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Ito S, Wang D, Purcell A, Chetlapalli K, Lee AI, Cuker A, Goshua G. Cost-effectiveness of sutimlimab in cold agglutinin disease. Am J Hematol 2024; 99:1475-1484. [PMID: 38733355 DOI: 10.1002/ajh.27358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/22/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Abstract
Primary cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia caused by cold-reactive antibodies that bind to red blood cells and lead to complement-mediated hemolysis. Patients with primary CAD experience the burden of increased health resource utilization and reduced quality of life. The standard-of-care (SOC) in patients with primary CAD has included cold avoidance, transfusion support, and chemoimmunotherapy. The use of sutimlimab, a humanized monoclonal antibody that selectively inhibits C1-mediated hemolysis, was shown to reduce transfusion-dependence and improve quality of life across two pivotal phase 3 studies, further supported by 2-year extension data. Using data from the transfusion-dependent patient population that led to sutimlimab's initial FDA approval, we performed the first-ever cost-effectiveness analysis in primary CAD. The projected incremental cost-effectiveness ratio (ICER) in our Markov model was $2 340 000/QALY, significantly above an upper-end conventional US willingness-to-pay threshold of $150 000/QALY. These results are consistent across scenarios of higher body weight and a pan-refractory SOC patient phenotype (i.e., treated sequentially with bendamustine-rituximab, bortezomib, ibrutinib, and eculizumab). No parameter variations in deterministic sensitivity analyses changed our conclusion. In probabilistic sensitivity analysis, SOC was favored over sutimlimab in 100% of 10 000 iterations. Exploratory threshold analyses showed that significant price reduction (>80%) or time-limited treatment (<18 months) followed by lifelong clinical remission off sutimlimab would allow sutimlimab to become cost-effective. The impact of sutimlimab on health system costs with longer term follow-up data merits future study and consideration through a distributional cost-effectiveness framework.
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MESH Headings
- Humans
- Anemia, Hemolytic, Autoimmune/therapy
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/economics
- Cost-Benefit Analysis
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Female
- Male
- Middle Aged
- Markov Chains
- Quality-Adjusted Life Years
- Aged
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Affiliation(s)
- Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Wang
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
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2
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Rossi C, Casasnovas RO. How to treat advanced Hodgkin lymphoma? Curr Opin Oncol 2024:00001622-990000000-00190. [PMID: 39007300 DOI: 10.1097/cco.0000000000001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
PURPOSE OF REVIEW In this review, we analyzed the different therapy options in patients with advanced Hodgkin lymphoma (HL). RECENT FINDINGS The treatment of advanced HL has greatly evolved during the last decade even still based on polychemotherapy. Mature data established that the better strategies require Positron emission tomography (PET)-driven treatments which allow to optimize the balance between disease control and both immediate and late treatment adverse effects, leading to cure most patients while minimizing the risk of toxicity. Indeed, PET-driven deescalated strategies offer the better treatment option. The recent incorporation of targeted therapies, anti-CD30 or anti-programmed cell death protein 1 (PD1) in combination with chemotherapy should quickly change the game and be a step forward to still decrease the risk of treatment toxicity and improve the cure rate. SUMMARY The standard of care for advanced HL remains currently PET-driven chemotherapy and should rapidly evolve with the addition of targeted therapy combined with chemotherapy.
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Affiliation(s)
- Cédric Rossi
- Department of Hematology, CHU Dijon Bourgogne
- INSERM 1231 Team Epi2THM ((Epi)genetics, Epidemiology and Targeted Therapy in Hematological Malignancies), Dijon, France
- Stanford University School of Medicine, Ash Alizadeh Lab, Stanford, California, USA
| | - René-Olivier Casasnovas
- Department of Hematology, CHU Dijon Bourgogne
- INSERM 1231 Team Epi2THM ((Epi)genetics, Epidemiology and Targeted Therapy in Hematological Malignancies), Dijon, France
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Evens AM, Yu KS, Liu N, Surinach A, Holmes K, Flores C, Fanale MA, Flora DR, Parsons SK. Physician frontline treatment preferences for stage III/IV classic Hodgkin lymphoma: the real-world US CONNECT study. Future Oncol 2024; 20:749-760. [PMID: 37665273 DOI: 10.2217/fon-2023-0358] [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] [Indexed: 09/05/2023] Open
Abstract
Aim: To understand US physicians' frontline (1L) treatment preferences/decision-making for stage III/IV classic Hodgkin lymphoma (cHL). Materials & methods: Medical oncologists and/or hematologists (≥2 years' practice experience) who treat adults with stage III/IV cHL were surveyed online (October-November 2020). Results: Participants (n = 301) most commonly considered trial efficacy/safety data and national guidelines when selecting 1L cHL treatments. Most physicians (91%) rated overall survival (OS) as the most essential attribute when selecting 1L treatment. Variability was seen among regimen selection for hypothetical newly diagnosed patients, with OS cited as the most common reason for regimen selection. Conclusion: While treatment selection varied based on patient characteristics, US physicians consistently cited OS as the top factor considered when selecting a 1L treatment for cHL.
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Affiliation(s)
- Andrew M Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
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Ren L, Ren N, Zheng Y, Yang Y, Xu Q. Economic evaluation of third-line neratinib plus capecitabine versus lapatinib plus capecitabine with HER2+ metastatic breast cancer. Front Oncol 2023; 13:1221969. [PMID: 37621688 PMCID: PMC10446218 DOI: 10.3389/fonc.2023.1221969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
Background Breast cancer (BC) is one of the most common malignant tumors in women. In addition, human epidermal growth factor receptor 2-positive (HER2+) BC is overexpressed in 25% of BC patients, resulting in the predicament of poor prognosis. Although first- and second-line treatments have been established, optimum third-line treatment is still mired in controversies for HER2+ metastatic BC (mBC). Therefore, this study analyzes the cost-effectiveness of neratinib plus capecitabine (N+C) and lapatinib plus capecitabine (L+C) over a 5-year time horizon from a payer perspective. Methods A half-cycle corrected four-state Markov model was established to simulate the course of BC events and deaths in N+C and L+C armed patients. The data of this model were derived from NCT01808573 trail and other published literatures. One-way deterministic sensitivity analysis (DSA) was conducted to investigate the impact of variables and probabilistic sensitivity analysis (PSA) was performed based on second-order Monte Carlo simulation. In addition, subgroup analysis was performed to verify its cost-effectiveness in China. Result The base-case results found that N+C was in dominant position in 82.70% of the generation scenarios, providing an improvement of 0.17 quality-adjusted life-years (QALYs) and a reduction of $1,861.28 compared with L+C. The ICER was $-1,3294.86/QALY, which did not exceed the willingness to pay (WTP) threshold, while in subgroup, the ICER decreased to $-2,448.17/QALY. Conclusion This analysis indicated that the combination of neratinib plus capecitabine is likely to be cost-effective in comparison with lapatinib plus capecitabine in patients with HER2+ mBC who continues to progress during or after second-line HER2-targeted therapy. So neratinib plus capecitabine can become a third-line treatment option.
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Affiliation(s)
- Lanqi Ren
- Fourth Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Ning Ren
- Fourth Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yu Zheng
- Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yibei Yang
- Fourth Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qiaoping Xu
- Department of Clinical Pharmacology, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Cancer Center, Zhejiang University School of Medicine, Hangzhou, China
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Yang J, Han J, Zeng N, Yan X. Cost-effectiveness of trastuzumab deruxtecan in previously treated human epidermal growth factor receptor 2-low metastatic breast cancer. Ther Adv Med Oncol 2023; 15:17588359231169983. [PMID: 37228255 PMCID: PMC10204055 DOI: 10.1177/17588359231169983] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 05/27/2023] Open
Abstract
Background Results from DESTINY-Breast04 trial revealed that trastuzumab deruxtecan (T-DXd) improved both progression-free survival and overall survival for patients with human epidermal growth factor receptor 2 (HER2)-low metastatic breast cancer (mBC). However, the economic impact of this practice remains unclear. The purpose of this study was to evaluate the cost-effectiveness of T-DXd on HER2-low mBC from the viewpoint of U.S. payers. Methods Using the clinical data from the DESTINY-Breast04 trial, a three-state Markov model was created to assess the economic and health effects of T-DXd versus chemotherapy. The incremental cost-effectiveness ratio (ICER) and willingness-to-pay threshold were determined and compared. One-way and probabilistic sensitivity analysis were used to measure parameter uncertainty. Results In the overall HER2-low population, T-DXd provided additional 0.47 quality-adjusted life-years (QALYs) at an increased cost of $149,222 compared with chemotherapy, yielding an ICER of $317,494/QALY. The ICER was $353,903/QALY in the hormone receptor (HR)-positive subgroup, which decreased to $259,825/QALY in the HR-negative subgroup. The sensitivity analysis found that T-DXd would not be cost-effective in the base-case. The expected cost of T-DXd will be less than $4,281/cycle ($11.33/mg) or $1,903/cycle ($5.03/mg) to achieve a 50 or 90% cost-benefit probability, respectively. Conclusions T-DXd provides significant health benefit for patients with HER2-low mBC compared with chemotherapy but is unlikely to be cost-effective in the United States.
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Affiliation(s)
| | | | - Ni Zeng
- Department of Head and Neck Oncology and
Department of Radiation Oncology, Cancer Center and State Key Laboratory of
Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R.
China
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6
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Potnis KC, Di M, Isufi I, Gowda L, Seropian SE, Foss FM, Forman HP, Huntington SF. Cost-effectiveness of chimeric antigen receptor T-cell therapy in adults with relapsed or refractory follicular lymphoma. Blood Adv 2023; 7:801-810. [PMID: 36342852 PMCID: PMC10011202 DOI: 10.1182/bloodadvances.2022008097] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/30/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
Follicular lymphoma (FL) is traditionally considered treatable but incurable. In March 2021, the US Food and Drug Administration approved the use of chimeric antigen receptor (CAR) T-cell therapy in patients with relapsed or refractory (R/R) FL after ≥2 lines of therapy. Priced at $373 000, CAR T-cell therapy is potentially curative, and its cost-effectiveness compared with other modern R/R FL treatment strategies is unknown. We developed a Markov model to assess the cost-effectiveness of third-line CAR T-cell vs standard of care (SOC) therapies in adults with R/R FL. We estimated progression rates for patients receiving CAR T-cell and SOC therapies from the ZUMA-5 trial and the LEO CReWE study, respectively. We calculated costs, discounted life years, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of CAR T-cell vs SOC therapies with a willingness-to-pay threshold of $150 000 per QALY. Our analysis was conducted from a US payer's perspective over a lifetime horizon. In our base-case model, the cost of the CAR T-cell strategy was $731 682 compared with $458 490 for SOC therapies. However, CAR T-cell therapy was associated with incremental clinical benefit of 1.50 QALYs, resulting in an ICER of $182 127 per QALY. Our model was most sensitive to the utilities associated with CAR T-cell therapy remission and third-line SOC therapies and to the total upfront CAR T-cell therapy cost. Under current pricing, CAR T-cell therapy is unlikely to be cost-effective in unselected patients with FL in the third-line setting. Both randomized clinical trials and longer term clinical follow-up can help clarify the benefits of CAR T-cell therapy and optimal sequencing in patients with FL.
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Affiliation(s)
| | - Mengyang Di
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Iris Isufi
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Lohith Gowda
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Stuart E. Seropian
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Francine M. Foss
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, CT
| | - Howard P. Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, Yale University, New Haven, CT
- Yale School of Management, Yale University, New Haven, CT
| | - Scott F. Huntington
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, Yale University, New Haven, CT
- Correspondence: Scott Huntington, Division of Hematology, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, PO Box 208028, New Haven, CT 06520;
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7
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Wu HL, Luo ZY, He ZL, Gong Y, Mo M, Ming WK, Liu GY. All HER2-negative breast cancer patients need gBRCA testing: cost-effectiveness and clinical benefits. Br J Cancer 2023; 128:638-646. [PMID: 36564566 PMCID: PMC9938252 DOI: 10.1038/s41416-022-02111-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The OlympiA trial demonstrated the benefits of adjuvant usage of olaparib for high-risk patients with human epidermal growth factor receptor 2 (HER2)-negative breast cancer (BC) and germline BRCA (gBRCA) mutation. This provoked thoughts on the clinical criteria of gBRCA testing. This study aims to estimate the costs and benefits of gBRCA testing and adjuvant olaparib therapy for patients with triple-negative breast cancer (TNBC) and hormone-receptor (HR)-positive and HER2-negative BC in China and the United States of America (USA). METHODS We used a Markov chain decision tree analytic model to compare three gBRCA screening policies in China and the USA: (1) no gBRCA testing; (2) selected gBRCA testing and (3) universal gBRCA testing for nonmetastatic TNBC and HR-positive HER2-negative BC patients. We modelled the benefit of systemic therapy and risk-reducing surgeries among patients identified with pathogenic or likely pathogenic variants (PVs) in BRCA1 and BRCA2. RESULTS Changing from the selected gBRCA testing to the universal gBRCA testing in TNBC patients is cost-effective, with the incremental cost-effectiveness ratios (ICERs) being 10991.1 and 56518.2 USD/QALY in China and the USA, respectively. Expanding universal gBRCA testing to HR-positive HER2-negative BC and TNBC patients has ICERs of 2023.3 and 16611.1 USD/QALY in China and the USA, respectively. DISCUSSION By performing gBRCA testing on all HER2-negative BC patients, adjuvant olaparib can be offered to high-risk patients with a PV in BRCA1 or BRCA2. These patients are also candidates for risk-reducing surgeries, an important aspect of their survivorship care, and these interventions can improve survival outcomes. With the willingness-to-pay thresholds being 31,500.0 and 100,000.0 USD per QALY gained in China and the USA, respectively, universal gBRCA testing is likely cost-effective for all HER2-negative BC patients. This simplified criterion of gBRCA testing for BC is recommended for adoption by current guidelines in China and the USA.
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Affiliation(s)
- Huai-Liang Wu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Department of Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zi-Yin Luo
- Department of Otorhinolaryngology Head and Neck Surgery, The Sixth Affiliated Hospital of Sun Yat‑sen University, Guangzhou, China
| | - Zong-Lin He
- Division of Life Science, The Hong Kong University of Science and Technology, Hong Kong SAR, China
| | - Yue Gong
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Department of Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Miao Mo
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wai-Kit Ming
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Science, City University of Hong Kong, Hong Kong SAR, China
| | - Guang-Yu Liu
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Department of Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
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Li SN, Wan X, Peng LB, Li YM, Li JH. Cost-effectiveness of immune checkpoint inhibition and targeted treatment in combination as adjuvant treatment of patient with BRAF-mutant advanced melanoma. BMC Health Serv Res 2023; 23:49. [PMID: 36653848 PMCID: PMC9847087 DOI: 10.1186/s12913-023-09058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) and targeted treatments have improved the health outcomes of patients with advanced melanoma. However, due to the high cost of novel therapies, it is crucial to evaluate their value by considering both effectiveness and cost. To compare the cost-effectiveness of these novel agents (atezolizumab-vemurafenib-cobimetinib, vemurafenib-plus-cobimetinib, dabrafenib-plus-trametinib, and encorafenib-plus-binimetinib) for first-line treatment of metastatic melanoma with the BRAFV600 mutation. METHODS A patient-level model was developed to project the health outcomes of 4 strategies for patients with advanced melanoma. We estimated transition probabilities from the IMspire150 (ClinicalTrials.gov, NCT02908672), COMBI-AD (NCT01682083), and COLUMBUS (NCT01909453) trials using a parametric survival model. All health outcomes, including direct cost, quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER), were estimated from the US payer perspective. Lifetime cost, QALYs, life-years (LYs), and ICERs were calculated. Univariable and probabilistic sensitivity analyses were performed to test model robustness, along with multiple scenario analyses. RESULTS Of the 4 competing strategies, atezolizumab-vemurafenib-cobimetinib produced the best health outcomes, and the vemurafenib-cobimetinib strategy was the least expensive option. Atezolizumab-vemurafenib-cobimetinib, dabrafenib-plus-trametinib, and vemurafenib-cobimetinib formed the cost-effective frontier, indicating that the ordered ICERs were $325,113/QALYs for dabrafenib-plus-trametinib vs. vemurafenib-cobimetinib strategies and $2,247,500/QALYs for atezolizumab-vemurafenib-cobimetinib vs. dabrafenib-plus-trametinib strategies. Encorafenib-plus-binimetinib was dominated by the other 3 competing strategies. The drug price and first-line utility significantly influenced the model utcomes. CONCLUSIONS For BRAF-mutant advanced melanoma, the vemurafenib-cobimetinib strategy could be considered the most cost-effective treatment at the willingness-to-pay threshold of $150,000.
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Affiliation(s)
- Si Ni Li
- grid.216417.70000 0001 0379 7164Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011 China ,grid.10784.3a0000 0004 1937 0482The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hongkong, China ,grid.11835.3e0000 0004 1936 9262School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Xiaomin Wan
- grid.216417.70000 0001 0379 7164Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 China
| | - Liu Bao Peng
- grid.216417.70000 0001 0379 7164Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 China
| | - Ya Min Li
- grid.216417.70000 0001 0379 7164Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011 China
| | - Jian He Li
- grid.216417.70000 0001 0379 7164Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 China ,grid.216417.70000 0001 0379 7164Present address: The Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Changsha, 410011 Hunan China
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Yang J, Han J, Zhang Y, Muhetaer M, Chen N, Yan X. Cost-effectiveness analysis of trastuzumab deruxtecan versus trastuzumab emtansine for HER2-positive breast cancer. Front Pharmacol 2022; 13:924126. [PMID: 36160459 PMCID: PMC9500475 DOI: 10.3389/fphar.2022.924126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background: The DESTINY-Breast03 clinical trial demonstrated that trastuzumab deruxtecan (T-DXd) outperformed trastuzumab emtansine (T-DM1) in progression-free survival (PFS) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (mBC). Considering the excessive cost of antibody-drug conjugates, the clinical value of T-DXd must be assessed by both its efficacy and cost. We compared the cost-effectiveness of T-DXd and T-DM1 for patients with HER2-positive mBC pretreated with anti-HER2 antibodies and a taxane from the perspectives of the United States (US) and China. Methods: A comprehensive Markov model based on the DESTINY-Breast03 phase III randomized clinical trial was used to compared the cost and effectiveness of T-DXd and T-DM1 for HER2-positive mBC. Data on direct medical cost and utilities were collected from published literatures. The recorded data included the costs, quality-adjusted life-year (QALY), incremental cost-effectiveness ratio (ICER) and incremental net-health benefit (INHB). Sensitivity analysis was conducted to measure the potential uncertainty due to parameter variability. Additional subgroup cost-effectiveness analysis was performed. Results: Treatment of HER2-positive mBC with T-DXd gained 0.73 QALYs compared with T-DM1 strategy. The incremental cost was $59,942 in the US, with an ICER of $ 82,112/QALY and an INHB of 0.33 QALYs, respectively. In China, the incremental cost of T-DXd versus T-DM1 was $222,680, with an ICER of $305,041/QALY and a negative INHB of -5.18 QALYs. At willingness-to-pay (WTP) threshold of $150,000/QALY in the US and $37,653/QALY in China, the probability of T-DXd as the dominant option was 77.5 and 0.1%, respectively. The unit price of T-DXd greatly influenced the results according to one-way sensitivity analysis. To meet the 50% or 90% chance of being cost-effective, the estimated cost of T-DXd would need to be less than $17.24/mg and $12.06/mg in China, respectively. Conclusion: T-DXd is more cost-effective than T-DM1 for patients with HER2-positive mBC in the US, but not in China at current drug prices.
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Affiliation(s)
- Jiangping Yang
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaqi Han
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Yalan Zhang
- State Key Laboratory of Biotherapy and Cancer Center, Collaborative Innovation Center for Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Muhelisa Muhetaer
- Department of Head, Neck and Mammary Gland Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Nianyong Chen
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Yan
- Department of Head, Neck and Mammary Gland Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xi Yan,
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Preckler V, Espín J. The Role of Indication-Based Pricing in Future Pricing and Reimbursement Policies: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:666-675. [PMID: 35227598 DOI: 10.1016/j.jval.2021.11.1376] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/16/2021] [Accepted: 11/16/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Indication-based pricing (IBP) has received growing attention because of the expected increase in the number of new medicines with multiple indications. In our systematic review, we assess the potential benefits, barriers, current experiences, and future perspectives of different IBP mechanisms. METHODS We searched publications in English, Spanish, or French assessing the impact, international experience, and future context of IBP systems on PubMed, Scopus, Cochrane, EconLit, American Society of Clinical Oncology, and National Institute for Health Research Health Technology Assessment from 2000 to 2020. This was complemented by a gray literature search in Google Scholar. RESULTS A total of 29 publications that specifically addressed the topic of IBP were retained. The most commonly reported benefits of IBP were a better alignment of medicines' value and price, optimization of research and development incentives and increase of competition, and improvement of patients' access to treatments. Data collection and proper infrastructures, and the risk of high administrative burden and associated costs, were seen as the main barriers for proper IBP implementation. International experience lacks concrete examples of IBP. A single weighted average price according to volume, value, or a combination of both, appears to be the most used methodology, followed by different confidential net prices per indication. Different brands with distinct price per indication are less common, although it is considered a pure IBP system. CONCLUSIONS Evidence of IBP impact is still scarce, and there is a need for pilot projects and experiences to monitor its real consequences. An appropriate price and reimbursement model for multi-indication medicines should be a priority, but political will and proper data collection systems remain crucial.
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Affiliation(s)
- Víctor Preckler
- Epidemiology, Health Policy and Health Management, Escuela Internacional de Doctorado Universidad de Sevilla, Sevilla, Spain.
| | - Jaime Espín
- Andalusian School of Public Health (EASP), Granada, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; Instituto de Investigación Biosanitaria (IBS), Granada, Spain
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Liu J, Zheng L, Chuang LH. Cost-effectiveness of brentuximab vedotin for relapsed or refractory systemic anaplastic large-cell lymphoma in China. J Med Econ 2022; 25:99-107. [PMID: 34927526 DOI: 10.1080/13696998.2021.2020567] [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] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Systemic anaplastic large-cell lymphoma (sALCL) is a rare hematological malignancy with poor prognosis, which is associated with a significant economic burden. This study aimed to evaluate the cost-effectiveness of brentuximab vedotin (BV) in comparison to conventional chemotherapy in patients with relapsed/refractory sALCL, from a Chinese healthcare perspective. METHODS A partitioned survival model with three health states (progression-free survival, post-progression survival, and death) was adapted to compare BV against chemotherapy. Comparator represented a basket of commonly used chemotherapies in China. Two cohorts in each arm were estimated, representing patients receiving no transplant and autologous stem cell transplant (ASCT) after BV or chemotherapy. Clinical data was obtained from the pivotal phase-II trial (NCT00866047) for BV and also from the literature for a comparator. Resource use items covered drug acquisition and administration; concomitant medications; ASCT; treatment of adverse events; and long-term follow-up. Cost parameters were based on Chinese sources. Outcomes were measured in quality-adjusted life-years (QALYs). Both costs and effects were discounted at 5% according to Chinese guidelines. The impact of uncertainty was evaluated using deterministic and probabilistic sensitivity analyses. RESULTS The incremental cost-effectiveness ratio (ICER) for BV vs. chemotherapy was $9,610 (¥62,084) per QALY in the base case. The main model driver was superior progression-free and overall survival benefits of BV. The ICERs were relatively robust in the majority of sensitivity analyses, ranging around ±10% of the base case. Under the conventional decision thresholds (1-3 times of Chinese per capita GDP), the probability of BV being cost-effective ranged from 56 to 100%. Limitations of the study included the lack of comparative data from the trial and the small and heterogeneous sample due to its disease nature. CONCLUSIONS BV may be a cost-effective treatment vs. chemotherapy in treating relapsed or refractory systemic anaplastic large-cell lymphoma in China.
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Affiliation(s)
- Jia Liu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- Center for Social Science Survey and Data, Tianjin University, Tianjin, China
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12
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Kim H, Richman A, Smith KJ, Shaikh PM, Beriwal S, Vargo JA. Is Radiotherapy Cost-effective in the PET/CT-era for Early-Stage Favorable Hodgkin's Lymphoma with Alternative Payment Models? Pract Radiat Oncol 2021; 12:e135-e143. [PMID: 34902637 DOI: 10.1016/j.prro.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/10/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Despite multiple randomized trials, there remains variation in practice regarding the most effective treatment for early-stage favorable-risk Hodgkin's lymphoma. With increasing emphasis on alternative payment models, we investigate the cost effectiveness of chemotherapy alone versus combined modality therapy (CMT). METHODS AND MATERIALS A Markov model was formed to compared 2 cycles of ABVD to 2 cycles of ABVD followed by 20 Gy in 10 fractions involved-site radiotherapy (CMT). Modalities were compared using the incremental cost-effectiveness ratio (ICER), with effectiveness measured in quality-adjusted life years (QALYs) and evaluated with a willingness to pay threshold of $100,000 per QALY gained. RESULTS Base case analysis showed that CMT is cost effective compared to ABVD alone, with an ICER of $8,028 per QALY gained, and an incremental cost of $236 gaining 0.029 QALYs. On sensitivity analyses, results were most sensitive to changes in recurrence rates, if recurrence rate differences were ≥6% CMT was cost effective. CONCLUSION CMT is a cost-effective strategy for early-stage favorable-risk Hodgkin's lymphoma based on currently available evidence. However, small variations in recurrence rate estimates dramatically impact strategy cost-effectiveness.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Adam Richman
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Parvez M Shaikh
- Department of Radiation Oncology, West Virginia University, Morgantown, WV USA
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Cost effectiveness of caplacizumab in acquired thrombotic thrombocytopenic purpura. Blood 2021; 137:969-976. [PMID: 33280030 DOI: 10.1182/blood.2020006052] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease characterized by thrombotic microangiopathy leading to end-organ damage. The standard of care (SOC) treatment is therapeutic plasma exchange (TPE) alongside immunomodulation with steroids, with increasing use of rituximab ± other immunomodulatory agents. The addition of caplacizumab, a nanobody targeting von Willebrand factor, was shown to accelerate platelet count recovery and reduce TPE treatments and hospital length of stay in TTP patients treated in 2 major randomized clinical trials. The addition of caplacizumab to SOC also led to increased bleeding from transient reductions in von Willebrand factor and increased relapse rates. Using data from the 2 clinical trials of caplacizumab, we performed the first-ever cost-effectiveness analysis in TTP. Over a 5-year period, the projected incremental cost-effectiveness ratio (ICER) in our Markov model was $1 482 260, significantly above the accepted 2019 US willingness-to-pay threshold of $195 300. One-way sensitivity analyses showed the utility of the well state and the cost of caplacizumab to have the largest effects on ICER, with a reduction in caplacizumab cost demonstrating the single greatest impact on lowering the ICER. In a probabilistic sensitivity analysis, SOC was favored over caplacizumab in 100% of 10 000 iterations. Our data indicate that the addition of caplacizumab to SOC in treatment of acquired TTP is not cost effective because of the high cost of the medication and its failure to improve relapse rates. The potential impact of caplacizumab on health system cost using longer term follow-up data merits further study.
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Diehl LF. A+AVD versus eBEACOPP in advanced-stage Hodgkin lymphoma. Lancet Haematol 2021; 8:e384-e386. [DOI: 10.1016/s2352-3026(21)00129-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 01/29/2023]
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Cost-effectiveness of azacitidine and venetoclax in unfit patients with previously untreated acute myeloid leukemia. Blood Adv 2021; 5:994-1002. [PMID: 33591323 DOI: 10.1182/bloodadvances.2020003902] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/08/2021] [Indexed: 01/03/2023] Open
Abstract
The phase 3 VIALE-A trial reported that venetoclax in combination with azacitidine significantly improved response rates and overall survival compared with azacitidine alone in older, unfit patients with previously untreated acute myeloid leukemia (AML). However, the cost-effectiveness of azacitidine-venetoclax in this clinical setting is unknown. In this study, we constructed a partitioned survival model to compare the cost and effectiveness of azacitidine-venetoclax with azacitidine alone in previously untreated AML. Event-free and overall survival curves for each treatment strategy were derived from the VIALE-A trial using parametric survival modeling. We calculated the incremental cost-effectiveness ratio (ICER) of azacitidine-venetoclax from a US-payer perspective. Azacitidine-venetoclax was associated with an improvement of 0.61 quality-adjusted life-years (QALYs) compared with azacitidine alone. However, the combination led to significantly higher lifetime health care costs (incremental cost, $159 595), resulting in an ICER of $260 343 per QALY gained. The price of venetoclax would need to decrease by 60% for azacitidine-venetoclax to be cost-effective at a willingness-to-pay threshold of $150 000 per QALY. These data suggest that use of azacitidine-venetoclax for previously untreated AML patients who are ineligible for intensive chemotherapy is unlikely to be cost-effective under current pricing. Significant price reduction of venetoclax would be required to reduce the ICER to a more widely acceptable value.
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Chen Z, Cheng Y, DeRemer D, Diaby V. Cost-effectiveness and drug wastage of immunotherapeutic agents for hematologic malignancies: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2021; 21:923-941. [PMID: 33934691 DOI: 10.1080/14737167.2021.1913056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Ziyan Chen
- Department of Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, University of Florida, Gainesville, Florida, United States
| | - Yue Cheng
- Institute for Pharmaceutical Outcomes & Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, United States
| | - David DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, United States
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, University of Florida, Gainesville, Florida, United States
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Knödler M, Buyel JF. Plant-made immunotoxin building blocks: A roadmap for producing therapeutic antibody-toxin fusions. Biotechnol Adv 2021; 47:107683. [PMID: 33373687 DOI: 10.1016/j.biotechadv.2020.107683] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/07/2020] [Accepted: 12/20/2020] [Indexed: 12/16/2022]
Abstract
Molecular farming in plants is an emerging platform for the production of pharmaceutical proteins, and host species such as tobacco are now becoming competitive with commercially established production hosts based on bacteria and mammalian cell lines. The range of recombinant therapeutic proteins produced in plants includes replacement enzymes, vaccines and monoclonal antibodies (mAbs). But plants can also be used to manufacture toxins, such as the mistletoe lectin viscumin, providing an opportunity to express active antibody-toxin fusion proteins, so-called recombinant immunotoxins (RITs). Mammalian production systems are currently used to produce antibody-drug conjugates (ADCs), which require the separate expression and purification of each component followed by a complex and hazardous coupling procedure. In contrast, RITs made in plants are expressed in a single step and could therefore reduce production and purification costs. The costs can be reduced further if subcellular compartments that accumulate large quantities of the stable protein are identified and optimal plant growth conditions are selected. In this review, we first provide an overview of the current state of RIT production in plants before discussing the three key components of RITs in detail. The specificity-defining domain (often an antibody) binds cancer cells, including solid tumors and hematological malignancies. The toxin provides the means to kill target cells. Toxins from different species with different modes of action can be used for this purpose. Finally, the linker spaces the two other components to ensure they adopt a stable, functional conformation, and may also promote toxin release inside the cell. Given the diversity of these components, we extract broad principles that can be used as recommendations for the development of effective RITs. Future research should focus on such proteins to exploit the advantages of plants as efficient production platforms for targeted anti-cancer therapeutics.
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Affiliation(s)
- M Knödler
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Forckenbeckstrasse 6, Aachen 52074, Germany; Institute for Molecular Biotechnology, RWTH Aachen University, Worringerweg 1, Aachen 52074, Germany.
| | - J F Buyel
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Forckenbeckstrasse 6, Aachen 52074, Germany; Institute for Molecular Biotechnology, RWTH Aachen University, Worringerweg 1, Aachen 52074, Germany.
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Patel KK, Giri S, Parker TL, Bar N, Neparidze N, Huntington SF. Cost-Effectiveness of First-Line Versus Second-Line Use of Daratumumab in Older, Transplant-Ineligible Patients With Multiple Myeloma. J Clin Oncol 2021; 39:1119-1128. [PMID: 33411586 DOI: 10.1200/jco.20.01849] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The MAIA trial found that addition of daratumumab to lenalidomide and dexamethasone (DRd) significantly prolonged progression-free survival in transplant-ineligible patients with newly diagnosed multiple myeloma, compared with lenalidomide and dexamethasone alone (Rd). However, daratumumab is a costly treatment and is administered indefinitely until disease progression. Therefore, it is unclear whether it is cost-effective to use daratumumab in the first-line setting compared with reserving its use until later lines of therapy. METHODS We created a Markov model to compare healthcare costs and clinical outcomes of transplant-ineligible patients treated with daratumumab in the first-line setting compared with a strategy of reserving daratumumab until the second-line. We estimated transition probabilities from randomized trials using parametric survival modeling. Lifetime direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for first-line daratumumab versus second-line daratumumab from a US payer perspective. RESULTS First-line daratumumab was associated with an improvement of 0.52 QALYs and 0.66 discounted life-years compared with second-line daratumumab. While both treatment strategies were associated with considerable lifetime expenditures ($1,434,937 v $1,112,101 in US dollars), an incremental cost of $322,836 for first-line daratumumab led to an ICER of $618,018 per QALY. The cost of daratumumab would need to be decreased by 67% for first-line daratumumab to be cost-effective at a willingness-to-pay threshold of $150,000 per QALY. CONCLUSION Using daratumumab in the first-line setting for transplant-ineligible patients may not be cost-effective under current pricing. Delaying daratumumab until subsequent lines of therapy may be a reasonable strategy to limit healthcare costs without significantly compromising clinical outcomes. Mature overall survival data are necessary to more fully evaluate cost-effectiveness in this setting.
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Affiliation(s)
- Kishan K Patel
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Smith Giri
- Department of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Terri L Parker
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Noffar Bar
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Natalia Neparidze
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Scott F Huntington
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
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Patel KK, Stein S, Lacy J, O’Hara M, Huntington SF. Evaluation of the Cost-effectiveness of Doublet Therapy in Metastatic BRAF Variant Colorectal Cancer. JAMA Netw Open 2021; 4:e2033441. [PMID: 33433598 PMCID: PMC7804917 DOI: 10.1001/jamanetworkopen.2020.33441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The BEACON trial showed that combination therapy with encorafenib (BRAF inhibitor) and cetuximab (EGFR inhibitor) was associated with prolonged overall survival compared with standard chemotherapy in patients with metastatic BRAF variant colorectal cancer. However, the cost-effectiveness of using these agents in this clinical setting is unknown. OBJECTIVE To create a cost-effectiveness model to compare doublet therapy (encorafenib plus cetuximab) with standard chemotherapy (cetuximab plus irinotecan or cetuximab plus folinic acid, fluorouracil, and irinotecan) in treating patients with metastatic BRAF variant colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation constructed a Markov model to compare the lifetime cost and utility of doublet therapy and standard chemotherapy. Parametric survival modeling was used to extrapolate the effectiveness of each line of therapy from large clinical trials. One-way and probabilistic sensitivity analyses assessed the uncertainty in the model. Patients mirrored the cohorts in the BEACON trial: they had metastatic BRAF variant colorectal cancer and were followed up as they progressed through multiple lines of therapy, best supportive care, and death. Data collection and data analysis were performed from November 15, 2019, to July 14, 2020. MAIN OUTCOMES AND MEASURES The main outcome was the incremental cost-effectiveness ratio, which was calculated using the cumulative cost and effectiveness in quality-adjusted life years (QALYs), of doublet therapy compared with standard chemotherapy. RESULTS The model patient cohort had a mean age of 61 years, and 53% of the patients were women, 66% had 1 previous line of therapy, and 8% had high microsatellite instability. Doublet therapy was associated with an improvement of 0.15 QALYs compared with standard chemotherapy. However, the incremental cost of doublet therapy was $78 233, leading to an incremental cost-effectiveness ratio of $523 374 per QALY gained. Concomitant decreases in the price of encorafenib and cetuximab are needed to achieve cost-effectiveness at a willingness-to-pay threshold of $150 000 per QALY gained. CONCLUSIONS AND RELEVANCE This study found that doublet therapy for metastatic BRAF variant colorectal cancer was unlikely to be cost-effective under current pricing. Cost-effectiveness needs to be considered in clinical trial design, particularly when combining new therapies with non-cost-effective treatments that are coadministered without a fixed duration.
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Affiliation(s)
- Kishan K. Patel
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut
| | - Stacey Stein
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut
| | - Jill Lacy
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut
| | - Mark O’Hara
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Scott F. Huntington
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
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Yang J, Han J, He J, Duan B, Gou Q, Ai P, Liu L, Li Y, Ren K, Wang F, Yao M, Chen N. Real-World Cost-Effectiveness Analysis of Gemcitabine and Cisplatin Compared to Docetaxel and Cisplatin Plus Fluorouracil Induction Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma. Front Oncol 2020; 10:594756. [PMID: 33425747 PMCID: PMC7786365 DOI: 10.3389/fonc.2020.594756] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/19/2020] [Indexed: 02/05/2023] Open
Abstract
Background Addition of gemcitabine and cisplatin (GP) or docetaxel and cisplatin plus fluorouracil (TPF) to concurrent chemoradiotherapy (CCRT) significantly improved survival in locoregionally advanced nasopharyngeal carcinoma (NPC). However, an economic evaluation of these regimens remains unknown. The purpose of this study is to compare the cost-effectiveness of GP versus TPF regimen in the treatment of locoregionally advanced NPC in China. Materials and methods A comprehensive Markov model was developed to evaluate the health and economic outcomes of GP versus TPF regimen for patients with locoregionally advanced NPC. Baseline and clinical outcome were derived from 158 patients with newly diagnosed stage III-IVA NPC between 2010 and 2015. We evaluated the quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) from the perspective of the Chinese healthcare system. One-way sensitive analysis explored the impact of uncertainty in key model parameters on results, and probabilistic uncertainty was assessed through a Monte Carlo probabilistic sensitivity analysis. Results GP regimen provided an additional 0.42 QALYs with incremental cost of $3,821.99, resulting in an ICER of $9,099.98 per QALY versus TPF regimen at the real-world setting. One-way sensitivity analysis found that the results were most sensitive to the cost and proportion of receiving subsequent treatment in two groups. The probability that GP regimen being cost-effective compared with TPF regimen was 86.9% at a willingness-to-pay (WTP) of $31,008.16 per QALY. Conclusion Using real-world data, GP regimen was demonstrated a cost-effective alternative to TFP regimen for patients with locoregionally advanced NPC in China. It provides valuable evidence for clinicians when making treatment decisions to improve the cost-effectiveness of treatment.
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Affiliation(s)
- Jiangping Yang
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaqi Han
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlan He
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Baofeng Duan
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Qiheng Gou
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Ai
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Liu
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Yanchu Li
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Kexing Ren
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Wang
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Min Yao
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Nianyong Chen
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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Yang J, Han J, Tian M, Tian K, Liao W, Yan X. Cost-Effectiveness of Ribociclib for Hormone Receptor-Positive HER2-Negative Advanced Breast Cancer. Cancer Manag Res 2020; 12:12905-12913. [PMID: 33364838 PMCID: PMC7751309 DOI: 10.2147/cmar.s284556] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/25/2020] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Ribociclib has provided significant improvements in progression-free survival (PFS) and overall survival (OS) of postmenopausal patients with hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC). However, given the high cost of ribociclib, its value must be evaluated based on cost-effectiveness. Thus, we aimed to explore the cost-effectiveness of ribociclib for postmenopausal patients with HR-positive and HER2-negative ABC. METHODS A comprehensive Markov model was developed to estimate the cost-effectiveness of ribociclib plus fulvestrant versus placebo plus fulvestrant as first-line treatment for HR-positive, HER2-negative ABC. Variables were estimated based on data from the randomized Phase III MONALEESA-3 trial. Ten-year values were estimated for quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Direct treatment costs were estimated from the perspective of a United States payer. One-way and probabilistic sensitivity analyses were conducted to confirm the model's robustness. RESULTS Ribociclib plus fulvestrant increased the treatment cost by $382,172 and provided 0.47 QALYs, relative to fulvestrant alone, which corresponded to an ICER of $813,132 per QALY. Sensitivity analyses revealed that ribociclib was unlikely to be cost-effective even under the most favorable assumptions. When the cost of ribociclib was <$1,384, there was a >50% chance of cost-effectiveness at a willingness-to-pay threshold of $150,000/QALY. Subgroup analyses also confirmed that ribociclib was not cost-effective. CONCLUSION At current drug prices in the United States, ribociclib is unlikely to be cost-effective for treating postmenopausal patients with HR-positive HER2-negative ABC. Despite the clinical benefits of ribociclib, its cost would need to decrease to provide more favorable economic outcomes.
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Affiliation(s)
- Jiangping Yang
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan610041, People’s Republic of China
| | - Jiaqi Han
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan610041, People’s Republic of China
| | - Maolang Tian
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan610041, People’s Republic of China
| | - Kun Tian
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
| | - Wenjun Liao
- Department of Head and Neck Oncology and Department of Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan610041, People’s Republic of China
| | - Xi Yan
- Department of Head, Neck and Mammary Gland Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan610041, People’s Republic of China
- Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan610041, People’s Republic of China
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Raymakers AJN, Costa S, Cameron D, Regier DA. Cost-effectiveness of brentuximab vedotin in advanced stage Hodgkin's lymphoma: a probabilistic analysis. BMC Cancer 2020; 20:992. [PMID: 33050897 PMCID: PMC7557030 DOI: 10.1186/s12885-020-07374-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) is a well-established therapy for advanced Hodgkin's lymphoma (HL). However, the recently completed ECHELON-1 trial showed potential net clinical benefit for brentuximab vedotin (BREN+AVD) compared to ABVD as frontline therapy in patients with advanced Hodgkin's lymphoma. The objective of this analysis is to determine whether, on current evidence, BREN+AVD is cost-effective relative to ABVD as frontline therapy in patients with advanced HL. METHODS We constructed a probabilistic Markov model with two arms and six mutually exclusive health states, using six-month cycle lengths, and a 15-year time horizon. Time-dependent transition probabilities were calculated from 'real-world' data collected by the BC Cancer's Centre for Lymphoid Cancer database or from the literature for ABVD. Time-dependent transition probabilities for BREN+AVD were taken from the ECHELON-1 trial. We estimated the incremental cost and effects per patient of each therapy and calculated the incremental cost-effectiveness ratio (ICER). Costs were measured in 2018 Canadian dollars and effects measured in quality-adjusted life years (QALYs). A probabilistic analysis was used to generate a cost-effectiveness acceptability curve (CEAC). RESULTS The incremental cost between standard therapy with ABVD and therapy with BREN+AVD was estimated to be $192,336. The regimen of BREN+AVD resulted in a small benefit in terms of QALYs (0.46 QALYs). The estimated ICER was $418,122 per QALY gained. The probabilistic analysis suggests very few (8%) simulations fall below $100,000 per QALY. Even at a threshold of $200,000 per QALY gained, there was only a 24% chance that BREN+AVD would be considered cost-effective. Sensitivity analyses evaluating price reductions for brentuximab showed that these reductions needed to be in excess of 70% for this regimen to be cost-effective at a threshold of $100,000 per QALY. CONCLUSIONS There may be a clinical benefit associated with BREN+AVD, but on current evidence the benefit is not adequately substantive compared to ABVD therapy given the cost of brentuximab vedotin. Agencies responsible for making decisions about BREN+AVD as frontline therapy for patients with advanced HL should consider whether they are willing to implement this treatment given the current uncertainty and cost-benefit profile, or negotiate substantial price-reductions from the manufacturer should they choose to reimburse.
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Affiliation(s)
- A J N Raymakers
- Health Economics Analytic Support and Research Unit (HEASRU), BC Cancer, Vancouver, Canada.
- Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer Research Centre, 2nd floor, 675 West 10th Avenue, Vancouver, BC, V5Z 1L3, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
| | - S Costa
- Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer Research Centre, 2nd floor, 675 West 10th Avenue, Vancouver, BC, V5Z 1L3, Canada
| | - D Cameron
- Health Economics Analytic Support and Research Unit (HEASRU), BC Cancer, Vancouver, Canada
- Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer Research Centre, 2nd floor, 675 West 10th Avenue, Vancouver, BC, V5Z 1L3, Canada
| | - D A Regier
- Health Economics Analytic Support and Research Unit (HEASRU), BC Cancer, Vancouver, Canada
- Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer Research Centre, 2nd floor, 675 West 10th Avenue, Vancouver, BC, V5Z 1L3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Abstract
Hodgkin lymphoma (HL) is a B cell lymphoma characterized by few malignant cells and numerous immune effector cells in the tumour microenvironment. The incidence of HL is highest in adolescents and young adults, although HL can affect elderly individuals. Diagnosis is based on histological and immunohistochemical analyses of tissue from a lymph node biopsy; the tissue morphology and antigen expression profile enable classification into one of the four types of classic HL (nodular sclerosis, mixed cellularity, lymphocyte-depleted or lymphocyte-rich HL), which account for the majority of cases, or nodular lymphocyte-predominant HL. Although uncommon, HL remains a crucial test case for progress in cancer treatment. HL was among the first systemic neoplasms shown to be curable with radiation therapy and multiagent chemotherapy. The goal of multimodality therapy is to minimize lifelong residual treatment-associated toxicity while maintaining high levels of effectiveness. Recurrent or refractory disease can be effectively treated or cured with high-dose chemotherapy followed by autologous haematopoietic stem cell transplantation, and prospective trials have demonstrated the potency of immunotherapeutic approaches with antibody-drug conjugates and immune checkpoint inhibitors. This Primer explores the wealth of information that has been assembled to understand HL; these updated observations verify that HL investigation and treatment remain at the leading edge of oncological research.
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Baumgardner JR, Brauer MS, Zhang J, Hao Y, Liu Z, Lakdawalla DN. CAR-T therapy and historical trends in effectiveness and cost–effectiveness of oncology treatments. J Comp Eff Res 2020; 9:327-340. [DOI: 10.2217/cer-2019-0065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Aim: This study examines how chimeric antigen receptor T-cell (CAR-T) therapy’s incremental effectiveness and cost–effectiveness profile fits into the recent history of anticancer treatments. Materials & methods: We conducted graphical and multivariable analyses using data from the Cost–Effectiveness Analysis Registry of the Tufts Medical Center and the Institute for Clinical and Economic Review’s analysis of CAR-T therapies. We collected additional information including the US FDA approval years for pharmacologic innovations. Results: CAR-T provided 5.03 (95% CI: 3.88–6.18) more incremental quality-adjusted life-years than the average pharmaceutical intervention and 4.61 (95% CI: 1.67–7.56) more than the average nonpharmaceutical intervention, while retaining similar cost–effectiveness. There was evidence of worsening cost–effectiveness by approval year for pharmaceutical interventions. Limitations: Analysis is limited to anticancer treatments studied in cost–utility analyses, estimated to cover approximately 60% of FDA-approved antineoplastic agents. Conclusion: CAR-T therapy breaks a pattern of stagnant efficacy growth in pharmaceutical innovation and demonstrates significantly greater incremental effectiveness and similar cost–effectiveness to prior innovations.
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Affiliation(s)
| | | | - Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
| | - Yanni Hao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
| | - Zhimei Liu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA
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Reid JH, Marini BL, Nachar VR, Brown AM, Devata S, Perissinotti AJ. Contemporary treatment options for a classical disease: Advanced Hodgkin lymphoma. Crit Rev Oncol Hematol 2020; 148:102897. [PMID: 32109715 DOI: 10.1016/j.critrevonc.2020.102897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 01/06/2020] [Accepted: 02/03/2020] [Indexed: 01/12/2023] Open
Abstract
Advanced classical Hodgkin lymphoma (cHL) is a rare lymphoid disease characterized by the presence of Hodgkin and Reed-Sternberg (HRS) cells. Each year, cHL accounts for 0.5% of all new cancer diagnoses and about 80% are diagnosed with advanced stage disease. Given the significant improvement in cure rates, the focus of treatment has shifted towards minimization of acute and long-term toxicities. PET-adapted strategies have largely been adopted as standard of care in the United States in an attempt to balance toxicities with adequate lymphoma control. However, the appropriate upfront chemotherapy regimen (ABVD versus eBEACOPP) remains controversial.
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Affiliation(s)
- Justin H Reid
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, 1540 E. Hospital Drive, CW 7-251B, Ann Arbor, MI 48109, United States
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, 1540 E. Hospital Drive, CW 7-251B, Ann Arbor, MI 48109, United States
| | - Victoria R Nachar
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, 1540 E. Hospital Drive, CW 7-251B, Ann Arbor, MI 48109, United States
| | - Anna M Brown
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, 1540 E. Hospital Drive, CW 7-251B, Ann Arbor, MI 48109, United States
| | - Sumana Devata
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, 1500 E Medical Center Drive, Ann Arbor, MI 48109, United States
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, 1540 E. Hospital Drive, CW 7-251B, Ann Arbor, MI 48109, United States.
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Perissinotti AJ. Cost considerations in the first-line treatment of advanced Hodgkin lymphoma. LANCET HAEMATOLOGY 2020; 7:e91-e93. [PMID: 31948929 DOI: 10.1016/s2352-3026(19)30213-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA.
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27
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Huntington SF. Cure at what (systemic) financial cost? Integrating novel therapies into first-line Hodgkin lymphoma treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:252-259. [PMID: 31808838 PMCID: PMC6913455 DOI: 10.1182/hematology.2019000030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Classic Hodgkin lymphoma (cHL) stands out as success story in the field of medical oncology, with multiagent chemotherapy with or without radiation leading to durable remission for most patients. Large-scale clinical trials during the past 40 years have sought to minimize toxicities while maintaining strong efficacy, including efforts to reduce the size of radiation fields, minimize alkylator chemotherapy, reduce the number of chemotherapy cycles, and omit radiation in select populations. The last decade has also ushered in novel therapies, including brentuximab vedotin (BV), that have improved clinical outcomes for patients with cHL resistant to standard cytotoxic therapies. More recently, a large randomized trial compared BV plus chemotherapy with chemotherapy alone for first-line treatment of advanced stage cHL. With ∼24 months of available follow-up, the BV containing regimen was found to be associated with a reduction in the risk of progression, death, or incomplete response to first-line treatment (modified progression-free survival). Whether this early signal of improved efficacy is worth the additional acute toxicities and added drug-related expenses associated with incorporating BV into first-line treatment remains controversial. This chapter provides historical background; reviews the cost-effectiveness of available cHL therapies; and summarizes potential ways to balance innovation, affordability, and patient access to novel therapeutics.
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Affiliation(s)
- Scott F. Huntington
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, CT
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Kunst NR, Alarid-Escudero F, Paltiel AD, Wang SY. A Value of Information Analysis of Research on the 21-Gene Assay for Breast Cancer Management. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1102-1110. [PMID: 31563252 PMCID: PMC7343670 DOI: 10.1016/j.jval.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 05/02/2023]
Abstract
OBJECTIVES The 21-gene assay Oncotype DX (21-GA) shows promise as a guide in deciding when to initiate adjuvant chemotherapy in women with hormone receptor-positive early-stage breast cancer. Nevertheless, its routine use remains controversial, owing to insufficient evidence of its clinical utility and cost-effectiveness. Accordingly, we aim to quantify the value of conducting further research to reduce decision uncertainty in the use of the 21-GA. METHODS Using value of information methods, we first generated probability distributions of survival and costs for decision making with and without the 21-GA alongside traditional risk prediction. These served as the input to a comparison of 3 alternative study designs: a retrospective observational study to update risk classification from the 21-GA, a prospective observational study to estimate prevalence of chemotherapy use, and a randomized controlled trial (RCT) of the 21-GA predictive value. RESULTS We found that current evidence strongly supports the use of the 21-GA in intermediate- and high-risk women. Further research should focus on low-risk women, among whom the cost-effectiveness findings remained equivocal. For this population, we identified a high value of reducing uncertainty in the 21-GA use for all proposed research studies. The RCT had the greatest potential to efficiently reduce the likelihood of choosing a suboptimal strategy, providing a value between $162 million and $1.1 billion at willingness-to-pay thresholds of $150 000 to $200 000/quality-adjusted life years. CONCLUSION Future research to inform 21-GA decision making is of high value. The RCT of the 21-GA predictive value has the greatest potential to efficiently reduce decision uncertainty around 21-GA use in women with low-risk early-stage breast cancer.
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Affiliation(s)
- Natalia R Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway; Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Department of Epidemiology and Biostatistics, Amsterdam UMC, Amsterdam, the Netherlands; LINK Medical Research, Oslo, Norway.
| | - Fernando Alarid-Escudero
- Drug Policy Program, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Mexico; National Council on Science and Technology (CONACyT), Mexico City, Mexico
| | - A David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, USA; Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA
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Giri S, Huntington SF. Changes to Model Assumptions of the Cost-effectiveness of Durvalumab Therapy for Non-Small Cell Lung Cancer. JAMA Oncol 2019; 5:1066. [PMID: 31095252 DOI: 10.1001/jamaoncol.2019.1088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Smith Giri
- Section of Hematology, Department of Internal Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University, New Haven, Connecticut
| | - Scott F Huntington
- Section of Hematology, Department of Internal Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University, New Haven, Connecticut
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30
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Milunović V, Mišura Jakobac K, Kursar M, Mandac Rogulj I, Ostojić Kolonić S. FDA's and EMA's approval of brentuximab vedotin for advanced Hodgkin lymphoma: Another player in the town? Eur J Haematol 2019; 103:145-151. [PMID: 31166030 DOI: 10.1111/ejh.13269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/12/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022]
Abstract
ECHELON-1 study is a randomized open-labeled controlled trial investigating whether addition of brentuximab vedotin to chemotherapy offers benefit over the standard chemotherapy regimen in advanced Hodgkin lymphoma. After a median follow-up of 24.6 months, it has met its primary endpoint the reduction of modified progression-free survival being 23 percent. However, the beneficial effects have not been seen across all subgroups leading to further questions. The main aim of this review is to tackle these questions to provide the reader with in-depth insight of pros and cons of this novel, promising but ultimately controversial regimen.
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Affiliation(s)
- Vibor Milunović
- Division of Hematology, Clinical Hospital Merkur, Zagreb, Croatia
| | | | - Marin Kursar
- Division of Hematology, Clinical Hospital Merkur, Zagreb, Croatia
| | | | - Slobodanka Ostojić Kolonić
- Division of Hematology, Clinical Hospital Merkur, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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31
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Lin JK, Muffly LS, Spinner MA, Barnes JI, Owens DK, Goldhaber-Fiebert JD. Cost Effectiveness of Chimeric Antigen Receptor T-Cell Therapy in Multiply Relapsed or Refractory Adult Large B-Cell Lymphoma. J Clin Oncol 2019; 37:2105-2119. [PMID: 31157579 DOI: 10.1200/jco.18.02079] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Two anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapies are approved for diffuse large B-cell lymphoma, axicabtagene ciloleucel (axi-cel) and tisagenlecleucel; each costs $373,000. We evaluated their cost effectiveness. METHODS We used a decision analytic Markov model informed by recent multicenter, single-arm trials to evaluate axi-cel and tisagenlecleucel in multiply relapsed/refractory, adult, diffuse large B-cell lymphoma from a US health payer perspective over a lifetime horizon. Under a range of plausible long-term effectiveness assumptions, each therapy was compared with salvage chemoimmunotherapy regimens and stem-cell transplantation. Main outcomes were undiscounted life years, discounted lifetime costs, discounted quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (3% annual discount rate). Sensitivity analyses explored uncertainty. RESULTS In an optimistic scenario, assuming a 40% 5-year progression-free survival (PFS), axi-cel increased life expectancy by 8.2 years at $129,000/QALY gained (95% uncertainty interval, $90,000 to $219,000). At a 30% 5-year PFS, improvements in life expectancy were more modest (6.4 years) and expensive ($159,000/QALY gained [95% uncertainty interval, $105,000 to $284,000]). In an optimistic scenario, assuming a 35% 5-year PFS, tisagenlecleucel increased life expectancy by 4.6 years at $168,000/QALY gained (95% uncertainty interval, $105,000 to $414,000/QALY). At a 25% 5-year PFS, improvements in life expectancy were smaller (3.4 years) and more expensive ($223,000/QALY gained [95% uncertainty interval, $123,000 to $1,170,000/QALY]). Administering CAR-T to all indicated patients would increase US health care costs by approximately $10 billion over 5 years. Price reductions to $250,000 and $200,000, respectively, or payment only for initial complete response (at current prices) would allow axi-cel and tisagenlecleucel to cost less than $150,000/QALY, even at 25% PFS. CONCLUSION At 2018 prices, it is possible that both CAR-T therapies meet a less than $150,000/QALY threshold. This depends on long-term outcomes compared with chemoimmunotherapy and stem-cell transplantation, which are uncertain. Widespread adoption would substantially increase non-Hodgkin lymphoma health care costs. Price reductions or payment for initial response would improve cost effectiveness, even with modest long-term outcomes.
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Affiliation(s)
- John K Lin
- 1Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,2Stanford University, Stanford, CA
| | - Lori S Muffly
- 3Stanford University School of Medicine, Stanford, CA
| | | | - James I Barnes
- 1Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,2Stanford University, Stanford, CA
| | - Douglas K Owens
- 1Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,2Stanford University, Stanford, CA
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32
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Huntington SF, von Keudell G, Davidoff AJ, Gross CP, Prasad SA. Reply to H.J.A. Adams et al. J Clin Oncol 2019; 37:853-854. [DOI: 10.1200/jco.18.02297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Scott F. Huntington
- Scott F. Huntington, MD, Yale University, New Haven, CT; Gottfried von Keudell, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY; Amy J. Davidoff, PhD, Yale University School of Public Health, New Haven, CT; Cary P. Gross, MD, Yale University School of Medicine, New Haven, CT; and Sapna A. Prasad, PhD, Yale-New Haven Hospital, New Haven, CT
| | - Gottfried von Keudell
- Scott F. Huntington, MD, Yale University, New Haven, CT; Gottfried von Keudell, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY; Amy J. Davidoff, PhD, Yale University School of Public Health, New Haven, CT; Cary P. Gross, MD, Yale University School of Medicine, New Haven, CT; and Sapna A. Prasad, PhD, Yale-New Haven Hospital, New Haven, CT
| | - Amy J. Davidoff
- Scott F. Huntington, MD, Yale University, New Haven, CT; Gottfried von Keudell, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY; Amy J. Davidoff, PhD, Yale University School of Public Health, New Haven, CT; Cary P. Gross, MD, Yale University School of Medicine, New Haven, CT; and Sapna A. Prasad, PhD, Yale-New Haven Hospital, New Haven, CT
| | - Cary P. Gross
- Scott F. Huntington, MD, Yale University, New Haven, CT; Gottfried von Keudell, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY; Amy J. Davidoff, PhD, Yale University School of Public Health, New Haven, CT; Cary P. Gross, MD, Yale University School of Medicine, New Haven, CT; and Sapna A. Prasad, PhD, Yale-New Haven Hospital, New Haven, CT
| | - Sapna A. Prasad
- Scott F. Huntington, MD, Yale University, New Haven, CT; Gottfried von Keudell, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY; Amy J. Davidoff, PhD, Yale University School of Public Health, New Haven, CT; Cary P. Gross, MD, Yale University School of Medicine, New Haven, CT; and Sapna A. Prasad, PhD, Yale-New Haven Hospital, New Haven, CT
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Adams HJ, Kwee TC. A 73% Price Reduction Does Not Indisputably Justify Routine Application of Brentuximab Vedotin as First-Line Treatment of Hodgkin Lymphoma. J Clin Oncol 2019; 37:852-853. [DOI: 10.1200/jco.18.01830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Hugo J.A. Adams
- Hugo J.A. Adams, MD, PhD, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and Thomas C. Kwee, MD, PhD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thomas C. Kwee
- Hugo J.A. Adams, MD, PhD, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and Thomas C. Kwee, MD, PhD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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