Painting cancer journeys by numbers

Which test, which treatment? Amanda Pereira-Salgado is connecting real-world data to help oncologists make complex decisions.

Amanda Pereira-Salgado: clinical health services researcher and health economist.
Role: Research Fellow, Health Economics and Cancer at the Cancer Health Services Research Unit, Victorian Comprehensive Cancer Centre, Centre for Health Policy, Melbourne School of Population and Global Health and University of Melbourne Centre for Cancer Research.
Research area: pharmaceutical treatment sequencing in metastatic castration resistant prostate cancer using real-world data
Previously: nurse, clinical trials coordinator

When frontline cancer therapies fail, how do oncologists make decisions about the best treatment sequence that improves progression-free and overall survival rates? A former clinical nurse, Amanda Pereira-Salgado has seen what cancer patients endure and this shaped her decision to retrain as a researcher and health economist.

Now based at the new Cancer Health Services Research Unit at the Melbourne School of Population and Global Health, and the University of Melbourne Centre for Cancer Research, she researches treatment sequencing outcomes in metastatic prostate cancer.

“We want to give oncologists the information they need to optimise treatment sequencing decisions and survival outcomes, help them gain a better understanding of the economic impact, and look at ways to improve efficiency,” she says. “If we know a particular treatment pattern has resulted in better survival outcomes, our job is to model the costs of that pattern.”

This is a big deal for governments: worldwide, drugs account for about a third of health system spending on cancer. The emergence of personalised medicine is already disrupting health budgets, especially with the discovery of common genetic signatures for what were once thought to be disparate cancers.  For instance, drugs originally designed for one condition are often not subsidised to the public if used to treat a different condition, such as a rare cancer.

Deciding on this test, that drug, becomes more complicated the farther along a patient is on their treatment journey. Insights from traditional clinical trials, which focus on “one population, one drug, one disease” are not enough to guide clinicians. Amanda knows this firsthand, having coordinated oncology clinical trials while she was in nursing.

“I guess the epiphany happened when I was working with these patients. I was happy to do the day-to-day trial management, but I was motivated to do more to help patients.

If we know a particular treatment pattern has resulted in better survival outcomes, our job is to model the costs of that pattern.

The key to taming this complexity is “real world data” – the numbers that tell what actually happened outside the tightly calibrated setting of a clinical trial.

“What’s right for one patient is not necessarily right for another patient. Clinical trials have very stringent eligibility criteria, and because of that you have to question whether it is really reflective of the general population.”

Amanda will make connections between databases – clinical cancer registries, hospital patient records, Medicare claims data, the Pharmaceutical Benefits Scheme, and the national death index – to approximate a cancer journey in numbers.

“When you look at the data and demographics in relation to the outcomes and the decisions, and you look at what the clinicians have chosen as factors in their decision making, that gives you a picture of what’s happening.”

Real-world data also can also offer progress on a difficult area of clinical trials research, which is head-to-head comparison of drugs (rather than a single drug versus a placebo).

“So much of this is about not only what’s there but what’s not there. I do expect there will be missing data, especially in relation to third and fourth-line treatment outcomes.”

The theme for this year's International Women's Day is 'Balance for better'– what does this mean to you?

“Clinicians and health economists really see things differently. Clinicians know the research questions that need to be asked to improve clinical practice, and translate it back so there is an improvement for patients. They’re at the forefront of those questions, but can sometimes overlook the economics of a particular intervention or model of care.  Conversely, I’ve heard of health economists designing long questionnaires that patients don’t want to fill out. The key is working together.”

What has surprised you about your career?

“I’ve had strong mentors who have helped me make difficult career decisions: when to say yes to opportunities, but just as importantly, when to say no.”

What myth would you like to bust in your field?

“When I first came to health economics, I was given well-meaning advice to downplay the fact that I was a nurse. A clinical background is important and useful, and at the same time you need to highlight your health economics technical skills; bringing them together is really important. Your clinical background speaks about who you are, your character, and what your interests are.”