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Qiu T, Aballéa S, Pochopień M, Toumi M, Dussart C, Yan D. A systematic review on the appropriate discounting rates for the economic evaluation of gene therapies: whether a specific approach is justified to tackle the challenges? Int J Technol Assess Health Care 2024; 40:e23. [PMID: 38725378 DOI: 10.1017/s0266462324000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
OBJECTIVES Discounting the cost and effect for health intervention is a controversial topic over the last two decades. In particular, the cost-effectiveness of gene therapies is especially sensitive to the discount rate because of the substantial delay between the upfront cost incurred and long-lasing clinical benefits received. This study aims to investigate the influence of employing alternative discount rates on the incremental cost-effectiveness ratio (ICER) of gene therapies. METHODS A systematic review was conducted to include health economic evaluations of gene therapies that were published until April 2023. RESULTS Sensitivity or scenario analysis indicated that discount rate represented one of the most influential factors for the ICERs of gene therapies. Discount rate for cost and benefit was positively correlated with the cost-effectiveness of gene therapies, that is, a lower discount rate significantly improves the ICERs. The alternative discount rate employed in some cases could be powerful to alter the conclusion on whether gene therapies are cost-effective and acceptable for reimbursement. CONCLUSIONS Although discount rate will have substantial influence on the ICERs of gene therapies, there lacks solid evidence to justify a different discounting rule for gene therapies. However, it is proposed that the discount rate in the reference case should be updated to reflect the real-time preference, which in turn will affect the ICERs and reimbursement of gene therapies more profoundly than conventional therapies.
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Affiliation(s)
- Tingting Qiu
- Beijing Institute of Clinical Pharmacy, Beijing Friendship Hospital of Capital Medical University, Beijing, China
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Samuel Aballéa
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Michal Pochopień
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Claude Dussart
- Faculté de Pharmacie, Université Claude Bernard Lyon 1, Lyon, France
| | - Dan Yan
- Beijing Institute of Clinical Pharmacy, Beijing Friendship Hospital of Capital Medical University, Beijing, China
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Tsutsué S, Makita S, Asou H, Matsuda H, Yamaura R, Taylor TD. Cost-effectiveness analysis 3L of axicabtagene ciloleucel vs tisagenlecleucel and lisocabtagene maraleucel in Japan. Future Oncol 2024:1-17. [PMID: 38597742 DOI: 10.2217/fon-2023-1114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/05/2024] [Indexed: 04/11/2024] Open
Abstract
Aim: Cost-effectiveness analysis (CEA) was performed to compare axicabtagene ciloleucel (axi-cel) with tisagenlecleucel (tisa-cel) and lisocabtagene (liso-cel) for treatment of relapsed or refractory large B-cell lymphoma in adult patients after ≥2 lines of therapy in Japan. Materials & methods: Cost-effectiveness analysis was conducted using the partition survival mixture cure model based on the ZUMA-1 trial and adjusted to the JULIET and TRANSCEND trials using matching-adjusted indirect comparisons. Results & conclusion: Axi-cel was associated with greater incremental life years (3.13 and 2.85) and incremental quality-adjusted life-years (2.65 and 2.24), thus generated lower incremental direct medical costs (-$976.29 [-¥137,657] and -$242.00 [-¥34,122]), compared with tisa-cel and liso-cel. Axi-cel was cost-effective option compared with tisa-cel and liso-cel from a Japanese payer's perspective.
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Affiliation(s)
- Saaya Tsutsué
- Gilead Sciences Japan,1-9-2 Marunouchi, Chiyoda-ku, Tokyo, 100-6616, Japan
| | - Shinichi Makita
- National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroya Asou
- Gilead Sciences Japan,1-9-2 Marunouchi, Chiyoda-ku, Tokyo, 100-6616, Japan
| | - Hiroyuki Matsuda
- IQVIA Solutions, Japan, 4-10-18 Takanawa Minato-ku, Tokyo, 108-0074, Japan
| | - Reiko Yamaura
- IQVIA Solutions, Japan, 4-10-18 Takanawa Minato-ku, Tokyo, 108-0074, Japan
| | - Todd D Taylor
- IQVIA Solutions, Japan, 4-10-18 Takanawa Minato-ku, Tokyo, 108-0074, Japan
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Masucci L, Tian F, Tully S, Feng Z, McFarlane T, Chan KKW, Wong WWL. CAR T-cell Therapy for Diffuse Large B-cell Lymphoma in Canada: A Cost-Utility Analysis. Med Decis Making 2024; 44:296-306. [PMID: 38486447 PMCID: PMC10988988 DOI: 10.1177/0272989x241234070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 01/28/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cell therapy is a novel cell therapy for treating non-Hodgkin lymphoma. The development of CAR T-cell therapy has transformed oncology treatment by offering a potential cure. However, due to the high cost of these therapies, and the large number of eligible patients, decision makers are faced with difficult funding decisions. Our objective was to assess the cost-effectiveness of tisagenlecleucel for adults with relapsed/refractory diffuse large B-cell lymphoma in Canada using updated survival data from the recent JULIET trial. METHODS We developed an individual-simulated discrete event simulation model to assess the costs and quality-adjusted life-years (QALY) of tisagenlecleucel compared with salvage chemotherapy. Survival estimates were obtained from a published clinical trial and retrospective analysis. If patients remained progression free for 5 y, they were assumed to be in long-term remission. Costing and utility data were obtained from reports and published sources. A Canadian health care payer perspective was used, and outcomes were modeled over a lifetime horizon. Costs and outcomes were discounted at 1.5% annually, with costs reported in 2021 Canadian dollars. A probabilistic analysis was used, and model parameters were varied in 1-way sensitivity analyses and scenario analyses. RESULTS After we incorporated the latest clinical evidence, tisagenlecleucel led to an additional cost of $503,417 and additional effectiveness of 2.48 QALYs, with an incremental cost-effectiveness ratio of $202,991 compared with salvage chemotherapy. At a willingness-to-pay threshold of $100,000/QALY, tisagenlecleucel had a 0% likelihood of being cost-effective. CONCLUSIONS At the current drug price, tisagenlecleucel was not found to be a cost-effective option. These results heavily depend on assumptions regarding long-term survival and the price of CAR T. Real-world evidence is needed to reduce uncertainty. HIGHLIGHTS For patients with diffuse large B-cell lymphoma who failed 2 or more lines of systemic therapy, CAR T was not found to be a cost-effective treatment option at a willingness-to-pay threshold of $100,000.These results heavily depend on the expected long-term survival. The uncertainty in the model may be improved using real-world evidence reported in the future.
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Affiliation(s)
- Lisa Masucci
- Toronto Health Economics and Technology Assessment Collaborative, Toronto General Hospital, ON, Canada
| | - Feng Tian
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Stephen Tully
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Zeny Feng
- Department of Mathematics and Statistics, University of Guelph, Guelph, ON, Canada
| | - Tom McFarlane
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Kelvin K. W. Chan
- Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
| | - William W. L. Wong
- Toronto Health Economics and Technology Assessment Collaborative, Toronto General Hospital, ON, Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
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Liu FF, Bartlett M, Craigie S. A Systematic Literature Review of Health-Related Quality of Life Outcomes and Associated Utility Values in Relapsed and/or Refractory Large B Cell Lymphoma. PHARMACOECONOMICS - OPEN 2024; 8:171-190. [PMID: 38198111 PMCID: PMC10883903 DOI: 10.1007/s41669-023-00464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND In this ever-expanding treatment landscape, there is a lack of consolidated health-related quality of life (HRQOL) outcomes and utility reports in relapsed or refractory (R/R) large B cell lymphoma (LBCL) to inform health care policy and decision-maker assessments for both old and new products. These assessments can have a direct effect on what treatment options are available to patients and physicians. OBJECTIVE A systematic literature review (SLR) was performed to understand the HRQOL evidence for treatments in R/R LBCL and identify associated health utility values. METHODS The SLR searched and screened literature published from 1 January 2003 to 2 May 2022. Studies were screened based on Population, Intervention, Comparator, Outcome, Study design criteria established a priori and were assessed by two independent reviewers; quality assessments of the evidence were performed in accordance with health technology assessment recommendations from the National Institute for Health and Care Excellence. Several types of therapies were included, such as chimeric antigen receptor (CAR) T cell products (lisocabtagene maraleucel, axicabtagene ciloleucel, tisagenlecleucel), novel therapies (selinexor, nivolumab, polatuzumab vedotin, and bendamustine), salvage therapies, and rituximab. RESULTS The review identified 33 unique studies reporting HRQOL, including 15 economic studies that reported health state utility values, 9 clinical trials, 7 health technology assessment reports, and 1 each of a vignette-based study and a point-in-time survey. Improvements in general and/or lymphoma-specific HRQOL measures were observed with CAR T cell therapy in both the second-line and third-line or later settings. On-treatment utility values for CAR T cell therapies ranged from 0.50 to 0.74. Values for remission/progression-free survival (0.70-0.90) and for disease progression (0.39-0.59) were similar across studies. For novel therapies, utility values were 0.83 for progression-free survival and ranged from 0.39 to 0.71 for disease progression. On-treatment utility values for salvage chemotherapy ranged from 0.63 to 0.67. CONCLUSIONS Overall, the evidence synthesized in this SLR provides a comprehensive understanding of the HRQOL evidence in R/R LBCL. This article identified several sources for utility values in the published literature showing variation in the HRQOL outcomes for patients across a variety of therapeutics. Treatment of R/R LBCL with CAR T cell therapies was associated with improvement in health utility values. Mixed results were found for novel therapies and salvage therapies. More data are needed as new therapies are used in this patient population to inform treatment decision-making.
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Affiliation(s)
- Fei Fei Liu
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, Princeton, NJ, 08648, USA.
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Ong MZ, Kimberly SA, Lee WH, Ling M, Lee M, Tan KW, Foo JB, Yow HY, Sellappans R, Hamzah S. FDA-approved CAR T-cell Therapy: A Decade of Progress and Challenges. Curr Pharm Biotechnol 2024; 25:1377-1393. [PMID: 39034731 DOI: 10.2174/0113892010257212231001082741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/12/2023] [Accepted: 08/07/2023] [Indexed: 07/23/2024]
Abstract
CAR T-cell therapy is a promising approach for cancer treatment, utilizing a patient's own T-cells (autologous cell) or T-cells from a healthy donor (allogeneic cell) to target and destroy cancer cells. Over the last decade, significant advancements have been made in this field, including the development of novel CAR constructs, improved understanding of biology and mechanisms of action, and expanded clinical applications for treating a wider range of cancers. In this review, we provide an overview of the steps involved in the production of CAR T-cells and their mechanism of action. We also introduce different CAR T-cell therapies available, including their implementation, dosage, administration, treatment cost, efficacy, and resistance. Common side effects of CAR T-cell therapy are also discussed. The CAR T-cell products highlighted in this review are FDA-approved products, which include Kymriah® (tisagenlecleucel), Tecartus® (brexucabtagene autoleucel), Abecma® (Idecabtagene vicleucel), Breyanzi® (lisocabtagene maraleucel), and Yescarta® (axicabtagene ciloleucel). In conclusion, CAR T-cell therapy has made tremendous progress over the past decade and has the potential to revolutionize cancer treatment. This review paper provides insights into the progress, challenges, and future directions of CAR T-cell therapy, offering valuable information for researchers, clinicians, and patients.
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Affiliation(s)
- Melissa Z Ong
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Sharon A Kimberly
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Wen-Hwei Lee
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Marcus Ling
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Michael Lee
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Ke-Wei Tan
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Jhi-Biau Foo
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
- Medical Advancement for Better Quality of Life Impact Lab, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Hui-Yin Yow
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Renukha Sellappans
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
| | - Sharina Hamzah
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
- Medical Advancement for Better Quality of Life Impact Lab, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia
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Oluwole OO, Ray MD, Davies N, Bradford R, Jones C, Patel AR, Locke FL. Cost-effectiveness of axicabtagene ciloleucel versus tisagenlecleucel for the treatment of 3L + relapsed/refractory large B-cell lymphoma in the United States: incorporating longer survival results. J Med Econ 2024; 27:230-239. [PMID: 38240256 DOI: 10.1080/13696998.2024.2305558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024]
Abstract
AIMS To provide an update on the cost-effectiveness of the chimeric antigen receptor (CAR) T-cell therapies axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) for the treatment of relapsed/refractory (r/r) large B-cell lymphoma (LBCL) among patients who have previously received ≥2 lines of systemic therapy using more mature clinical trial data cuts (60 months for axi-cel overall survival [OS] and 45 months for tisa-cel OS and progression-free survival [PFS]). METHODS A partitioned survival model consisting of three health states (pre-progression, post-progression and death) was used to estimate quality-adjusted life years (QALYs) and costs associated with axi-cel and tisa-cel over a lifetime horizon. PFS and OS inputs for axi-cel and tisa-cel were based on a previously published matching-adjusted indirect treatment comparison (MAIC). Long-term OS and PFS were extrapolated using parametric survival mixture cure models (PS-MCMs). Costs of CAR-T cell therapy drug acquisition and administration, conditioning chemotherapy, apheresis, CAR T-specific monitoring, stem cell transplant, hospitalization, adverse events, routine care, and terminal care were sourced from US cost databases. Health state utilities were derived from previous publications. Model inputs were varied using a range of sensitivity and scenario analyses. RESULTS Compared with tisa-cel, axi-cel resulted in 2.51 additional QALYs and $50,185 additional costs (an incremental cost-effectiveness ratio [ICER] of $19,994 per QALY gained). In probabilistic sensitivity analysis (PSA), the ICER for axi-cel versus tisa-cel was ≤$50,000/QALY in 99.4% of simulations and ≤$33,500 in 99% of simulations. Axi-cel remained cost-effective versus tisa-cel (assuming a willingness-to-pay threshold of $150,000 per QALY) across a range of scenarios. CONCLUSIONS With longer-term survival data, axi-cel continues to represent a cost-effective option versus tisa-cel for treatment of r/r LBCL among patients who have previously received ≥2 lines of systemic therapy, from a US payer perspective.
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Yamamoto C, Minakata D, Yokoyama D, Furuki S, Noguchi A, Koyama S, Oyama T, Murahashi R, Nakashima H, Ikeda T, Kawaguchi SI, Hyodo K, Toda Y, Ito S, Nagayama T, Umino K, Morita K, Ashizawa M, Ueda M, Hatano K, Sato K, Ohmine K, Fujiwara SI, Kanda Y. Cost-Effectiveness of Anti-BCMA Chimeric Antigen Receptor T Cell Therapy in Relapsed/Refractory Multiple Myeloma. Transplant Cell Ther 2024; 30:118.e1-118.e15. [PMID: 37802181 DOI: 10.1016/j.jtct.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/06/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023]
Abstract
Despite its promising outcomes, anti-BCMA chimeric antigen receptor T cell therapy (CAR-T) is the most expensive myeloma treatment developed to date, and its cost-effectiveness is an important issue. This study aimed to assess the cost-effectiveness of anti-BCMA CAR-T compared to standard antimyeloma therapy in patients with relapsed/refractory multiple myeloma. The model included myeloma patients in Japan and the United States who have received ≥3 prior lines of antimyeloma therapy, including immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies. A Markov model was constructed to compare the CAR-T strategy, in which patients receive either idecabtagene vicleucel (ide-cel) or ciltacabtagene autoleucel (cilta-cel) followed by 3 lines of multiagent chemotherapy after relapse, and the no CAR-T strategy, in which patients receive only chemotherapy. Data from the LocoMMotion, KarMMa, and CARTITUDE-1 trials were extracted. Several assumptions were made regarding long-term progression-free survival (PFS) with CAR-T. Extensive scenario analyses were made regarding regimens for no CAR-T strategies. The outcome was an incremental cost-effectiveness ratio (ICER) with willingness-to-pay thresholds of ¥7,500,000 in Japan and $150,000 in the United States. When a 5-year PFS of 40% with cilta-cel was assumed, the ICER of the CAR-T strategy versus the no CAR-T strategy was ¥7,603,823 per QALY in Japan and $112,191 per QALY in the United States over a 10-year time horizon. When a 5-year PFS of 15% with ide-cel was assumed, the ICER was ¥20,388,711 per QALY in Japan and $261,678 per QALY in the United States over a 10-year time horizon. The results were highly dependent on the PFS assumption with CAR-T and were robust to changes in most other parameters and scenarios. Although anti-BCMA CAR-T can be cost-effective even under current pricing, a high long-term PFS is necessary.
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Affiliation(s)
- Chihiro Yamamoto
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Daisuke Minakata
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Daizo Yokoyama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shuka Furuki
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Atsuto Noguchi
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shunsuke Koyama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takashi Oyama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Rui Murahashi
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Hirotomo Nakashima
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takashi Ikeda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shin-Ichiro Kawaguchi
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kazuki Hyodo
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yumiko Toda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shoko Ito
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takashi Nagayama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kento Umino
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kaoru Morita
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Masuzu Ueda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kaoru Hatano
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kazuya Sato
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ken Ohmine
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan; Division of Cell Transplantation and Transfusion, Jichi Medical University, Tochigi, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan.
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Wu W, Zhou Y, Wang Y, Keramat SA, Balasooriya NN, Zhao Z, Yang Y, Comans T, Dong H. Value for Money of CAR-T Cell Therapy for Patients with Diffuse Large B-cell Lymphoma in China: Evidence from a Cost-Effectiveness Analysis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:773-783. [PMID: 37356080 DOI: 10.1007/s40258-023-00817-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE This research assesses the cost effectiveness of Axicabtagene ciloleucel (Axi-cel), Tisagenlecleucel (Tis-cel), Relmacabtagene autoleucel (Rel-cel) and Lisocabtagene maraleucel (Lis-cel) against standard of care (SOC) for patients with diffuse large B-cell lymphoma (DLBCL) in the first-line setting (1L), second-line setting (2L) and third-line or later setting (3L+). METHODS Markov modelling based on a flexible survival model was adopted to evaluate four chimeric antigen receptor T-cell (CAR-T) therapies compared with SOC for patients with diffuse large B-cell lymphoma (DLBCL). The clinical inputs and utility values of the model were derived from the most recent clinical trials and the health care costs from a Chinese provincial clinical center. Costs and quality-adjusted life years (QALYs) were used to derive incremental cost-effectiveness ratios (ICERs) from the Chinese health care system perspective. RESULTS The ICER of Axi-cel (1L) versus SOC was approximately Chinese Yuan (CNY) 2,125,311 per QALY. The ICER for Axi-cel (2L), Tis-cel (2L) and Liso-cel (2L)) versus SOC in transplant-eligible patients were approximately CNY363,977, CNY32,066,781 and CNY347,746 per quality-adjusted life year (QALY), respectively. The ICER for Liso-cel (2L) versus SOC in transplant-ineligible patients was approximately CNY1,233,972 per QALY. The ICERs for Axi-cel (3L+), Tis-cel (3L+), Rel-cel (3L+) and Liso-cel (3L+) versus SOC were approximately CNY346,009, CNY654,344, CNY280,964 and CNY436,858 per QALY, respectively. In the scenario analysis using mixture cure models, the long-term survival benefit for CAR-T and SOC groups was found higher, and only Rel-cel (3L+) was found to be cost effective. CONCLUSION Our results demonstrated that CAR-T treatments are not cost effective in any-line settings for DLBCL patients at the WHO-recommended willingness-to-pay threshold (CNY257,241 per QALY) in the base-case analysis. Price reduction of CAR-T therapies is the main approach for lowering ICERs and ensuring that the drug costs are proportional to patient health benefits.
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Affiliation(s)
- Weijia Wu
- Department of Science and Education of the Fourth Affiliated Hospital, Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
- Faculty of Medicine, Centre for Health Services Research, Queensland of University, Brisbane, Australia
| | - Yuping Zhou
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Yannan Wang
- Center for Clinical Pharmacy, Cancer Center, Clinical Research Institute, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Zhejiang, China
| | - Syed Afroz Keramat
- Faculty of Medicine, Centre for Health Services Research, Queensland of University, Brisbane, Australia
| | - Namal N Balasooriya
- Faculty of Medicine, Centre for Health Services Research, Queensland of University, Brisbane, Australia
| | - Zixuan Zhao
- Department of Science and Education of the Fourth Affiliated Hospital, Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Yang
- Department of Science and Education of the Fourth Affiliated Hospital, Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Tracy Comans
- Faculty of Medicine, Centre for Health Services Research, Queensland of University, Brisbane, Australia
| | - Hengjin Dong
- Department of Science and Education of the Fourth Affiliated Hospital, Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China.
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Gavan SP, Wright SJ, Thistlethwaite F, Payne K. Capturing the Impact of Constraints on the Cost-Effectiveness of Cell and Gene Therapies: A Systematic Review. PHARMACOECONOMICS 2023; 41:675-692. [PMID: 36905571 DOI: 10.1007/s40273-022-01234-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Decision-makers need to resolve constraints on delivering cell and gene therapies to patients as these treatments move into routine care. This study aimed to investigate if, and how, constraints that affect the expected cost and health consequences of cell and gene therapies have been included in published examples of cost-effectiveness analyses (CEAs). METHOD A systematic review identified CEAs of cell and gene therapies. Studies were identified from previous systematic reviews and by searching Medline and Embase until 21 January 2022. Constraints described qualitatively were categorised by theme and summarised by a narrative synthesis. Constraints evaluated in quantitative scenario analyses were appraised by whether they changed the decision to recommend treatment. RESULTS Thirty-two CEAs of cell (n = 20) and gene therapies (n = 12) were included. Twenty-one studies described constraints qualitatively (70% cell therapy CEAs; 58% gene therapy CEAs). Qualitative constraints were categorised by four themes: single payment models; long-term affordability; delivery by providers; manufacturing capability. Thirteen studies assessed constraints quantitatively (60% cell therapy CEAs; 8% gene therapy CEAs). Two types of constraint were assessed quantitatively across four jurisdictions (USA, Canada, Singapore, The Netherlands): alternatives to single payment models (n = 9 scenario analyses); improving manufacturing (n = 12 scenario analyses). The impact on decision-making was determined by whether the estimated incremental cost-effectiveness ratios crossed a relevant cost-effectiveness threshold for each jurisdiction (outcome-based payment models: n = 25 threshold comparisons made, 28% decisions changed; improving manufacturing: n = 24 threshold comparisons made, 4% decisions changed). CONCLUSION The net health impact of constraints is vital evidence to help decision-makers scale up the delivery of cell and gene therapies as patient volume increases and more advanced therapy medicinal products are launched. CEAs will be essential to quantify how constraints affect the cost-effectiveness of care, prioritise constraints to be resolved, and establish the value of strategies to implement cell and gene therapies by accounting for their health opportunity cost.
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Affiliation(s)
- Sean P Gavan
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - Stuart J Wright
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Fiona Thistlethwaite
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, M13 9PL, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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10
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Carey N, Leahy J, Trela-Larsen L, Mc Cullagh L, Barry M. Cost-utility and value of information analysis of tisagenlecleucel for relapsed/refractory diffuse large B-cell lymphoma in the Irish healthcare setting. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2166375. [PMID: 36684853 PMCID: PMC9858398 DOI: 10.1080/20016689.2023.2166375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The evidence base of tisagenlecleucel is uncertain. OBJECTIVE To evaluate the cost-effectiveness of tisagenlecleucel. To conduct expected value of perfect information (EVPI) and partial EVPI (EVPPI) analyses. STUDY DESIGN A three-state partitioned survival model. A short-term decision tree partitioned patients in the tisagenlecleucel arm according to infusion status. Survival was extrapolated to 5 years; general population mortality with a standardised mortality ratio was then applied. EVPI and EVPPI were scaled up to population according to the incidence of the decision. SETTING Irish healthcare payer. PARTICIPANTS Patients with relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL). INTERVENTIONS Tisagenlecleucel versus Salvage Chemotherapy (with or without haematopoietic stem cell transplant). MAIN OUTCOME MEASURE Incremental cost-effectiveness ratio (ICER). Population EVPI and EVPPI. RESULTS At list prices, the ICER was €119,509 per quality-adjusted life year (QALY) (incremental costs €218,092; incremental QALYs 1.82). Probability of cost-effectiveness, at a €45,000 per QALY threshold, was 0%. Population EVPI was €0.00. Population EVPI, at the price of tisagenlecleucel that reduced the ICER to €45,000 per QALY, was €3,989,438. Here, survival analysis had the highest population EVPPI (€1,128,053). CONCLUSION Tisagenlecleucel is not cost-effective, versus salvage chemotherapy (with or without haematopoietic stem cell transplant), for R/R DLBCL in Ireland. At list prices, further research to decrease decision uncertainty may not be of value.
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Affiliation(s)
- Niamh Carey
- National Centre for Pharmacoeconomics, Old Stone Building, St James's Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Joy Leahy
- National Centre for Pharmacoeconomics, Old Stone Building, St James's Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Lea Trela-Larsen
- National Centre for Pharmacoeconomics, Old Stone Building, St James's Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Laura Mc Cullagh
- National Centre for Pharmacoeconomics, Old Stone Building, St James's Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Michael Barry
- National Centre for Pharmacoeconomics, Old Stone Building, St James's Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
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11
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Perales MA, Anderson LD, Jain T, Kenderian SS, Oluwole OO, Shah GL, Svoboda J, Hamadani M. Role of CD19 Chimeric Antigen Receptor T Cells in Second-Line Large B Cell Lymphoma: Lessons from Phase 3 Trials. An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy. Transplant Cell Ther 2022; 28:546-559. [PMID: 35768052 PMCID: PMC9427727 DOI: 10.1016/j.jtct.2022.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 12/25/2022]
Abstract
Since 2017, 3 CD19-directed chimeric antigen receptor (CAR) T cell therapies-axicabtagene ciloleucel, tisagenlecleucel, and lisocabtagene maraleucel-have been approved for relapsed/refractory aggressive diffuse large B cell lymphoma after 2 lines of therapy. Recently, 3 prospective phase 3 randomized clinical trials were conducted to define the optimal second-line treatment by comparing each of the CAR T cell products to the current standard of care: ZUMA-7 for axicabtagene ciloleucel, BELINDA for tisagenlecleucel, and TRANSFORM for lisocabtagene maraleucel. These 3 studies, although largely addressing the same question, had different outcomes, with ZUMA-7 and TRANSFORM demonstrating significant improvement with CD19 CAR T cells in second-line therapy compared with standard of care but BELINDA not showing any benefit. The US Food and Drug Administration has now approved axicabtagene ciloleucel and lisocabtagene maraleucel for LBCL that is refractory to first-line chemoimmunotherapy or relapse occurring within 12 months of first-line chemoimmunotherapy. Following the reporting of these practice changing studies, here a group of experts convened by the American Society for Transplantation and Cellular Therapy provides a comprehensive review of the 3 studies, emphasizing potential differences, and shares perspectives on what these results mean to clinical practice in this new era of treatment of B cell lymphomas.
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Affiliation(s)
- Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Larry D Anderson
- Hematologic Malignancies, Transplantation, and Cellular Therapy Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Tania Jain
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, Mayo Clinic Graduate School of Biomedical Sciences, Division of Hematology, Department of Immunology and Department of Molecular Medicine, Rochester, Minnesota
| | - Olalekan O Oluwole
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Gunjan L Shah
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jakub Svoboda
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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12
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Chen AJ, Zhang J, Agarwal A, Lakdawalla DN. Value of Reducing Wait Times for Chimeric Antigen Receptor T-Cell Treatment: Evidence From Randomized Controlled Trial Data on Tisagenlecleucel for Diffuse Large B-Cell Lymphoma. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1344-1351. [PMID: 35341689 DOI: 10.1016/j.jval.2022.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to quantify the value of reducing chimeric antigen receptor T-cell (CAR-T) treatment wait times on patients with refractory and relapsed aggressive blood cancer who can newly gain access to treatment or access treatment earlier in their disease course. METHODS Using data from the JULIET clinical trial, we first identified the number of additional patients with diffuse large B-cell lymphoma that would have been treated with tisagenlecleucel CAR-T therapy if wait times were shortened. For these patients, we estimated mortality benefits using literature estimates of CAR-T effectiveness. Next, among patients who already received CAR-T, we estimated tumor burden progression over time using a linear probability regression model. The primary outcome variable was an indicator for having above-normal lactate dehydrogenase, and we controlled for time, use of bridging therapy, and time-invariant patient characteristics. The regression results, along with literature estimates relating lactate dehydrogenase to CAR-T effectiveness, were used to compute the survival benefits of earlier CAR-T treatment. RESULTS Reducing wait times by 2 months increased the number of eligible patients receiving CAR-T by at least 10.7%. For patients already receiving tisagenlecleucel CAR-T, a 2-month reduction in wait times generated a 3.3% increase in survival gains per treated patient. Thus, among patients seeking treatment, the combined treatment efficacy increased by 14%, with approximately one-quarter of survival benefits accruing to existing patients receiving faster treatment. CONCLUSIONS Delays affected not only access to CAR-T treatments but also treatment effectiveness. Our results highlight the survival benefits of expediting treatment access and may help explain some observed differences in CAR-T effectiveness across countries.
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Affiliation(s)
- Alice J Chen
- Sol Price School of Public Policy and Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Jie Zhang
- Novartis Pharmaceuticals, Basel, Switzerland
| | | | - Darius N Lakdawalla
- Sol Price School of Public Policy and Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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13
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Wang XJ, Wang YH, Ong MJC, Gkitzia C, Soh SY, Hwang WYK. Cost-Effectiveness and Budget Impact Analyses of Tisagenlecleucel in Pediatric and Young Adult Patients with Relapsed or Refractory B-Cell Acute Lymphoblastic Leukemia from the Singapore Healthcare System Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:333-355. [PMID: 35535300 PMCID: PMC9078873 DOI: 10.2147/ceor.s355557] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/07/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose Children and young adults with relapsed or refractory (r/r) acute lymphoblastic leukemia (ALL) have poor survival due to ineffective therapy options. The newly approved chimeric antigen receptor T-cell (CAR-T) therapy, tisagenlecleucel, has demonstrated improved survival but at a high up-front cost. The study aims to evaluate the cost-effectiveness and budget impact of tisagenlecleucel versus salvage chemotherapy regimen (SCR) or blinatumomab (BLN) for the treatment of pediatric and young adult patients with relapsed/refractory B-cell ALL from the Singapore healthcare system perspective. Patients and Methods A three-health state partitioned survival model was constructed to analyze the cost-effectiveness of tisagenlecleucel vs SCR/BLN with/without allogenic hematopoietic stem cell transplantation (allo-HSCT) over a lifetime period. Clinical efficacy for tisagenlecleucel, SCR and BLN were based on pooled data from ELIANA, ENSIGN and B2101J trials, the study by von Stackelberg et al 2011, and MT103-205 respectively. Medical costs from pre-treatment until terminal care, including treatment, side effects, follow-up, subsequent allo-HSCT and relapse, were considered. Incremental cost-effectiveness ratios (ICERs) were estimated as the incremental costs per quality-adjusted life-year (QALY) gain. Additionally, the financial impact of tisagenlecleucel introduction in Singapore was estimated, comparing the present treatment scenario (without tisagenlecleucel) with a future scenario (with tisagenlecleucel), over 5 years. Results In the base-case analysis, tisagenlecleucel treatment demonstrated cost-effectiveness with an ICER of S$45,840 (US$34,762) per QALY (vs SCR) and S$51,978 (US$39,315) per QALY (vs BLN). The estimated budget ranges from S$477,857 (US$361,438) to S$1.4 million (US$1.05 million) annually for the initial 5 years. Conclusion Tisagenlecleucel is likely to be a cost-effective treatment option with limited budget implications while treating r/r ALL patients who have failed at least 2 lines of prior therapies.
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Affiliation(s)
- Xiao Jun Wang
- Novartis Singapore Pte Ltd, Singapore
- Correspondence: Xiao Jun Wang, Novartis Singapore Pte Ltd, 20 Pasir Panjang Road, #10-25/28 Mapletree Business City (West Tower), 117439, Singapore, Tel +65 67226010, Email
| | - Yi-Ho Wang
- Novartis Asia Pacific Pharmaceuticals Pte Ltd, Singapore
| | | | | | | | - William Ying Khee Hwang
- National Cancer Centre Singapore, Singapore
- Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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14
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Wang XJ, Wang YH, Li SCT, Gkitzia C, Lim ST, Koh LP, Lim FLWI, Hwang WYK. Cost-effectiveness and budget impact analyses of tisagenlecleucel in adult patients with relapsed or refractory diffuse large B-cell lymphoma from Singapore's private insurance payer's perspective. J Med Econ 2021; 24:637-653. [PMID: 33904359 DOI: 10.1080/13696998.2021.1922066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients experiencing relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) have limited treatment options and poor prognosis. Tisagenlecleucel (TIS) has shown improved clinical outcomes, but at a high upfront cost. Singapore has a multi-payer healthcare system where private insurance is one of the major payers. This study evaluated the cost-effectiveness and budget impact of TIS against salvage chemotherapy regimen (SCR) for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapy from Singapore's private insurance payer's perspective. METHODS Over a life-time horizon, a partitioned survival model with three health-states was developed to evaluate the cost-effectiveness of TIS vs. SCR with or without hematopoietic stem cell transplantation (HSCT). Efficacy inputs for TIS and SCR were based on 43 months of observation data from pooled JULIET and UPenn trials, and CORAL extension studies respectively. Direct costs for pre-treatment, treatment, adverse events, follow-up, subsequent-HSCT, relapse, and terminal care were included. Incremental cost-effectiveness ratios (ICERs) were calculated as the total incremental costs per quality-adjusted life-year (QALY) gained. Additionally, the financial implication of introducing TIS in Singapore from a private payer's perspective was analyzed, comparing the current treatment pathway (without TIS) with a future scenario (with TIS) over 5 years. RESULTS Compared with SCR, TIS was the dominant option, with cost savings of S$8,477 alongside an additional gain of 2.78 QALYs in privately insured patients who shifted from private to public hospitals for TIS treatment. Scenario analyses for patients starting in public hospitals show ICERs of S$99,623 (no subsidy) and S$133,261 (50% subsidy for SCR treatment, no subsidy for TIS), supporting the base case. The projected annual budget impact ranges from S$850,000 to S$3.4 million during the first 5 years. CONCLUSIONS TIS for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapies, is likely to be cost effective with limited budget impact.
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Affiliation(s)
| | - Yi-Ho Wang
- Novartis Singapore Pte Ltd., Singapore, Singapore
| | | | | | - Soon Thye Lim
- National Cancer Centre Singapore, Singapore, Singapore
| | - Liang Piu Koh
- National University Cancer Institute, Singapore, Singapore
| | | | - William Ying Khee Hwang
- National University Cancer Institute, Singapore, Singapore
- Singapore General Hospital, Singapore, Singapore
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