{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T04:12:07Z","timestamp":1792469527096,"version":"4.5.0"},"reference-count":33,"publisher":"American Society of Clinical Oncology (ASCO)","issue":"11","content-domain":{"domain":["ascopubs.org"],"crossmark-restriction":true},"short-container-title":["JCO Glob Oncol"],"published-print":{"date-parts":[[2025,5]]},"abstract":"<jats:sec>\n            <jats:title>PURPOSE<\/jats:title>\n            <jats:p>In Armenia, a lower-middle-income country, cancer causes 21% of all deaths, with over half of cases diagnosed at advanced stages. Without universal health insurance, patients rely on out-of-pocket payments or black-market channels for costly immunotherapies, underscoring the need for real-world data to inform equitable policy reforms.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>METHODS<\/jats:title>\n            <jats:p>We conducted a multicenter, retrospective cohort study of patients who received at least one dose of an immune checkpoint inhibitor (ICI) between January 2017 and December 2023 across six Armenian oncology centers. Eligible patients had histologically confirmed malignancy and \u22656 months of follow-up. Demographic, clinical, biomarker, and treatment data were extracted from records. Overall survival (OS) was estimated by the Kaplan-Meier method; log-rank tests and Cox models evaluated associations. A 6-month landmark analysis adjusted for immortal time bias.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>RESULTS<\/jats:title>\n            <jats:p>\n              Of the 585 patients screened, 373 met inclusion criteria (67% male; median age, 61 years); 68% had stage IV disease. The median OS was 31 months. Liver metastases predicted poorer survival (19\n              <jats:italic toggle=\"yes\">v<\/jats:italic>\n              26 months,\n              <jats:italic toggle=\"yes\">P<\/jats:italic>\n              = .027). Nonsmokers had better OS than smokers (31\n              <jats:italic toggle=\"yes\">v<\/jats:italic>\n              24 months,\n              <jats:italic toggle=\"yes\">P<\/jats:italic>\n              = .019). High PD-L1 expression (\u226550%) was associated with improved OS (40\n              <jats:italic toggle=\"yes\">v<\/jats:italic>\n              16 months,\n              <jats:italic toggle=\"yes\">P<\/jats:italic>\n              = .025). Receiving &gt;6 ICI cycles conferred longer OS (45\n              <jats:italic toggle=\"yes\">v<\/jats:italic>\n              23 months,\n              <jats:italic toggle=\"yes\">P<\/jats:italic>\n              &lt; .001), although not significant in landmark analysis (\n              <jats:italic toggle=\"yes\">P<\/jats:italic>\n              = .64). Financial hardship and disease progression were key reasons for early discontinuation.\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>CONCLUSION<\/jats:title>\n            <jats:p>Immunotherapy shows promise in Armenia despite financial barriers. Drawing on models from India and China, pooled procurement, negotiated pricing, and partial reimbursement, Armenia could expand biomarker testing, reduce drug costs, and implement tiered insurance. These steps are vital to optimize access and outcomes in this resource-limited setting.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1200\/go-25-00040","type":"journal-article","created":{"date-parts":[[2025,9,9]],"date-time":"2025-09-09T19:59:06Z","timestamp":1757447946000},"update-policy":"https:\/\/doi.org\/10.1200\/crossmark","source":"Crossref","is-referenced-by-count":1,"title":["Nationwide Insights on Immunotherapy in a Low- and Middle-Income Country: Armenia's Struggle for Equitable Cancer Care in an Out-of-Pocket System"],"prefix":"10.1200","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2580-9212","authenticated-orcid":true,"given":"Amalya","family":"Sargsyan","sequence":"first","affiliation":[{"name":"Yeolyan Hematology and Oncology Center, Yerevan, Armenia"},{"name":"Immune Oncology Research Institute, Yerevan, Armenia"},{"name":"Yerevan State Medical University, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2740-9215","authenticated-orcid":true,"given":"Gevorg","family":"Tamamyan","sequence":"additional","affiliation":[{"name":"Immune Oncology Research Institute, Yerevan, Armenia"},{"name":"Yerevan State Medical University, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0437-4611","authenticated-orcid":true,"given":"Arman","family":"Oganisian","sequence":"additional","affiliation":[{"name":"Brown University, Providence, RI"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davit","family":"Zohrabyan","sequence":"additional","affiliation":[{"name":"Yeolyan Hematology and Oncology Center, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liana","family":"Safaryan","sequence":"additional","affiliation":[{"name":"Yeolyan Hematology and Oncology Center, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Armen","family":"Avagyan","sequence":"additional","affiliation":[{"name":"Yerevan State Medical University, Yerevan, Armenia"},{"name":"Mikaelyan Institute of Surgery, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0174-6977","authenticated-orcid":true,"given":"Lilit","family":"Harutyunayn","sequence":"additional","affiliation":[{"name":"Yerevan State Medical University, Yerevan, Armenia"},{"name":"Mikaelyan Institute of Surgery, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariam","family":"Sargsyan","sequence":"additional","affiliation":[{"name":"Yerevan State Medical University, Yerevan, Armenia"},{"name":"Mikaelyan Institute of Surgery, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Harutyunyan","sequence":"additional","affiliation":[{"name":"Yerevan State 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Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haykuhi","family":"Geokchyan","sequence":"additional","affiliation":[{"name":"Erebuni Medical Center, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7395-6199","authenticated-orcid":true,"given":"Vardan","family":"Bardakhchyan","sequence":"additional","affiliation":[{"name":"Alikhanyan National Science Laboratory, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0200-6954","authenticated-orcid":true,"given":"Elen","family":"Baloyan","sequence":"additional","affiliation":[{"name":"Immune Oncology Research Institute, Yerevan, Armenia"},{"name":"Yerevan State Medical University, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hasmik","family":"Petrosyan","sequence":"additional","affiliation":[{"name":"Astghik Medical Center, Yerevan, 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