In some clinical areas, new drugs and biologics have emerged rapidly enough that insufficient time has passed for comparative evaluations to be made of available therapies. In advanced renal cell carcinoma, for example, seven new targeted agents came on the market between 2006 and 2012 [1,2]. Similarly, in metastatic breast cancer there are many treatment options, the decision tree is complex and the relative benefits of a particular choice are often unclear [3–5]. In these settings, the challenge for providers is not only to know the comparative effectiveness of individual agents, but to understand the optimal order to administer those agents (first line, second line, among others) taking into account comparative toxicities , which can be cumulative across lines of therapy.
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