Figure 75: Percentage of resectable Stage II gastric cancer patients receiving each type of perioperative therapy in the US, five major European markets (5EU) and Japan, 2010 109
Figure 76: Percentage of Stage III gastric cancer patients treated initially with surgery in the seven major pharmaceutical markets, 2010 117
Figure 77: Percentage of resectable Stage III gastric cancer patients receiving each type of therapy (neoadjuvant, adjuvant, both neoadjuvant and adjuvant) and surgery alone in the US, five major European markets (5EU) and Japan, 2010 117
Figure 78: Percentage of resectable Stage III gastric cancer patients receiving each type of neoadjuvant therapy in the US, five major European markets (5EU) and Japan, 2010 118
Figure 79: Percentage of resectable Stage III gastric cancer patients receiving each type of adjuvant therapy in the US, five major European markets (5EU) and Japan, 2010 122
Figure 80: Percentage of resectable Stage III gastric cancer patients receiving each type of perioperative therapy in the US, five major European markets (5EU) and Japan, 2010 125
Figure 81: Percentage of unresectable Stage II gastric cancer patients receiving chemotherapy, radiotherapy, chemoradiotherapy, and best supportive care as first-line treatment in the US, five major European markets (5EU) and Japan, 2010 131
Figure 82: Percentage of unresectable Stage III gastric cancer patients receiving chemotherapy, radiotherapy, chemoradiotherapy, and best supportive care as first-line treatment in the US, five major European markets (5EU) and Japan, 2010 137
Figure 83: Percentage of unresectable Stage III gastric cancer patients receiving 5-fluorouracil and Xeloda-based regimens as first-line therapies in the US, five major European markets (5EU) and Japan, 2010 140
Figure 84: Percentage of Stage IV gastric cancer patients receiving chemotherapy, radiotherapy and best supportive care as first-line treatment in the US, five major European markets (5EU) and Japan, 2010 143
Figure 85: Percentage of Stage IV gastric cancer patients receiving 5-fluorouracil- and Xeloda-based regimens as first-line therapies in the US, five major European markets (5EU) and Japan, 2010 147
Figure 86: HER2 status by stage of disease for gastric cancer patients who are tested for HER2 status in the seven major pharmaceutical markets, 2010 151
Figure 87: Percentage of Stage IV gastric cancer patients receiving second-line chemotherapy (CT) in the seven major pharmaceutical markets, 2010 152
Figure 88: Percentage of Stage IV gastric cancer patients treated with second-line chemotherapy (CT) who receive further lines of CT in the seven major pharmaceutical markets, 2010 156
Figure 89: Mean points allocated to each drug attribute (out of 100 points), indicating their degree of influence on treatment decisions for gastric cancer, 2010 158
Figure 90: Average percentage of Stage I gastric cancer patients who achieve remission/cure and average percentage of patients who, following remission/cure, suffer a relapse in the US, five major European markets (5EU) and Japan, 2010 162
Figure 91: Average percentage of resectable Stage II gastric cancer patients who achieve remission/cure and average percentage of patients who, following remission/cure, suffer a relapse in the US, five major European markets (5EU) and Japan, 2010 163
Figure 92: Average percentage of resectable Stage III gastric cancer patients who achieve remission/cure and average percentage of patients who, following remission/cure, suffer a relapse in the US, five major European markets (5EU) and Japan, 2010 164
Figure 93: Average duration between curative treatment and relapse for Stage I, resectable Stage II and resectable Stage III gastric cancer in the seven major pharmaceutical markets, 2010 164
Figure 94: Japan’s percentage increase in the rate of remission/cure and percentage decrease in the rate of relapse compared with the corresponding US rates for Stage I, resectable Stage II and resectable Stage III gastric cancer, 2010 166
Figure 95: Average survival time in months for Stage I gastric cancer patients who receive neoadjuvant and/or adjuvant therapy versus no therapy in addition to surgery in the US, five major European markets (5EU) and Japan, 2010 167
Figure 96: Average survival time in months for resectable Stage II gastric cancer patients who receive neoadjuvant and/or adjuvant therapy versus no therapy in addition to surgery in the US, five major European markets (5EU) and Japan, 2010 168
Figure 97: Average survival time in months for resectable Stage III gastric cancer patients who receive neoadjuvant and/or adjuvant therapy versus no therapy in addition to surgery in the US, five major European markets (5EU) and Japan, 2010 168
Figure 98: Japan’s percentage increase in survival time compared with the US for Stage I, resectable Stage II, and resectable Stage III gastric cancer patients who receive neoadjuvant and/or adjuvant therapy, 2010 170
Figure 99: Average survival time in months for unresectable Stage II gastric cancer patients who receive first-line therapy plus best supportive care (BSC) versus BSC alone in the US, five major European markets (5EU) and Japan , 2010 171
Figure 100: Average survival time in months for unresectable Stage III gastric cancer patients who receive first-line therapy plus best supportive care (BSC) versus BSC alone in the US, five major European markets (5EU) and Japan, 2010 171
Figure 101: Average survival time in months for unresectable Stage IV gastric cancer patients who receive first-line therapy plus best supportive care (BSC) versus BSC alone in the US, five major European markets (5EU) and Japan, 2010 172
Figure 102: Mean ranking of each attribute for a pipeline drug for gastric cancer (scale 1-7), indicating their relative importance, 2010 182