The

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rationale to use irRECIST criteria to account for unconventional responses. Therefore, we assessed tumor response using standard RECIST criteria, and despite the tendency of these criteria to underestimate the efficacy of nivolumab, the clinical benefit of nivolumab was clearly shown. Furthermore, our study allowed for treatment beyond RECIST-defined progression in recognition that some nivolumab-treated patients who would be considered to have progression (i.e., pseudoprogression) according to conventional RECIST but not irRECIST could still benefit from continued nivolumab treatment. As noted in our article, 16 of 71 patients (23%) who were treated with nivolumab beyond initial progression had an unconventional pattern of benefit. We agree that the treatment effect of immunotherapies can be better measured by overall

of

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survival than by progression-free survival. However, consideration of tumor assessments such as irRECIST may be warranted, particularly because the increasing availability of immunotherapy treatment may confound the assessment of overall survival in future trials. Hossein Borghaei, D.O. Fox Chase Cancer Center Philadelphia, PA hossein​.­borghaei@​­fccc​.­edu

Julie Brahmer, M.D. Johns Hopkins University School of Medicine Baltimore, MD Since publication of their article, the authors report no further potential conflict of interest. 1. Hodi FS, O’Day SJ, McDermott DF, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010;​363:​711-23. DOI: 10.1056/NEJMc1514790

Politics and Universal Health Coverage To the Editor: In the map in the Perspective article by Gupta et al. (Sept. 24 issue),1 the six member states of the Cooperation Council for the Arab States of the Gulf (CCASG) — Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates — should have been shaded. All these countries provide universal health coverage to their citizens. The dynamics in these oil-rich countries are different from those in other countries that the authors describe. The governments and citizens of the CCASG member states expect universal coverage because of the strength of their economies. However, the cost of health care is burgeoning in these countries, fueled by the availability of new medications and therapeutic options. Meanwhile, CCASG countries are blamed for underinvesting in health care, even though their per-capita gross domestic products are similar to those of other high-income countries.2 In 2013, as compared with an average of $4,456 (in

U.S. dollars) in high-income countries, per-capita health expenditures were $1,507 in Kuwait, $1,569 in the United Arab Emirates, and $2,043 in Qatar.3 Although the health care spending levels in CCASG countries are higher than those in most developing countries, the incidence of chronic diseases such as diabetes and associated complications are increasing in these member states.2 P. Dileep Kumar, M.D. McLaren Port Huron Hospital Port Huron, MI No potential conflict of interest relevant to this letter was reported. 1. Gupta V, Kerry VB, Goosby E, Yates R. Politics and universal health coverage — the post-2015 global health agenda. N Engl J Med 2015;​373:​1189-92. 2. Klautzer L, Becker J, Mattke S. The curse of wealth — Middle Eastern countries need to address the rapidly rising burden of diabetes. Int J Health Policy Manag 2014;​2:​109-14. 3. The World Bank. Health expenditure per capita (current US$) (http://data​.worldbank​.org/​indicator/​SH​.XPD​.PCAP). DOI: 10.1056/NEJMc1513946

More on Merkel-Cell Carcinoma To the Editor: Shiver et al. (Oct. 15 issue)1 de- Activation of phosphoinositide 3-kinase (PI3K) scribe the efficacy of idelalisib in a patient with signaling has long been identified in Merkel-cell metastasis of Merkel-cell carcinoma to the liver. carcinoma,2 and this therapeutic intervention in494

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