Cost-Effectiveness Model for Chemoimmunotherapy Options in Patients with Previously Untreated Chronic Lymphocytic Leukemia Unsuitable for Full-Dose Fludarabine-Based Therapy

Sensitivity Analysis in Economic Evaluations of Immuno-Oncology Drugs: A Systematic Literature Review

OBJECTIVES

This study aimed to review, assess, and report the characteristics and strategies of sensitivity analyses (SAs) that were performed in the context of published economic evaluations of immuno-oncology drugs.

METHODS

The systematic literature search was conducted in Scopus and MEDLINE for articles published from 2005 to 2021. Study selection, based on a predefined set of criteria, was performed by 2 reviewers independently. We included economic evaluations of Food and Drug Administration-approved immuno-oncology drugs that were published in English and assessed the accompanying SAs on a set of items, including the range justification of the baseline parameters within the deterministic SA, the provisions for the correlation/overlay between parameters, and the justification of the chosen parameter distribution for the probabilistic SA, among others.

RESULTS

A total of 98 of 295 publications met the inclusion criteria. A total of 90 studies included a one-way and probabilistic SA and 16 of 98 studies had one-way and scenario analysis, alone or together with probabilistic analysis. Most studies provide explicit references as to the choice of parameters and values; nevertheless, there is a lack of a reference of correlation/overlay between parameters in most of the evaluations. In 26 of 98 studies, the most influential parameter for the incremental cost-effectiveness ratio was the under-evaluation drug cost.

CONCLUSIONS

Most of included articles contained an SA that was implemented according to commonly accepted published guidance. The under-evaluation drug cost, the estimates of progression-free survival, the hazard ratio for overall survival, and the time horizon of the analysis seem to play an important part in the robustness of the outcomes.

Cost-effectiveness analysis of different combination therapies for the treatment of chronic lymphocytic leukaemia in India

Background

Over the years, there has been introduction of newer drugs, like bendamustine and ibrutinib, for the management of chronic lymphocytic leukaemia (CLL). Though these drugs lead to better survival, they are also associated with higher cost. The existing evidence on cost effectiveness of these drugs is from high-income countries, which has limited generalisability for low-income and middle-income counties. Therefore, the present study was undertaken to assess the cost-effectiveness of three therapeutic regimens, chlorambucil plus prednisolone (CP), bendamustine plus rituximab (BR) and ibrutinib for CLL treatment in India.

Methods

A Markov model was developed for estimating lifetime costs and consequences in a hypothetical cohort of 1000 CLL patients following treatment with different therapeutic regimens. The analysis was performed based on a limited societal perspective, 3% discount rate and lifetime horizon. The clinical effectiveness of each regime in the form of progression-free survival and occurrence of adverse events were assessed from various randomised controlled trials. A structured comprehensive review of literature was undertaken for the identification of relevant trials. The data on utility values and out of pocket expenditure was obtained from primary data collected from 242 CLL patients across six large cancer hospitals in India.

Findings

As compared to the most affordable regimen comprising of CP as first-line followed by BR as second-line therapy, none of the other therapeutic regimens were cost-effective at one time per capita gross-domestic product of India. However, if the current price of either combination of BR and ibrutinib or even ibrutinib alone could be reduced by more than 80%, regimen comprising of BR as first-line therapy followed by second-line ibrutinib would become cost-effective.

Interpretation

At the current market prices, regimen comprising of CP as first-line followed by BR as second-line therapy is the most cost-effective strategy for CLL treatment in India.

Funding

Department of Health Research, Government of India.

Systematic Literature Review of Economic Evaluations of Treatment Alternatives in Chronic Lymphocytic Leukemia

BACKGROUND

Economic evaluations are widely used to predict the economic impact of new treatment alternatives. Comprehensive economic reviews in the field of chronic lymphocytic leukemia (CLL) are warranted to supplement the existing analyses focused on specific therapeutic areas.

METHODS

A systematic literature review was conducted based on literature searches in Medline and EMBASE to summarize the published health economics models related to all types of CLL therapies. Narrative synthesis of relevant studies was performed focusing on compared treatments, patient populations, modelling approaches and key findings.

RESULTS

We included 29 studies, the majority of which were published between 2016 and 2018, when data from large clinical trials in CLL became available. Treatment regimens were compared in 25 cases, while the remaining four studies considered treatment strategies with more complex patient pathways. Based on the review results, Markov modelling with a simple structure of three health states (progression-free, progressed, death) can be considered as the traditional basis to simulate cost effectiveness. However, more recent studies added further complexity, including additional health states for different therapies (e.g. best supportive care or stem cell transplantation), for progression-free state (e.g. by differentiating between with or without treatment), or for response status (i.e. partial response and complete response).

CONCLUSIONS

As personalized medicine is increasingly gaining recognition, we expect that future economic evaluations will also incorporate new solutions, which are necessary to capture a larger number of genetic and molecular markers and more complex patient pathways with individual patient-level allocation of treatment options and thus economic assessments.

A Probabilistic Cost-Effectiveness Analysis of Venetoclax and Obinutuzumab as a First-Line Therapy in Chronic Lymphocytic Leukemia in Canada

BACKGROUND

Venetoclax is a first-in-class targeted therapy option that is an inducer of apoptosis in chronic lymphocytic leukemia (CLL) cells. The open-label phase III CLL14 clinical trial showed that venetoclax combined with obinutuzumab (VEN+O) is superior to obinutuzumab combined with chlorambucil in newly diagnosed patients with CLL. The aim of this study was to assess the health economic value of VEN+O for the frontline treatment of CLL in Canada from a publicly funded healthcare system perspective.

METHODS

A partitioned survival analyses model was developed including three health states: progression free, progressed, and death. A cycle length of 28 days and a time horizon of 10 years was assumed. VEN+O treatment for a fixed duration of 12 months was compared to obinutuzumab combined with chlorambucil, fludarabine plus cyclophosphamide plus rituximab, bendamustine plus rituximab, chlorambucil plus rituximab, ibrutinib, and acalabrutinib. The population in the model included both unfit and overall frontline CLL patients, two subgroups were also assessed (patients with del17p/TP53 mutations and patients without del17p/TP53 mutations). Survival data extrapolated from the CLL14 trial were used to populate the model. Uncertainty was assessed via one-way sensitivity analyses, probabilistic analyses, and scenario analyses.

RESULTS

Based on the probabilistic analyses, unfit frontline CLL patients receiving VEN+O were estimated to incur costs of Canadian dollars ($) 217,727 [confidence interval (CI) $170,725, $300,761] (del17p/TP53: $209,102 [CI $159,698, $386,190], non-del17p/TP53: $217,732 [CI $171,232, $299,063]) and accrue 4.96 [CI 4.04, 5.82] quality-adjusted life-years (del17p/TP53: 3.11 [CI 2.00, 4.20], non-del17p/TP53: 5.04 [CI 4.05, 5.92]). Obinutuzumab combined with chlorambucil, bendamustine plus rituximab, chlorambucil plus rituximab, and ibrutinib accrued lower quality-adjusted life-years and higher costs and as such, VEN+O was the dominant treatment option. The full incremental analysis showed that acalabrutinib was more expensive and more efficacious compared with VEN+O with an incremental-cost-effectiveness-ratio of $2,139,180/quality-adjusted life-year versus VEN+O and not a cost-effective option in Canada. Probabilistic analyses show that at a willingness to pay of $50,000/quality-adjusted life-year gained, VEN+O has the greatest probability of being cost effective.

CONCLUSIONS

VEN+O is a cost-effective treatment option for unfit frontline CLL patients and provides value for money to healthcare payers.

Pharmacoeconomic analysis of cost-effectiveness when using obinutuzumab (Gazyva ® drug) in treating chronic lymphocytic leukemia in Ukraine

Background. Chronic lymphocytic leukemia (CLL) is the most common type of leukemia. Annual incidence rate of CLL is 2 to 6 per 100000 population. CLL is currently a disease which leads to significant social and financial costs. CLL remains an incurable disease up to this date. However, at the moment there is a bunch of drugs available on the pharmaceutical market, which can substantially elongate progression-free survival, increase duration, and improve the patients’ quality of life. One of such drugs is obinutuzumab. Positive evaluation findings of economic feasibility of using obinutuzumab in elderly patients with CLL have been received in some countries of the European Union, but under the conditions of healthcare of Ukraine pharmacoeconomic analysis of obinutuzumab use in the treatment of CLL has not been performed. The purpose of the work is to determine economic feasibility of using obinutuzumab (Gazyva® drug) under the conditions of healthcare system of Ukraine for the treatment of chronic lymphocytic leukemia in patients who did not receive treatment earlier. Materials and methods. An analysis using the Markov analysis model was performed, and it allowed the comparison between life years gained (LYG) and quality adjusted life years (QALY) to be made, which can be obtained when using alternative regimens (O+Clb or R+Clb) and expenditures on these regiments in treating patients with CLL. The analysis modelling was performed on the basis of the results of international randomized multicenter open phase III clinical trial of CLL11. Results. The results of Markov modelling have shown that O+Clb treatment regimen, which consists of obinutuzumab and chlorambucil, provides every patient with CLL with additional 0,1 LYG on average over a period of three years compared to R+Clb regimen. The average lifespan of the patients in whom the disease did not progress was higher in O+Clb group than in R+Clb group by more than a year – 51,2 and 38,1 months respectively. O+Clb regimen not only increases lifespan, but also improves life quality. The patients of R+Clb group have additional 0,14 QALY during the analyzed period compared to O+Clb group. The calculation of expenses on CLL treatment with consideration for time horizon of 3 years has shown that using obinutuzumab in the first line of treatment was almost twice as expensive as the alternative first-line regimen, provided that original pharmaceutical drugs were used. At the same time, due to the greater effectiveness, the high cost of the regimen with obinutuzumab is compensated by reduction in expenses on the second line of chemotherapy. The cost saving on the second line covers the cost difference of the first line of therapy when using obinutuzumab. When using original, as well as generic chemotherapeutic drugs, O+Clb (obinutuzumab + chlorambucil) regimen as a first-line therapy of patients with CLL provides the higher level of effectiveness at smaller cost. Conclusions. The available data of randomized control trials to this date are indicative of high clinical effectiveness of first-line therapy with the use of obinutuzumab + chlorambucil regimen in the patients with CLL. This regimen allows progression-free survival to be substantially elongated. It also increases the number of life years gained and improves the quality of life. Markov modelling shows that obinutuzumab + chlorambucil regimen compared to rituximab + chlorambucil regimen requires bigger expenses as a first-line therapy of the patients with CLL. At the same time, due to the greater effectiveness and longer progression-free survival, this regimen allows the amount of expenses on the next lines of therapy in the patients with CLL to be reduced, consequently total expenses on the treatment of the patients with CLL are also reduced. Pharmacoeconomic analysis based on the Markov analysis model and calculations by the «cost-effectiveness» and «cost-utility» methods allow obinutuzumab + chlorambucil regimen to be considered dominant in comparison with rituximab + chlorambucil regimen as a first-line therapy of the patients with CLL (provided that original pharmaceutical drugs are used).

Cost-Effectiveness and Economic Burden Analyses on All First-Line Treatments of Chronic Lymphocytic Leukemia

OBJECTIVES

Several chemoimmunotherapy and targeted treatment regimens are approved as front-line therapies in chronic lymphocytic leukemia. We estimated for the 10-year cost-effectiveness of these treatment regimens and the economic burden of following the estimated risk-stratified 21 040 patients with chronic lymphocytic leukemia diagnosed in 2020 for 10 years.

METHODS

A Markov model with 7 exclusive health states was specified over a 10-year time horizon. Treatment effectiveness inputs were obtained from a novel network meta-analysis on the progression-free survival, overall survival curves, and time to next treatment. Costs and utilities inputs were included for each health state for each treatment and discounted at 3.0%/year. Life-years (LYs) and quality-adjusted LYs (QALYs) for each treatment were determined. Using the lowest cost regimen as reference, the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were estimated. The 10-year per-patient cost was determined by risk status and by initial treatment.

RESULTS

Venetoclax-plus-obinutuzumab was the lowest cost regimen, hence the reference. Superior in effectiveness to all chemoimmunotherapies, it was cost saving. With the highest effectiveness gains at 6.26 LYs and 5.01 QALYs and despite being the most expensive regimen ($1 298 638 per patient), acalabrutinib-plus-obinutuzumab yielded the best ICER ($409 343/LY gained) and ICUR ($501 236/QALY gained). The remaining ICERs of targeted therapies ranged from $512 101/LY gained to $793 236/LY gained and the ICURs from $579 737/QALY gained to $869 300/QALY gained. The 10-year postdiagnosis low/high (venetoclax-plus-obinutuzumab/acalabrutinib-plus-obinutuzumab) economic burden ranges were $42 690 to $98 665 for low-risk, $141 339 to $326 660 for intermediate-risk, and $273 650 to $632 453 for high-risk patients.

CONCLUSIONS

Compared with venetoclax-plus-obinutuzumab, chemoimmunotherapies are associated with less health benefits at higher cost. The targeted therapies achieve greater benefits at higher cost.

Cost-effectiveness and drug wastage of immunotherapeutic agents for hematologic malignancies: a systematic review

Introduction: Novel immunotherapeutic agents (e.g. monoclonal antibodies, antibody-drug conjugates, bispecific T-cell engagers) as treatment options for hematologic malignancies continue to emerge. These agents have been used as the standard of care in specific disease states and are associated with high costs. Value assessment of these therapies is of critical importance for coverage and reimbursement decision-making.Areas covered: We identified 15 immunotherapeutic agents through the U.S. FDA approvals for hematologic malignancies until 2018 and systematically reviewed related cost-effectiveness studies. Additionally, we examined whether drug wastage was accounted for in these studies.Expert opinion: We reviewed 51 studies for 14 identified immunotherapeutic agents that met the inclusion criteria for this systematic review. Three studies were observational-based, one study was model-based and incorporated observational data. The remaining studies were model-based with the majority of the model parameters extracted from randomized control trials (RCTs). Among 43 model-based economic evaluations, 13 studies accounted for drug wastage. Most of the studies showed favorable incremental cost-effectiveness ratios of immunotherapeutic agents-containing regimens when compared with no immunotherapeutic agents-containing regimens. Alemtuzumab, brentuximab vedotin, and daratumumab were not considered cost-effective across all the studies. Further investigations are warranted to establish the value of recent immunotherapeutic agents for hematologic malignancies.

Health Technology Assessment Challenges in Oncology: 20 Years of Value in Health

BACKGROUND

Oncology treatments have changed from chemotherapies to targeted therapies and more recently immuno-oncology. This has posed special challenges in the field of health technology assessment (HTA): capturing quality of life (QOL) associated with toxicity due to chemotherapy, crossover upon progression in targeted therapy trials, and survival extrapolation for immuno-oncology drugs.

OBJECTIVES

To showcase 20 years of Value in Health (ViH) publications in oncology.

METHODS

A review was undertaken of oncology articles published in ViH from May 1998 to August 2018. Full-length articles published in ViH with the keywords "oncology," "cancer," "h(a)ematology," and "malignancy" were included for review. Conference abstracts were excluded.

RESULTS

Four major themes were identified: (1) QOL and the development of multiple functional assessment of cancer therapy tools and mapping instruments; (2) analysis of clinical evidence using indirect comparisons, network analyses, and adjustment for crossovers; (3) modeling, Markov models, partitioned survival models, and extrapolation methods; and (4) financial implications and how to deal with uncertainty, introduction of conditional reimbursement, managed entry, and risk share agreements.

DISCUSSION

This review article highlights the important role ViH has played in disseminating HTA research in oncology. A few key issues loom on the horizon: precision medicine, further development and practical application of new QOL measures, methods for translating clinical evidence, and exploration of modeling techniques. For a better understanding of the complex interplay between access and financial risk management, ViH will no doubt continue to promote pioneering research in HTA and oncology.

Cost-Effectiveness Analysis of Obinutuzumab for Previously Untreated Chronic Lymphocytic Leukaemia in Portuguese Patients who are Unsuitable for Full-Dose Fludarabine-Based Therapy

BACKGROUND

Chronic lymphocytic leukaemia (CLL) mostly affects patients with comorbidities and limited therapeutic options. Obinutuzumab in combination with chlorambucil (GClb) is a new therapeutic option for previously untreated CLL patients who are unsuitable for full-dose fludarabine-based therapy. This combination delays disease progression but incurs additional costs; thus, an assessment of its value for money is relevant.

OBJECTIVE

To estimate the incremental cost-utility ratio of GClb in comparison with (i) rituximab in combination with chlorambucil (RClb), and (ii) chlorambucil alone (Clb) from the perspective of the Portuguese National Health Service (NHS).

METHODS

A Markov model was used to predict disease progression. Pre-progression clinical data were based on the latest CLL11 trial data, and post-progression clinical data were obtained from CLL5 trial data. Utility values are from Kosmas et al. (Leuk Lymphoma 56:1320-1326, 14). Only direct medical costs were included. The resource consumption was estimated by a panel of Portuguese experts, and the unit costs were obtained from official sources. A discount rate of 5% was applied to costs and consequences.

RESULTS

GClb and RClb were associated with an increase of 1.06 and 0.39 quality-adjusted life-years (QALY) at an additional cost of €21,720 and €9836 when compared to Clb, respectively. The cost-utility ratio of GClb versus Clb was €20,397/QALY, while RClb was extendedly dominated.

CONCLUSIONS

The use of GClb for previously untreated CLL patients who are unsuitable for full-dose fludarabine-based therapy incurs an incremental cost per QALY that is generally accepted in Portugal. Therefore, although there is some uncertainty, obinutuzumab is probably a cost-effective therapy in the Portuguese setting.

A Systematic Review and Network Meta-Analysis to Evaluate the Comparative Efficacy of Interventions for Unfit Patients with Chronic Lymphocytic Leukemia

INTRODUCTION

Rituximab plus fludarabine and cyclophosphamide (RFC) is the standard of care for fit patients with untreated chronic lymphocytic leukemia (CLL); however, its use is limited in 'unfit' (co-morbid and/or full-dose F-ineligible) patients due to its toxicity profile. We conducted a systematic review and Bayesian network meta-analysis (NMA) to determine the relative efficacy of commercially available interventions for the first-line treatment of unfit CLL patients.

METHODS

For inclusion in the NMA, studies had to be linked via common treatment comparators, report progression-free survival (PFS), and/or overall survival (OS), and meet at least one of the five inclusion criteria: median cumulative illness score >6, median creatinine clearance ≤70 mL/min, existing co-morbidities, median age ≥70 years, and no full-dose F in the comparator arm. A manual review, validated by external experts, of all studies that met at least one of these criteria was also performed to confirm that they evaluated first-line therapeutic options for unfit patients with CLL.

RESULTS

In unfit patients, the main NMA (five studies for PFS and four for OS) demonstrated clear preference in terms of PFS for obinutuzumab + chlorambucil (G-Clb) versus rituximab + chlorambucil (R-Clb), ofatumumab + chlorambucil (O-Clb), fludarabine and chlorambucil (median hazard ratios [HRs] 0.43, 0.33, 0.20, and 0.19, respectively), and a trend for better efficacy versus rituximab + bendamustine (R-Benda) and RFC-Lite (median HR 0.81 and 0.88, respectively). OS results were generally consistent with PFS data, (median HR 0.48, 0.53, and 0.81, respectively) for G-Clb versus Clb, O-Clb, and R-Clb 0.35 and 0.81 versus F and R-Benda, respectively); however, the OS findings were associated with higher uncertainty. Treatment ranking reflected improved PFS and OS with G-Clb over other treatment strategies (median rank of one for both endpoints).

CONCLUSION

G-Clb is likely to show superior efficacy to other treatment options selected in our NMA for unfit treatment-naïve patients with CLL.

FUNDING

F. Hoffmann-La Roche Ltd.