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Alrawashdh N, McBride A, Erstad B, Sweasy J, Persky DO, Abraham I. Cost-Effectiveness and Economic Burden Analyses on All First-Line Treatments of Chronic Lymphocytic Leukemia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1685-1695. [PMID: 35537984 DOI: 10.1016/j.jval.2022.04.001] [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: 09/09/2021] [Revised: 03/10/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Neda Alrawashdh
- Center for Health Outcomes and PharmacoEconomic Research, Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA; Department of Clinical Translational Sciences, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Ali McBride
- Center for Health Outcomes and PharmacoEconomic Research, Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Brian Erstad
- Center for Health Outcomes and PharmacoEconomic Research, Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Joann Sweasy
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - Daniel O Persky
- University of Arizona Cancer Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA; University of Arizona Cancer Center, Tucson, AZ, USA.
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Treatment Options for Elderly/Unfit Patients with Chronic Lymphocytic Leukemia in the Era of Targeted Drugs: A Comprehensive Review. J Clin Med 2021; 10:jcm10215104. [PMID: 34768624 PMCID: PMC8584288 DOI: 10.3390/jcm10215104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) incidence increases with age reaching 37.9/100,000 in patients over 85 years. Although there is no standardized geriatric tool specifically validated for CLL, a correct framing of the fitness status is of critical importance to individualize treatment strategies. Based on the evidence available to date, frontline chemoimmunotherapy has an increasingly narrowing application, being eligible for candidacy only in elderly fit patients without or with minimal geriatric syndromes. On the other hand, treatment with BCR inhibitors, monotherapy, or in combination with anti-CD20 antibodies (e.g., obinutuzumab), must be preferred both for frontline and relapsed CLL not only in unfit patients, but also in fit patients with unmutated IGHV or harboring del(17p) and/or TP53 mutations/deletions. Second-generation inhibitors (e.g., acalabrutinib, zanubrutinib, pirtobrutinib) are novel compounds that, due to their better safety profile and different specificity, will help physicians overcome some of the safety issues and treatment resistances. In the era of targeted therapies, treatment decisions in elderly and/or unfit patients with CLL must be a balance between efficacy and safety, carefully evaluating comorbidities and geriatric syndromes to ensure the best approach to improve both quality of life and life expectancy.
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Alrawashdh N, Persky DO, McBride A, Sweasy J, Erstad B, Abraham I. Comparative Efficacy of First-Line Treatments of Chronic Lymphocytic Leukemia: Network Meta-Analyses of Survival Curves. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e820-e831. [PMID: 34274291 DOI: 10.1016/j.clml.2021.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/06/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Multiple treatment options in first-line chronic lymphocytic leukemia (CLL) pose a challenge in identifying the best treatment. We performed novel network meta-analyses (NMA; 8 trials, 11 treatments) on the Kaplan-Meier curves to compare treatments for fludarabine-ineligible patients on progression-free survival (PFS), time-to-next-treatment (TTNT) and overall survival (OS). METHODS Using the Guyot method of enhanced secondary analysis of digitized survival data and applying the fixed lognormal distribution model, we extracted the survival proportions and hazard ratios (HR) over 60 months of follow-up, including PFS comparisons by unmutated/mutated IGHV and del 17p. RESULTS Acalabrutinib-plus-obinutuzumab was associated with higher 5-year PFS proportions than ibrutinib (HR = 0.42, 95% CrI = 0.25-0.63) but not acalabrutinib, ibrutinib-plus-obinutuzumab, ibrutinib-plus-rituximab or venetoclax-plus-obinutuzumab. In patients with un-mutated (but not with mutated) IGHV higher PFS proportions and favorable HRs were observed for acalabrutinib, acalabrutinib-plus-obinutuzumab, and ibrutinib-plus-obinutuzumab relative to ibrutinib; and targeted therapies were superior over chemoimmunotherapies in patients with del 17p. Targeted therapies containing ibrutinib or acalabrutinib regimens were associated with superior TTNT over venetoclax-plus-obinutuzumab and all chemoimmunotherapies. OS NMA generally found no difference between therapies except for some chemoimmunotherapies. CONCLUSIONS Overall, only acalabrutinib-plus-obinutuzumab was associated with superior 5-year PFS gains over ibrutinib, which in turn was similar or superior in PFS benefit over other targeted therapies. Acalabrutinib and ibrutinib with obinutuzumab and acalabrutinib monotherapy were associated with greater 5-year TTNT benefits. Despite marked 5-year OS for many regimens, a differential 5-year OS benefit could not be ascertained.
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Affiliation(s)
- Neda Alrawashdh
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ; Department of Clinical Translational Sciences, College of Medicine, University of Arizona, Tucson, AZ
| | - Daniel O Persky
- Banner University Medical Center, Tucson, AZ; University of Arizona Cancer Center, Tucson, AZ
| | - Ali McBride
- University of Arizona Cancer Center, Tucson, AZ
| | | | - Brian Erstad
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ; University of Arizona Cancer Center, Tucson, AZ; Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ.
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Milunović V, Mišura Jakobac K, Mandac Rogulj I, Martinović M, Radić-Krišto D, Ostojić Kolonić S. The fading star of obinutuzumab-chlorambucil regimen in patients with comorbidities with chronic lymphocytic leukemia - are we ready for chemo-free immunotherapy approach? Expert Rev Hematol 2020; 13:771-779. [PMID: 32579408 DOI: 10.1080/17474086.2020.1775575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) is the most common leukemia in Western countries occurring typically in elderly patients. These patients often present with comorbidities limiting treatment options. During the last decade, the treatment paradigm has rapidly changed with the introduction of novel oral targeted agents and monoclonal antibodies. AREAS COVERED The review focuses on the combination of type II antiCD20 antibody obinutuzumab in combination with chemotherapy or oral targeted agents in patients not suited for fludarabine-based therapy because of comorbidities or age. The main focus of the review is whether classical immunochemotherapy with obinutuzumab-chlorambucil is still a valid therapeutic option or whether the combination of obinutuzumab and ibrutinib or venetoclax presents novel standard of care. EXPERT OPINION Both pivotal and registrational studies iLLLUMINATE study testing the combination of ibrutinib and obinutuzumab and CLL14 study testing the fixed combination of venetoclax and obinutuzumab have shown major benefit over chemoimmunotherapy approach in this population. Furthermore, they have excellent activity in high-risk subgroups of CLL paving the road toward a chemo-free immunotherapy approach in this setting. However, there are some pitfalls in these strategies warranting further research.
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Affiliation(s)
- Vibor Milunović
- Division of Hematology, Clinical Department of Internal Diseases, Clinical Hospital Merkur , Zagreb, Croatia
| | - Karla Mišura Jakobac
- Division of Hematology, Clinical Department of Internal Diseases, Clinical Hospital Merkur , Zagreb, Croatia
| | - Inga Mandac Rogulj
- Division of Hematology, Clinical Department of Internal Diseases, Clinical Hospital Merkur , Zagreb, Croatia
| | - Marko Martinović
- Division of Hematology, Clinical Department of Internal Diseases, Clinical Hospital Merkur , Zagreb, Croatia
| | - Delfa Radić-Krišto
- Division of Hematology, Clinical Department of Internal Diseases, Clinical Hospital Merkur , Zagreb, Croatia.,School of Medicine in Osijek, Josip Juraj Strossmajer University in Osijek , Osijek, Croatia
| | - Slobodanka Ostojić Kolonić
- Division of Hematology, Clinical Department of Internal Diseases, Clinical Hospital Merkur , Zagreb, Croatia.,School of Medicine in Zagreb, University of Zagreb , Zagreb, Croatia
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Luan C, Chen B. Clinical application of obinutuzumab for treating chronic lymphocytic leukemia. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:2899-2909. [PMID: 31692500 PMCID: PMC6707935 DOI: 10.2147/dddt.s212500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/14/2019] [Indexed: 12/02/2022]
Abstract
Alkylators and nucleoside analogs were the main drugs for treatingchronic lymphoblastic leukemia (CLL), which have been replaced by monoclonal antibodies, such as rituximab in the past 10 years for refractory or relapsed CLL. The first-line immunochemotherapy regimen, rituximab combined with nucleoside analogs, significantly increased CLL patients’ first-reaction rate and improved progression-free survival. Despite the long-lasting remissions by the use of chemoimmunotherapy, most CLL patients will relapse eventually. The obinutuzumab (GA101), an updated CD20 antibody, that is thought to achieve a more durable response with unique molecular and functional characteristics. Obinutuzumab is a humanized, monoclonal type II CD20 antibody modified by glycoengineering. The glycoengineered Fc portion enhances the binding affinity to the FcγRIII receptor on immune effector cells, resulting in increased antibody-dependent cellular cytotoxicity and phagocytosis. In addition, the type II antibody binding characteristics of obinutuzumab to CD20 lead to an efficient induction of direct non-apoptotic cell death. This review summarizes the results of clinical studies using obinutuzumab and looks forward to its further application in treating CLL clinically.
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Affiliation(s)
- Chunyan Luan
- Department of Hematology and Oncology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province 210009, People's Republic of China
| | - Baoan Chen
- Department of Hematology and Oncology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province 210009, People's Republic of China
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Blood and Guts: Diarrhea from Colonic Involvement in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. Dig Dis Sci 2019; 64:345-348. [PMID: 30155841 DOI: 10.1007/s10620-018-5264-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Tomuleasa C, Selicean C, Cismas S, Jurj A, Marian M, Dima D, Pasca S, Petrushev B, Moisoiu V, Micu WT, Vischer A, Arifeen K, Selicean S, Zdrenghea M, Bumbea H, Tanase A, Grewal R, Pop L, Aanei C, Berindan-Neagoe I. Minimal residual disease in chronic lymphocytic leukemia: A consensus paper that presents the clinical impact of the presently available laboratory approaches. Crit Rev Clin Lab Sci 2018; 55:329-345. [PMID: 29801428 DOI: 10.1080/10408363.2018.1463508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a malignancy defined by the accumulation of mature lymphocytes in the lymphoid tissues, bone marrow, and blood. Therapy for CLL is guided according to the Rai and Binet staging systems. Nevertheless, state-of-the-art protocols in disease monitoring, diagnostics, and prognostics for CLL are based on the assessment of minimal residual disease (MRD). MRD is internationally considered to be the level of disease that can be detected by sensitive techniques and represents incomplete treatment and a probability of disease relapse. MRD detection has been continuously improved by the quick development of both flow cytometry and molecular biology technology, as well as by next-generation sequencing. Considering that MRD detection is moving more and more from research to clinical practice, where it can be an independent prognostic marker, in this paper, we present the methodologies by which MRD is evaluated, from translational research to clinical practice.
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Affiliation(s)
- Ciprian Tomuleasa
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania.,b Research Center for Functional Genomics and Translational Medicine/Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Cristina Selicean
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Sonia Cismas
- c Department of Genetics , Victor Babes University of Medicine and Pharmacy , Timisoara , Romania.,d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Anca Jurj
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Mirela Marian
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Delia Dima
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Sergiu Pasca
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Bobe Petrushev
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Vlad Moisoiu
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Wilhelm-Thomas Micu
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Anna Vischer
- d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Kanza Arifeen
- d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Sonia Selicean
- d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Mihnea Zdrenghea
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania.,d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Horia Bumbea
- f Department of Hematology , Carol Davila University of Medicine and Pharmacy , Bucharest , Romania.,g Department of Hematology , University Clinical Hospital , Bucharest , Romania
| | - Alina Tanase
- h Department of Stem Cell Transplantation , Fundeni Clinical Institute , Bucharest , Romania
| | - Ravnit Grewal
- i South African Medical Research Council Bioinformatics Unit , The South African National Bioinformatics Institute (SANBI), University of the Western Cape , Bellville , South Africa
| | - Laura Pop
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Carmen Aanei
- j Hematology Laboratory, Pole de Biologie-Pathologie , University Hospital of St. Etienne , St. Etienne , France
| | - Ioana Berindan-Neagoe
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
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