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The CTLA-4 (cytotoxic T lymphocyte-associated antigen 4) inhibitor ipilimumab was the first ICI to be approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) in 2011 after showing an improvement in median overall survival (OS) of 4 months [1,2], and was primarily implemented in Denmark in 2012. After approval by regulatory authorities, the BRAFi vemurafenib was approved as monotherapy in 2011 and more widely used in Denmark during 2012, while combination therapy with the BRAFi dabrafenib and the MEKi trametinib was introduced in 2013. Treatment with anti-programmed death 1 (PD1)-inhibitor was approved and implemented in routine clinical practice in Denmark in 2016.
There were only minor differences in the distribution of prognostic factors between the two periods for all patients, primarily in favor of the pre-ICI era with better PS and lower LDH levels. Thus, we consider it unlikely that the improved mOS and long-term survival can be explained by these differences in baseline characteristics. It was unexpected that treatment with BRAFi/MEKi did not affect OS, as it has been shown to improve OS in phase 3 trials [3,4]. Use of BRAFi/MEKi in national practice could be biased by patient selection towards patients with symptomatic large tumor burden, rapidly progressive disease, poor prognostic factors, or patients unfit for ICI, as indicated in our data. Moreover, the results could be influenced by BRAFi given as monotherapy in the early ICI era, because MEKi was implemented in Denmark from 2013. It is important to notice that our findings do not mean that BRAFi/MEKi is not an effective treatment. Still, it should be noticed that the findings from clinical trials are not directly referable to real-life patients and selection is essential.
Nonetheless, even with an improvement in mOS to 11.3 months, metastatic melanoma still has a dismal prognosis. However, there were significant further improvements since 2015 as anti-PD1 and combination ICI became standard first-line treatment. Moreover, it is encouraging that a higher proportion of patients obtained long-term survival without progression not only at first-line treatment, but also later treatment lines, and the need for further treatment lines declined over time in the ICI era. These findings might reflect that ipilimumab initially was approved as a second-line treatment and anti-PD1 treatment became available in later lines during the implementation period. Most long-term survivors had limited disease, but also, patients with M1b and M1c disease, and there were even indications of patients with M1d disease, had a higher chance of becoming a long-term survivor in the ICI era. Still, a large proportion of real-life patients do not benefit sufficiently from the new treatment possibilities and we find it concerning that almost no patients in PS 2 become long-term survivors.
Our survival data are in coherence with data from a large hospital-based cancer-registry that covers approximately 70% of all newly diagnosed cancers in the United States, although the percentual coverage of metastatic melanoma is uncertain [15]. Their database contained comprehensive information of pre-systemic treatment with data on prior surgery, comorbidity, insurance status, LDH level, and type of first-line treatment, but not later lines. In their retrospective dataset of more than 15,000 patients with synchronous metastatic melanoma, mOS improved from 8.4 months at pre-approval (of ICI and BRAFi) to 10.2 months at post-approval for patients treated for cutaneous stage 4 melanoma. Their 4-year OS improved from 18% to 23.5%, which is similar to our 4-year OS in the ICI era, but with a lower relative increase than in our nation-wide cohort. Baseline characteristics were only reported for patients receiving ICI, while survival was reported for all patients pre- and post-approval; therefore, it is uncertain if general baseline characteristics are similar between cohorts. Mangana et al. compared survival between treatment types in a retrospective real-life cohort of 395 patients treated at three Swiss hospitals [16]. Median OS for their reference chemotherapy (treatment-naïve) group from 2008 to 2009 was 7.1 months, and comparable to our pre-ICI group, while treatment-naïve patients on targeted therapy or ICI from 2010 to 2014 had an mOS of 14.6 months, which is considerably higher than both the American cohort and our cohort. It should be noted that there was a high proportion of CNS metastases in all patient cohorts, ranging between 33% to 53%, which could be owing to meticulous screening for CNS metastases before the treatment started and not only for symptomatic CNS metastases. In both studies, a description of metastatic sites for all treated patients besides CNS metastases, PS, or subsequent treatment lines received was not reported. On the other hand, both studies had a more detailed histopathological description of the primary tumor compared with ours. These differences may make direct comparison difficult.
Let every nation know, whether it wishes us well or ill, that we shall pay any price, bear any burden, meet any hardship, support any friend, oppose any foe to assure the survival and the success of liberty.
The United States has received from the Greek Government an urgent appeal for financial and economic assistance. Preliminary reports from the American Economic Mission now in Greece and reports from the American Ambassador in Greece corroborate the statement of the Greek Government that assistance is imperative if Greece is to survive as a free nation.
One of the primary objectives of the foreign policy of the United States is the creation of conditions in which we and other nations will be able to work out a way of life free from coercion. This was a fundamental issue in the war with Germany and Japan. Our victory was won over countries which sought to impose their will, and their way of life, upon other nations.
To ensure the peaceful development of nations, free from coercion, the United States has taken a leading part in establishing the United Nations, The United Nations is designed to make possible lasting freedom and independence for all its members. We shall not realize our objectives, however, unless we are willing to help free peoples to maintain their free institutions and their national integrity against aggressive movements that seek to impose upon them totalitarian regimes. This is no more than a frank recognition that totalitarian regimes imposed on free peoples, by direct or indirect aggression, undermine the foundations of international peace and hence the security of the United States.
The world is not static, and the status quo is not sacred. But we cannot allow changes in the status quo in violation of the Charter of the United Nations by such methods as coercion, or by such subterfuges as political infiltration. In helping free and independent nations to maintain their freedom, the United States will be giving effect to the principles of the Charter of the United Nations.
It is necessary only to glance at a map to realize that the survival and integrity of the Greek nation are of grave importance in a much wider situation. If Greece should fall under the control of an armed minority, the effect upon its neighbor, Turkey, would be immediate and serious. Confusion and disorder might well spread throughout the entire Middle East.
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General population life tables are used to calculate expected survival, representing survival for a comparable group of individuals free of cancer used in calculations of relative survival and crude probability of death statistics. These life tables are available and distributed with the SEER*Stat software. They represent the expected probabilities of surviving the interval conditional on being alive at the beginning of the interval, and are generated from the U.S. mortality data.We have two sets of life tables: SES/Geography/Race Annual, available for years 1992+ and the U.S. Annual, available from 1970 with less detail by race.
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As protectionist barriers crumble in emerging markets around the world, multinational companies are rushing in to find new opportunities for growth. Their arrival is a boon to local consumers, who benefit from the wider choices now available. For local companies, however, the influx often appears to be a death sentence. Accustomed to dominant positions in protected markets, they suddenly face foreign rivals wielding a daunting array of advantages: substantial financial resources, advanced technology, superior products, powerful brands, and seasoned marketing and management skills. Often, the very survival of local companies in emerging markets is at stake.
For companies in many emerging markets, giving up control is the option of last resort. This is especially true for the family-owned businesses that play a leading role in most of these economies. But alliances with multinationals do not always involve a loss of independence. When carried out within well-defined parameters, they can actually help a company preserve its freedom in the face of competitive threats. 041b061a72
