The cost-effectiveness of initial treatment of multiple myeloma in the U.S. with bortezomib plus melphalan and prednisone versus thalidomide plus melphalan and prednisone or lenalidomide plus melphalan and prednisone with continuous lenalidomide maintenance treatment

Cost-Effectiveness of Novel Agent Regimens for Transplant-Eligible Newly Diagnosed Multiple Myeloma Patients in India

BACKGROUND

Survival outcomes for multiple myeloma have improved dramatically since the introduction of novel therapeutic agents. While these drugs are highly effective in improving survival outcomes and quality of life in patients with multiple myeloma, they come at a significant cost. We assessed the cost-effectiveness of bortezomib-based triplet or quadruplet drug regimens in isolation and followed by autologous hematopoietic stem cell transplantation (AHSCT) for the treatment of newly diagnosed multiple myeloma (NDMM) in the Indian context.

METHODS

A Markov model was developed to assess the health and economic outcomes of novel drug regimens with and without AHSCT for the treatment of NDMM in India. We estimated the lifetime quality-adjusted life-years (QALYs) and costs in each scenario. The incremental cost-effectiveness ratios (ICERs) were computed and compared against the current willingness-to-pay threshold of a one-time per capita gross domestic product of ₹146,890 (US$1,927.70) for India. Parameter uncertainty was assessed through Monte Carlo probabilistic sensitivity analysis.

RESULTS

Among seven treatment sequences, the VCd (bortezomib, cyclophosphamide, dexamethasone) alone arm has the lowest cost and health benefits as compared to four treatment sequences, namely VTd (bortezomib, thalidomide, dexamethasone) alone, VRd (bortezomib, lenalidomide, dexamethasone) alone, VRd plus AHSCT and DVRd (Daratumumab, bortezomib, lenalidomide, dexamethasone) plus AHSCT. It was found that VTd plus AHSCT and VCd plus AHSCT arms were extendedly dominated (ED) by combination of two alternative treatments. Among the five non-dominated strategies, VRd has a lowest incremental cost of ₹ 2,20,093 (US$2,888) per QALY gained compared to VTd alone followed by VRd plus AHSCT [₹3,14,530 (US$4,128) per QALY gained] in comparison to VRd alone. None of the novel treatment sequences were found to be cost-effective at the current WTP threshold of ₹1,46,890 (US$1,927.7).

CONCLUSION

At the current WTP threshold of one-time per capita GDP (₹ 146,890) of India, VRd alone and VRd plus AHSCT has 38.1% and 6.9% probability to be cost-effective, respectively. Reduction in current reimbursement rates of novel drugs, namely VRd, lenalidomide, and pomalidomide plus dexamethasone under national insurance program and societal cost of transplant by 50%, would make VRd plus AHSCT and VTd plus AHSCT cost-effective at an incremental cost of ₹40,671 (US$34) and ₹97,639 (US$1,281) per QALY gained, respectively.

Anti-BCMA CAR-T therapy for multiple myeloma with extramedullary disease: A case report and review of the literature

INTRODUCTION

Multiple myeloma (MM) with extramedullary disease (EMD) is rare in clinical practice, and B cell maturation antigen (BCMA) CAR-T cell therapy is a novel therapy for hematologic malignancies. Very few reports have been published on the effect of CAR-T-cell therapy in MM with EMD. Here, we report a case of MM with extramedullary lesions treated with BCMA CAR-T therapy.

CASE PRESENTATION

A 66-year-old female patient presented to our hospital with an enlarged left maxillary gingiva.

DIAGNOSIS

Diagnosis of indolent MM stage III (DS staging) and stage III (ISS and R ISS) with extramedullary lesions.

INTERVENTION

The patient underwent a clinical trial of humanized anti-BCMA CAR T cell therapy.

RESULTS

Symptoms improved; left gingival hyperplasia and swelling resolved; left buccal mass resolved; and neck and submandibular masses resolved. Pathological examination of the exfoliated masses showed necrotic tissue.

CONCLUSION

MM with extramedullary lesions often has limited treatment options, and traditional chemotherapy methods are ineffective; however, BCMA CAR-T cell therapy can significantly improve the symptoms of extramedullary lesions in MM.

Dysregulation of Non-Coding RNAs: Roles of miRNAs and lncRNAs in the Pathogenesis of Multiple Myeloma

The dysregulation of non-coding RNAs (ncRNAs), specifically microRNAs (miRNAs) and long non-coding RNAs (lncRNAs), leads to the development and advancement of multiple myeloma (MM). miRNAs, in particular, are paramount in post-transcriptional gene regulation, promoting mRNA degradation and translational inhibition. As a result, miRNAs can serve as oncogenes or tumor suppressors depending on the target genes. In MM, miRNA disruption could result in abnormal gene expression responsible for cell growth, apoptosis, and other biological processes pertinent to cancer development. The dysregulated miRNAs inhibit the activity of tumor suppressor genes, contributing to disease progression. Nonetheless, several miRNAs are downregulated in MM and have been identified as gene regulators implicated in extracellular matrix remodeling and cell adhesion. miRNA depletion potentially facilitates the tumor advancement and resistance of therapeutic drugs. Additionally, lncRNAs are key regulators of numerous cellular processes, such as gene expression, chromatin remodeling, protein trafficking, and recently linked MM development. The lncRNAs are uniquely expressed and influence gene expression that supports MM growth, in addition to facilitating cellular proliferation and viability via multiple molecular pathways. miRNA and lncRNA alterations potentially result in anomalous gene expression and interfere with the regular functioning of MM. Thus, this review aims to highlight the dysregulation of these ncRNAs, which engender novel therapeutic modalities for the treatment of MM.

Systematic literature review of health economic models developed for multiple myeloma to support future analyses

AIMS

The goal of this study was to review the economic evaluations of health technologies in multiple myeloma (MM) and provide guidance and recommendations for future health economic analyses.

MATERIALS AND METHODS

A systemic literature review (SLR) was conducted on original economic assessment studies and structured review papers focusing on the studies in MM. The search was limited to English language papers published from 1 January 2000 onwards. Publications not applying any type of modelling methodology to describe disease progression and patient pathways over a specific time horizon were excluded.

RESULTS

A total of 2,643 publications were initially identified, of which 148 were eligible to be included in the full-text review phase. From these, 49 publications were included in the final analysis. Most published health economic analyses supported by models came from high-income countries. Evaluations from middle-income countries were rarely published. Diagnostic technologies were rarely modelled and integrated care had not been modelled. Very few models investigated MM treatments from a societal perspective and there was a relative lack of evaluations regarding minimal residual disease (MRD).

LIMITATIONS

Limitations of the publications included differences between trial populations and modelled populations, justification of methods, lack of confounder analyses, and small trial populations. Limitations of our study included the infeasibility of comparing MM economic evaluations due to the significant variance in modelled therapeutic lines and indications, and the relative scarcity of published economic evaluations from non-high-income countries.

CONCLUSIONS

As published economic models lacked many of the elements of the complex and heterogeneous patient pathways in MM and they focused on single decision problems, a thorough, open-source economic whole disease modelling framework is needed to assess the economic value of a wide range of technologies across countries with various income levels with a more detailed view on MM, by including patient-centric and societal aspects.

Multiple Myeloma: Challenges Encountered and Future Options for Better Treatment

Multiple myeloma (MM) is a malignant hematological disease. The disease is characterized by the clonal proliferation of malignant plasma cells in the bone marrow. MM accounts for 1.3% of all malignancies and has been increasing in incidence all over the world. Various genetic abnormalities, mutations, and translocation, including epigenetic modifications, are known to contribute to the disease’s pathophysiology. The prognosis is good if detected early, or else the outcome is very bad if distant metastasis has already occurred. Conventional treatment with drugs poses a challenge when there is drug resistance. In the present review, we discuss multiple myeloma and its treatment, drug resistance, the molecular basis of epigenetic regulation, the role of natural products in epigenetic regulators, diet, physical activity, addiction, and environmental pollutants, which may be beneficial for clinicians and researchers.

The Cost-Effectiveness Analysis of Transplant-Ineligible Myeloma Patients with Bortezomib plus Thalidomide plus Dexamethasone (VTD) or Bortezomib plus Melphalan plus Prednisolone (VMP) Treatment in Southern Taiwan

Background: This study aimed to evaluate the cost-effectiveness of treating transplant-ineligible myeloma patients with either a bortezomib plus thalidomide plus dexamethasone (VTD) or a bortezomib plus melphalan plus prednisolone (VMP) treatment in Taiwan. Methods: Newly diagnosed, transplant-ineligible myeloma patients with VTD or VMP therapy were enrolled from two medical centers in southern Taiwan. Quality-adjusted life years (QALYs) were used as the measurement unit of the effectiveness evaluation, and the incremental cost-effectiveness ratio (ICER) was used for comparison between the two groups. A net monetary benefit approach and cost-effectiveness acceptability curve were also used for the cost-effectiveness assessment. A one-way sensitivity analysis was used to check the impact of different parameters. In total, 77 patients were enrolled in the study with 43 patients in the VTD group and 34 patients in the VMP group. Clinical presentations were similar without significant difference, except the VTD group had a higher survival rate (p = 0.029). Comparisons of the two groups over an eight-month time horizon revealed a significant lower mean of direct medical costs in the VTD group than in the VMP group (p < 0.001), and a significantly higher average QALY was gained (p < 0.001). Conclusions: The study demonstrated the greater clinical benefit and cost-effectiveness of VTD compared to VMP therapy in transplant-ineligible, newly diagnosed myeloma patients.

The Cost of Enfortumab Vedotin Wastage Due to Vial Size-A Real-World Analysis

Simple Summary

Enfortumab Vedotin (EV) is FDA-approved for advanced urothelial cancer in patients previously treated with chemotherapy and immunotherapy. In this report, we looked at the extent of EV wastage (i.e., discarding of leftover drug not administered to the patient) in a single institute and estimated the financial impact of EV wastage annually in the United States. We found that wastage occurred in 46% of administered doses, with an average waste per dose of 2.9% (range 0–18%). The average drug wastage cost per patient was $3127 ($252 per dose). The annual cost of EV wastage in the US is estimated to be $15 million.

Abstract

Enfortumab Vedotin (EV) is FDA-approved for advanced urothelial cancer in patients previously treated with platinum-based chemotherapy and a checkpoint inhibitor. We conducted a real-world study to determine the extent of EV wastage in a single institution and assessed the financial impact of EV wastage annually in the United States. Systematic examination of the usage and wastage of all standard-of-care EV treatments administered to urothelial cancer patients at Memorial Sloan Kettering Cancer Center (MSKCC) between 1 January 2020 and 31 December 2020 was performed. Drug wastage was calculated by subtracting the actual administered dose from the total dose in an optimal set of vials. We built a pharmacoeconomic model to assess the financial impact of EV wastage annually in the US using the January 2021 Average Sales Prices from the Centers for Medicare and Medicaid Services. Sixty-four patients were treated with standard-of-care EV, with a median of 11 doses per patient (range 1–28). Wastage occurred in 46% of administered doses (367/793), with a mean waste per dose of 2.9% (0–18%). The average drug wastage cost per patient was $3127 ($252/dose). The annual cost of EV wastage in the US is estimated to be $15 million based on wastage data from a single center in the US. In summary, EV wastage due to available vial sizes was 2.9%, which falls under acceptable thresholds. While the percentage of EV wastage is relatively low, waste-minimizing practices may reduce the financial toxicity for the individual patient and for society.

Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Introduction

Evidence on long-term effectiveness and cost effectiveness of treatment sequences for multiple myeloma (MM) is sparse. We used published data and country-specific data to assess the cost effectiveness of four-line treatment sequences for elderly transplant-ineligible patients with MM in Serbia.

Method

We developed a Markov cohort model to compare long-term effectiveness and cost effectiveness of five sequential MM treatment alternatives from the perspective of the national healthcare provider. Effectiveness parameters on progression, mortality and adverse events were extracted from published clinical trials. Costs were based on price lists of the National Health Insurance Fund. We compared life expectancy, costs, and incremental cost-effectiveness ratios among alternative courses of action. The model was analyzed over a lifelong time horizon applying a 3% annual discount rate for effectiveness outcomes and costs. Robustness of the model was tested in multiple deterministic sensitivity analyses.

Results

The sequences were defined by the frontline treatment: MPT (melphalan-prednisone-thalidomide), MPV (melphalanprednisone-bortezomib), CTD (cyclophosphamide-thalidomide-dexamethasone), VCD (bortezomib-cyclophosphamidedexamethasone) and BP (bendamustine-prednisone). MPV sequence resulted in the highest remaining life expectancy (4.76 life years). Cost-effectiveness analysis resulted in three non-dominated strategies: MPT, VCD, and MPV sequences, with an incremental cost-effectiveness ratio of EUR 35,300 per life-year gained (LYG) for VCD and EUR 47,200/LYG for MPV relative to MPT.

Conclusion

MPV sequence was the most effective in terms of life expectancy for elderly transplant-ineligible MM patients in Serbia. Bortezomib-based strategies would be recommended for the frontline treatment of patients with MM in Serbia if the willingness-to-pay threshold is around EUR 35,000-60,000/LYG.

A systematic review of economic evaluations of treatment regimens in multiple myeloma

BACKGROUND

The expansion of advanced expensive therapeutic innovations for Multiple Myeloma (MM) led to increased disclosure of economic evaluations. The present analysis systematically reviewed and appraised the reporting quality of economic evaluations in MM.

METHODOLOGY

A comprehensive literature search in Ovid, MEDLINE(R), PubMed, and Cochrane libraries was conducted for studies published in the past decade. Two independent authors performed study selection and data extraction in a standardized form. Study methodological quality assessment was performed using 10-item Drummond's tool.

RESULTS

Of potentially eligible 1150 retrieved studies, 17 met eligibility criteria. Six evaluations (35%) were in newly diagnosed MM and 11 (65%) in relapse refractory (RR) MM. Nine studies (53%) embraced the payer's perspective, five (29%) adopted health care system, one (6%) societal and two did not report. Six (35%) employed partitioned survival model, 4(24%) discrete event simulation, 4(24%) Markov model and 2(12%) used decision tree model. The methodological quality has improved significantly; 16 (94%) studies comprehended a well-defined question by affirming the analysis perspective and examined both costs and outcomes while 13 (71%) provided a comprehensive description of competing alternatives.

CONCLUSION

The addition of novel drugs to the treatment armamentarium of MM is considerably cost-effective. The evaluations became more frequent, methodological quality has improved in the last decade.

Reduced Weekly Subcutaneous Doses of Bortezomib in Combination with Cyclophosphamide and Dexamethasone for Newly Diagnosed Multiple Myeloma

Objective:

A combination of bortezomib, cyclophosphamide, and dexamethasone is highly effective in the treatment of newly diagnosed multiple myeloma. Neuropathy is a dose-limiting adverse effect of this regimen. Subcutaneous and weekly injection instead of biweekly intravenous administration are used to reduce neuropathy. In this study, patients treated with subcutaneous weekly reduced the dose of bortezomib to reduce neuropathy and cost of treatment.

Methods:

This is an interventional study, including 16 patients. Enrolled patients received bortezomib 1 mg/m² subcutaneously, cyclophosphamide 300 mg/m² intravenously, and dexamethasone 40 mg intravenously days 1, 8, 15, and 22 of a 28 cycle.

Findings:

The overall response rate (≥partial response [PR]) was 93.8%. Thirteen of 16 patients (81.3%) were in an acceptable PR and complete response. Two patients (12.5%) achieving a PR. Meantime to achievement, the best response was 71 (55–87) days. Median progression-free survival was 33 (2–56) months, and autologous stem cell transplantation was performed for 68.8% of patients. Five patients (31.25%) experienced Grade I and one patient (6.25%) Grade III (no Grade 2 or 4) of peripheral neuropathy. Dose reduction and drug discontinuation was required in one patient (6.25%).

Conclusion:

A reduced subcutaneous, weekly dose of bortezomib in combination with cyclophosphamide and dexamethasone is effective with manageable profile toxicity and acceptable cost.

The tale of lenalidomide clinical superiority over thalidomide and regulatory and cost-effectiveness issues

In April 2017, the National Sanitary Surveillance Agency (ANVISA-Brazil) approved lenalidomide (LEN) for multiple myeloma (MM) and myelodysplastic syndrome. ANVISA had rejected the first application in 2010, and denied a request for reconsideration in 2012. The reason for rejection was the lack of comparative effectiveness studies proving that LEN was more effective than thalidomide (THAL), a strictly controlled drug regulated by Federal law 10.651/2003 and dispensed to patients (at no costs) through public health system units and hospitals. ANVISA unexplained retreat on the LEN approval for marketing was an unquestionable triumph of the lobbying that ensued the denial, at the forefront of which were politicians, Congress members, patient organizations and medical societies. Two randomized (phase III) trials and three observational (case-control and population-based cohort) compared the effectiveness of THAL- versus LEN-based therapies in MM. Overall, these studies showed no difference in efficacy between LEN- and THAL-based therapies. LEN caused less neuropathy, and more severe hematologic adverse effects. It is much costlier than THAL, and substitution of THAL by LEN shall raise considerably public healthcare costs in Brazil.

Cost Effectiveness of Transplant, Conventional Chemotherapy, and Novel Agents in Multiple Myeloma: A Systematic Review

BACKGROUND

Treatments for multiple myeloma (MM) have been rapidly evolving. Newly developed treatment regimens are likely to be more effective but also cost more than conventional therapies.

OBJECTIVE

We conducted a systematic review to compare the cost effectiveness of different classes of MM treatment.

METHODS

We searched the PubMed, MEDLINE, Web of Science, and EMBASE databases for studies published during 1990-2018 comparing the cost effectiveness of transplant, chemotherapeutic and novel MM treatments. Titles and abstracts were independently reviewed for eligibility by two investigators. The quality of the included studies was evaluated using the 16-item, validated Quality of Health Economics Studies instrument.

RESULTS

Twenty-four publications were included in the systematic review and summarized according to treatment regimen and line. For first-line treatment, transplant was the most cost-effective option for transplant-eligible MM patients [the incremental cost-effectiveness ratio (ICER) was $4053-€45,460 per quality-adjusted life-year (QALY) gained, and $3848-$72,852 per life-year gained (LYG)], and the ICER for novel agents compared with conventional chemotherapy was $59,076 per QALY and $220,681 per LYG. For second-line treatment, in comparisons of novel agent-based regimens, ICERs were inconsistent. However, bortezomib-based regimens, lenalidomide plus dexamethasone, and pomalidomide plus dexamethasone were each cost effective compared with dexamethasone alone (ICERs showed cost saving, £30,153 per QALY gained, and €39,911 per LYG, respectively).

CONCLUSIONS

For transplant-eligible MM patients, transplant is a cost-effective first-line treatment. More cost-effectiveness analyses comparing novel agents in the first-line treatment regimen are warranted to determine which agent or regimen is the most cost effective. In the second-line setting, it is unclear which novel agent-based regimen is most cost effective, but bortezomib-based regimens, lenalidomide plus dexamethasone, and pomalidomide plus dexamethasone were each cost effective compared with dexamethasone alone.

Lenalidomide maintenance post-transplantation in newly diagnosed multiple myeloma: real-world outcomes and costs

Aim: To compare real-world outcomes and costs among patients with newly diagnosed multiple myeloma receiving lenalidomide-only maintenance (Len-Mt) versus no maintenance after autologous hematopoietic stem cell transplantation. Patients & methods: Time to next treatment (TTNT) was evaluated; costs were calculated for 0–12, 12–24 and 24–36 months postindex date. Results: Len-Mt cohort had longer TTNT (HR: 0.43; p < 0.0001). Per-patient per-month costs during months 0–12 were higher among patients, receiving Len-Mt (USD 13,095 vs USD 8910; p < 0.0001), due to higher pharmacy costs – outpatient costs were lower. During months 12–24 and 24–36, outpatient costs were similar in both cohorts; total and pharmacy costs remained elevated for patients receiving Len-Mt. Conclusion: Len-Mt improved TTNT, initially reduced outpatient costs, but resulted in higher overall and pharmacy costs.

Cancer drug development: The missing links

IMPACT STATEMENT

The success rate for cancer drugs which enter into phase 1 clinical trials is utterly less. Why the vast majority of drugs fail is not understood but suggests that pre-clinical studies are not adequate for human diseases. In 1975, as per the Tufts Center for the Study of Drug Development, pharmaceutical industries expended 100 million dollars for research and development of the average FDA approved drug. By 2005, this figure had more than quadrupled, to $1.3 billion. In order to recover their high and risky investment cost, pharmaceutical companies charge more for their products. However, there exists no correlation between drug development cost and actual sale of the drug. This high drug development cost could be due to the reason that all patients might not respond to the drug. Hence, a given drug has to be tested in large number of patients to show drug benefits and obtain significant results.

Analysis of Availability and Access of Anti-myeloma Drugs and Impact on the Management of Multiple Myeloma in Latin American Countries

INTRODUCTION

Latin American countries (LATAMC) represent a large fraction of patients treated for multiple myeloma (MM) worldwide. In order to understand the difficulty of access to anti-myeloma therapy in LATAMC, we designed this study that explores areas involved in the availability of drugs, such as health care systems, approval times, coverage of new agents, old drugs, use of generics, and the first-line treatments.

MATERIAL AND METHODS

We collected data from 16 countries in 2015.

RESULTS

The majority of LATAMC (88%; n = 14) had mixed public and private coverage, with patients with MM cared for in public institutions. Although bortezomib and lenalidomide were approved in 100% and 73% in LATAMC, these figures did not translate to real-world practice as one-half of the nations reported unequal access to the new agents (thalidomide, bortezomib, and lenalidomide) in both public and private systems. Conversely, cheaper old drugs, represented by melphalan, were not available commercially in 44% (n = 7) of nations. Thus, first-line MM treatments for old and young patients in public practice were triplets with thalidomide-alkylating agent-steroid, whereas in private practice, treatments involved bortezomib-alkylating agent-steroid. An alarming rate of 30% of the nations reported suboptimal regimens (eg, VAD [vincristine, adriamycin, and dexamethasone]) or the impossibility of transplantation.

CONCLUSION

Our data indicates that bortezomib and transplant are still an unmet medical necessity in public systems. In the complex puzzle of myeloma drug access in LATAMC, important issues, such as the adjustment of disparities between health systems, the incorporation of new drugs with an economic cost-effectiveness view, and the re-establishment of essential old drugs, can be a platform to the future.

Immunosuppressants in Brazil: underlying drivers of spending trends, 2010-2015

BACKGROUND

Immunosuppressants are recommended for treatment of autoimmune diseases, and in transplant therapy. The high cost of these drugs has been causing an important impact on global pharmaceutical spending.

OBJECTIVE

Analyzing immunosuppressant expenditure in Brazil, using data from the Federal Procurement System database (SIASG), between 2010 and 2015.

METHODS

The pharmaceutical products were classified in accordance with the Anatomical, Therapeutic and Chemical (ATC) classification system recommended by World Health Organization (WHO) and aggregated by volume and by expenditure. The expenditure variation was decomposed into three broad categories: price effects, quantity effects, and drug mix effects.

RESULTS

During the period, annual expenditure increased by 49%, ranging from USD 494.5 million in 2010 to USD 738.7 million in 2015, while purchased quantities increased by 294%, ranging from 49.8 million in 2010 to 196.5 million in 2015. Two factors drove expenditures: the quantity effect and the drug-mix effect.

CONCLUSION

These findings may contribute to understand immunosuppressant spending trends and the factors that influence them in order to formulate effective cost containment strategies and design optimum drug policy. Rigorous evaluations are recommended to reduce the drug-mix effect, including systems to monitor price, effectiveness, safety, therapeutic value and budget impact of pharmaceutical innovations.

Response and progression-free survival according to planned treatment duration in patients with relapsed multiple myeloma treated with carfilzomib, lenalidomide, and dexamethasone (KRd) versus lenalidomide and dexamethasone (Rd) in the phase III ASPIRE study

Background

In ASPIRE, carfilzomib, lenalidomide, and dexamethasone (KRd) significantly improved progression-free survival (PFS) and response rates versus lenalidomide and dexamethasone (Rd) in patients with relapsed multiple myeloma. Per protocol, patients received KRd for a maximum of 18 cycles followed by Rd to progression, so the benefit/risk profile of KRd to progression was not established.

Methods

This post hoc analysis evaluated the efficacy and safety of KRd versus Rd at 18 months from randomization. Cumulative rates of complete response (CR) or better over time and PFS hazard ratio (HR) at 18 months were evaluated for KRd versus Rd. PFS HRs were also assessed according to cytogenetic risk, prior lines of therapy, and prior bortezomib treatment. Cox regression analysis was used to evaluate PFS HRs.

Results

The hazard ratio (HR) for PFS at 18 months was 0.58 versus 0.69 for the overall ASPIRE study. Patients with high-risk cytogenetics, ≥ 1 prior lines of therapy, and prior bortezomib exposure benefited from KRd up to 18 months versus Rd. The HRs for PFS at 18 months in the pre-defined subgroups were lower than those in the overall study. The difference in the proportion of KRd and Rd patients achieving at least a complete response (CR) increased dramatically over the first 18 months and then remained relatively constant. The safety profile at 18 months was consistent with previous findings.

Conclusions

The improved PFS HR at 18 months and the continued increase in CR rates for KRd through 18 cycles suggest that there may be a benefit of continued carfilzomib treatment.

Trial registration

Clinical trials.gov NCT01080391. Registered 2 March 2010.

Temporal Trends in Survival and Healthcare Costs in Patients with Multiple Myeloma in the United States

BACKGROUND

In recent years, the development of new therapies for multiple myeloma has improved the survival of patients, but newer treatments may also affect healthcare costs. To date, no real-world study has examined the concurrent changes in survival and total healthcare costs over time in patients with multiple myeloma.

OBJECTIVE

To examine the temporal changes in survival and healthcare costs among patients with multiple myeloma in the United States.

METHOD

This retrospective claims-based cohort study is based on death files in the Truven Health MarketScan Research Commercial and Medicare Supplemental databases. The study included adults who had at least 1 inpatient or 2 outpatient claims with a diagnosis of multiple myeloma between January 1, 2006, and December 31, 2014; continuous insurance enrollment for at least 12 months before and at least 30 days after the first diagnosis (ie, index date); and no previous malignancy. Patients were followed from the index date through the earliest among (1) the date of death recorded in the death files, (2) the end of enrollment in the MarketScan database, or (3) end of the study (September 30, 2015). The mortality rates and the total all-cause and multiple myeloma-specific healthcare costs per patient per month were compared between patients diagnosed in 2006-2010 and those diagnosed in 2011-2014.

RESULTS

A total of 5199 patients were included in the study (2597 diagnosed between 2006 and 2010 and 2602 diagnosed between 2011 and 2014). We found a 35% decrease in the risk for death (hazard ratio, 0.65; 95% confidence interval, 0.57-0.74) among patients diagnosed in 2011-2014 compared with those diagnosed in 2006-2010. In addition, 18% and 26% increases were found in all-cause and multiple myeloma-specific healthcare costs, respectively, over the same time period (adjusted mean all-cause costs, $13,960 vs $16,449, respectively; adjusted mean multiple myeloma-specific costs, $7476 vs $9422, respectively).

CONCLUSION

The percent decrease in mortality in patients with multiple myeloma has been greater than the percent increase in healthcare costs in recent years, which may be attributable to improved treatments for multiple myeloma and changes in disease management. With the mortality rate having decreased more than the increase in healthcare costs over the same time period, the results of this study suggest that although healthcare spending has increased over time, there is a survival benefit.

Therapeutic experience of vincristine/cyclophosphamide/melphalan or mitoxantrone/prednisone combination therapy plus thalidomide as first-line induction therapy for newly diagnosed multiple myeloma in a single institution of China

INTRODUCTION

To investigate the safety and efficacy of the combination regimen vincristine, cyclophosphamide, melphalan or mitoxantrone and prednisone (VCMP) plus thalidomide as first-line induction therapy for newly diagnosed multiple myeloma (MM).

METHODS

Three hundred and ninety-six symptomatic, newly diagnosed MM patients were treated with VCMP plus thalidomide in our hospital for the past 11 years, and clinical data of these patients were retrospectively analyzed.

RESULTS

Of the 396 patients enrolled, the total response rate was 77.3%. Forty-three patients relapsed after sCR and CR. Mean cycles to first response were six cycles (range 1-16 cycles). A total of 53% of patients achieved at least a PR within the first cycle of therapy. The actuarial 1-year, 3-year and 5-year overall survival of all patients were 89.4%, 29.5% and 10.6%, respectively. The probabilities of 1-year, 3-year and 5-year progression-free survival of all patients were 84.0%, 23.1% and 8.4%, respectively. The major adverse events were gastrointestinal symptoms, electrolytes and glucose metabolism disorders, hypertension, infection, peripheral nerve disease and hematological adverse events, which were mostly below grade 3 and could be alleviated by symptomatic treatment.

CONCLUSION

We concluded that VCMP plus thalidomide is an effective regimen with manageable side effects in the treatment of symptomatic, newly diagnosed MM including elderly patients and patients with renal failure.

Trends in overall survival and costs of multiple myeloma, 2000-2014

Little real-world evidence is available to describe the recent trends in treatment costs and outcomes for patients with multiple myeloma (MM). Using the Truven Health MarketScan Research Databases linked with social security administration death records, this study found that the percentage of MM patients using novel therapy continuously increased from 8.7% in 2000 to 61.3% in 2014. Compared with MM patients diagnosed in earlier years, those diagnosed after 2010 had higher rates of novel therapy use and better survival outcomes; patients diagnosed in 2012 were 1.25 times more likely to survive 2 years than those diagnosed in 2006. MM patients showed improved survival over the study period, with the 2-year survival gap between MM patients and matched controls decreasing at a rate of 3% per year. Total costs among MM patients have increased in all healthcare services over the years; however, the relative contribution of drug costs has remained fairly stable since 2009 despite new novel therapies coming to market. Findings from this study corroborate clinical data, suggesting a paradigm shift in MM treatment over the past decade that is associated with substantial survival gains. Future studies should focus on the impact on specific novel agents on patients' outcomes.

Management of Multiple Myeloma and Usage of Bortezomib: Perspective from India and Ukraine

Novel treatment strategies have remarkably improved the multiple myeloma (MM) patients’ survival, with associated increased costs. A joint panel meet of international experts from India and Ukraine was held in New Delhi on May 19, 2016 focusing on MM management, bortezomib role, unmet medical needs, and current challenges. The health-care system for oncology in India is majorly private vs. government-based in Ukraine. In India, electrophoresis, serum-free light chain assays, bone marrow tests, and X-rays are available modes of diagnosis. Despite of the numerous cancer centers and stem cell transplant centers, most patients do not prefer transplant owing to its high-cost and social stigma. Majority of the patients are treated with bortezomib or lenalidomide-based regimens. Most patients buy drug themselves. The expanding generic drugs market is a ray of hope for the affordable drugs. In Ukraine, immuno-fixation, bone marrow analysis, and magnetic resonance imaging are common diagnostic modalities. Due to high cost, only few patients undergo transplant. Bortezomib-based regimens are preferred in most of the patients; however, usage is limited due to high costs and lack of funds. Thalidomide-based regimens are used for maintenance therapy due to affordability. In case of relapsed MM, bortezomib is preferred in triple therapy; however, more affordable option is cyclophosphamide, thalidomide, and dexamethasone (CTD). Issues, such as cost containment, common treatment strategies, enhanced collaboration, and improved health-care access, need immediate attention. High-quality generics access will improve outcomes and support health-care cost containment. Pharmacoeconomic studies and head-to-head trials are warranted to determine the cost-effectiveness and benefit of novel therapies in MM.

Multiple myeloma and persistence of drug resistance in the age of novel drugs (Review)

Multiple myeloma (MM) is a mature B cell neoplasm that results in multi-organ failure. The median age of onset, diverse clinical manifestations, heterogeneous survival rate, clonal evolution, intrinsic and acquired drug resistance have impact on the therapeutic management of the disease. Specifically, the emergence of multidrug resistance (MDR) during the course of treatment contributes significantly to treatment failure. The introduction of the immunomodulatory agents and proteasome inhibitors has seen an increase in overall patient survival, however, for the majority of patients, relapse remains inevitable with evidence that these agents, like the conventional chemotherapeutics are also subject to the development of MDR. Clinical management of patients with MM is currently compromised by lack of a suitable procedure to monitor the development of clinical drug resistance in individual patients. The current MM prognostic measures fail to pick the clonotypic tumor cells overexpressing drug efflux pumps, and invasive biopsy is insufficient in detecting sporadic tumors in the skeletal system. This review summarizes the challenges associated with treating the complex disease spectrum of myeloma, with an emphasis on the role of deleterious multidrug resistant clones orchestrating relapse.

Cost-effectiveness of bortezomib for multiple myeloma: a systematic review

OBJECTIVES

To review published cost-effectiveness analyses (CEA) assessing bortezomib (BTZ) for multiple myeloma (MM) and explore possible bias affecting the cost-effectiveness of BTZ.

METHODS

Literature was searched for published CEAs assessing BTZ or BTZ-containing regimens for MM from 2003 to 2015. The reported incremental cost-effectiveness ratios (ICER) were adjusted by 2014 country-specific gross domestic product per capita (GDPPC) to compare the cost-effectiveness threshold of the World Health Organization (3 GDPPC per gained quality-adjusted life year [QALY]).

RESULTS

A total of 17 published CEAs were included in this review. When compared to non-BTZ treatments, BTZ-containing regimens were cost-effective for induction treatment prior to stem cell transplantation (SCT) in Canada, Poland, and Germany (ICER per QALY: 0.9299-2.254 GDPPC). BTZ/melphalan/prednisolone (VMP) was cost-effective for previously untreated and SCT-ineligible MM patients when compared to melphalan plus prednisolone (MP), melphalan/prednisone/lenalidomide with lenalidomide maintenance, and cyclophosphamide/thalidomide/dexamethasone (CTD) (ICER per QALY: dominant to 2.374 GDPPC) in Canada, UK, and USA. BTZ was cost-effective for relapsed/refractory MM when compared to best supportive care (ICER per life year: 0.9317-1.8210 GDPPC) in the UK and the USA, thalidomide in USA (0.5178 GDPPC/LY), and dexamethasone (DEX) in four Nordic countries (€54,451-€81,560/QALY). However, the cost-effectiveness for VMP versus MP plus thalidomide (MPT) and continuous lenalidomide (LEN) plus low-dose DEX (RD) for previously untreated and SCT-ineligible MM patients and BTZ versus LEN/DEX for relapsed/refractory MM patients could be unreliable because of the bias associated with model design and the indirect comparisons of treatment effects.

CONCLUSION

Published CEAs suggested that BTZ or BTZ-containing regimens were cost-effective when compared to most non-BTZ treatments for MM. However, the conflicting cost-effectiveness for VMP versus MPT for previously untreated and SCT-ineligible MM and BTZ versus LEN/DEX for relapsed/refractory MM needs more robust evidence for further clarification.

Lenalidomide: a review of its continuous use in patients with newly diagnosed multiple myeloma not eligible for stem-cell transplantation

Lenalidomide (Revlimid(®)) is a second-generation immunomodulatory drug structurally related to thalidomide, with improved efficacy and tolerability, for which the label in the EU was recently expanded to include continuous therapy in patients with previously untreated multiple myeloma not eligible for stem-cell transplantation. In randomized, controlled clinical trials, continuous lenalidomide therapy, either in combination with dexamethasone (FIRST trial) or as maintenance monotherapy following induction with melphalan/prednisone/lenalidomide (MM-015 trial), significantly improved progression-free survival (PFS) compared with induction therapy alone (with non-lenalidomide- or lenalidomide-containing regimens) in patients with newly diagnosed multiple myeloma not eligible for stem-cell transplantation. The improvements in PFS with continuous lenalidomide were reflected in improved health-related quality-of-life measures. An overall survival benefit was observed in the FIRST trial, but not in the MM-015 trial. Continuous lenalidomide and continuous thalidomide regimens displayed similar efficacy, but lenalidomide was associated with significantly less toxicity than thalidomide. Continuous use of lenalidomide did not appear to negatively impact on the drug's tolerability and did not increase the incidence of neutropenia or second primary malignancy compared with shorter-term use. The incidence of most adverse events began to reduce after about 18 months of therapy. In conclusion, continuous lenalidomide regimens provide an effective longer-term treatment option in patients with newly diagnosed multiple myeloma ineligible for stem-cell transplantation.

Adjusting for Drug Wastage in Economic Evaluations of New Therapies for Hematologic Malignancies: A Systematic Review

Purpose:

As costs of cancer care rise, there has been a shift to focus on value. Drug wastage affects costs to patients and health care systems without adding value. Historically, cost-effectiveness analyses have used models that assume no drug wastage; however, this may not reflect real-world practices. We sought to identify the frequency of drug wastage modeling in economic evaluations of modern parenteral therapies for hematologic malignancies.

Methods:

We conducted a systematic literature review of economic evaluations of new US Food and Drug Administration–approved parenteral chemotherapies with indications for the treatment of hematologic malignancies. The primary outcome of interest was the proportion of studies that modeled drug wastage in base-case analyses. If wastage was considered in primary analyses, we reported the impact of wastage on incremental cost-effectiveness ratios (ICERs) and drug acquisition costs.

Results:

Wastage was considered in base-case analyses in less than one third of all publications reviewed (12 of 38; 32%). Of these, two studies went on to complete sensitivity analyses and reported significant changes in the calculated ICER as a result. In one study, the ICER increased by 32%, and in the second, accounting for wastage changed a positive ICER to a dominant result.

Conclusion:

Potential costs associated with drug wastage are considered in only one third of modern cost-effectiveness models. The impact of wastage on calculated ICERs and drug acquisition costs is potentially substantial. The modeling of wastage in base-case and sensitivity analyses is recommended for future economic evaluations of new intravenous therapies for hematologic malignancies.

Multiple myeloma in the marrow: pathogenesis and treatments

Multiple myeloma (MM) is a B cell malignancy resulting in osteolytic lesions and fractures. In the disease state, bone healing is limited owing to increased osteoclastic and decreased osteoblastic activity, as well as an MM-induced forward-feedback cycle where bone-embedded growth factors further enhance tumor progression as bone is resorbed. Recent work on somatic mutation in MM tumors has provided insight into cytogenetic changes associated with this disease; the initiating driver mutations causing MM are diverse because of the complexity and multitude of mutations inherent in MM tumor cells. This manuscript provides an overview of MM pathogenesis by summarizing cytogenic changes related to oncogenes and tumor suppressors associated with MM, reviewing risk factors, and describing the disease progression from monoclonal gammopathy of undetermined significance to overt MM. It also highlights the importance of the bone marrow microenvironment (BMM) in the establishment and progression of MM, as well as associated MM-induced bone disease, and the relationship of the bone marrow to current and future therapeutics. This review highlights why understanding the basic biology of the healthy and diseased BMM is crucial in the quest for better treatments and work toward a cure for genetically diverse diseases such as MM.

Cost-effectiveness of lenalidomide plus dexamethasone vs. bortezomib plus melphalan and prednisone in transplant-ineligible U.S. patients with newly-diagnosed multiple myeloma

OBJECTIVE

To conduct a cost-effectiveness assessment of lenalidomide plus dexamethasone (Rd) vs bortezomib plus melphalan and prednisone (VMP) as initial treatment for transplant-ineligible patients with newly-diagnosed multiple myeloma (MM), from a U.S. payer perspective.

METHODS

A partitioned survival model was developed to estimate expected life-years (LYs), quality-adjusted LYs (QALYs), direct costs and incremental costs per QALY and LY gained associated with use of Rd vs VMP over a patient's lifetime. Information on the efficacy and safety of Rd and VMP was based on data from multinational phase III clinical trials and a network meta-analysis. Pre-progression direct costs included the costs of Rd and VMP, treatment of adverse events (including prophylaxis) and routine care and monitoring associated with MM. Post-progression direct costs included costs of subsequent treatment(s) and routine care and monitoring for progressive disease, all obtained from published literature and estimated from a U.S. payer perspective. Utilities were obtained from the aforementioned trials. Costs and outcomes were discounted at 3% annually.

RESULTS

Relative to VMP, use of Rd was expected to result in an additional 2.22 LYs and 1.47 QALYs (discounted). Patients initiated with Rd were expected to incur an additional $78,977 in mean lifetime direct costs (discounted) vs those initiated with VMP. The incremental costs per QALY and per LY gained with Rd vs VMP were $53,826 and $35,552, respectively. In sensitivity analyses, results were found to be most sensitive to differences in survival associated with Rd vs VMP, the cost of lenalidomide and the discount rate applied to effectiveness outcomes.

CONCLUSIONS

Rd was expected to result in greater LYs and QALYs compared with VMP, with similar overall costs per LY for each regimen. Results of this analysis indicated that Rd may be a cost-effective alternative to VMP as initial treatment for transplant-ineligible patients with MM, with an incremental cost-effectiveness ratio well within the levels for recent advancements in oncology.

Overview of cost-effectiveness analysis and health state utilities in multiple myeloma and estimations of health state utilities from real-world macedonian data

Multiple myeloma (MM) is a hematological neoplastic plasma-cell disorder in the bone marrow. Nowadays, the survival of MM patients has improved by using novel therapies (e.g., bortezomib, thalidomide). Decision-analytic models (DAM) are known to be very useful in guiding clinical and health policy decisions by systematically evaluating expected outcomes of alternative treatments. When conducting DAM, it is recommended by National Institute for Clinical Excellence (NICE) as the preferred framework to use qualityadjusted life years as the main measure for health outcomes derived from generic preference-based instruments. The objective of our study was to identify and analyze the structural and methodological approaches of published studies that evaluated: (1) DAM for various treatment strategies in MM and (2) published health utility values (HUVs) after MM treatment. The searches were developed in the electronic literature database PubMed/MEDLINE. Additionally, we aimed to derive real-world data for HUVs from the current patients’ treatment landscape in the Hematology Clinical Center in Skopje. The survey collecting national HUVs was conducted during the period January-November 2016, using the generic preference-based instrument EQ-5D-5L, administered at one-time point in 20 MM patients. Only five studies reported on using a DAM. Seven studies were included in the extraction of already published HUVs. The calculated national health utility score of 0.723 was comparable to the published data in the previously identified studies reporting on similar MM treatment protocols. Several modeling approaches and HUVs, developed for different treatment strategies and target groups in MM were identified. Those data could be used to parameterize a DAM for MM treatment.

Evaluation of immunomodulatory drugs in multiple myeloma: single center experience

OBJECTIVE

Multiple myeloma (MM) comprises 1% of all cancers and 10% of hematologic malignancies and known as an incurable disease. The introduction of immunomodulatory drugs (IMiDs) has brought a major shift in therapeutic paradigm in the treatment of newly diagnosed and relapsed/refractory MM patients. The aim of this study was to evaluate the relationship between response status and hematological parameters in patients with MM treated with thalidomide or lenalidomide.

METHODS

Sixty-eight patients who were treated with IMiDs in Ege University, School of Medicine, Department of Hematology, between 2005 and 2012, were evaluated, retrospectively.

RESULTS AND CONCLUSION

We could not find any difference between the hematological parameters before and after the treatment neither with thalidomide nor lenalidomide. However, the heterogenity of our groups, the difference in treatment strategies and potential side effects would have an impact on this result. It is needed to perform prospective clinical trials to prove that whether correction of hematological parameters would reflect the response status in patients with myeloma that treated with IMiDs.

Cost-effectiveness of rituximab in addition to fludarabine and cyclophosphamide (R-FC) for the first-line treatment of chronic lymphocytic leukemia

The cost-effectiveness of rituximab in combination with fludarabine/cyclophosphamide (R-FC) for the first line treatment of chronic lymphocytic leukemia (CLL) was evaluated. Based on long-term clinical data (follow-up of 5.9 years) from the CLL8-trial, a Markov-model with three health states (Free from disease progression, Progressive disease, Death) was used to evaluate the cost per quality-adjusted life-year (QALY) and cost per life years gained (LYG) of R-FC from the perspective of the German statutory health insurance (SHI). The addition of rituximab to FC chemotherapy results in a gain of 1.1 quality-adjusted life-years. The incremental cost-effectiveness ratio (ICER) of R-FC compared with FC was €17,979 per QALY (€15,773 per LYG). Results were robust in deterministic and probabilistic sensitivity analyses. From the German SHI perspective, rituximab in combination with FC chemotherapy represents good value for first-line treatment of patients with CLL and compares favorably with chemotherapy alone.

Cost-Effectiveness of Autologous Hematopoietic Stem Cell Transplantation for Elderly Patients with Multiple Myeloma using the Surveillance, Epidemiology, and End Results-Medicare Database

In the past decade, the number of autologous hematopoietic stem cell transplants (Auto HSCT) for older patients with multiple myeloma (MM) has increased dramatically, as has the cost of transplantation. The cost-effectiveness of this modality in patients over age 65 is unclear. Using the Surveillance, Epidemiology, and End Results-Medicare database to create a propensity-score matched sample of patients over age 65 between 2000 and 2007, we compared the survival and cost for those who received Auto HSCT to those who did not undergo transplantation but survived at least 6 months after diagnosis, and we calculated an incremental cost-effectiveness ratio (ICER). Two hundred seventy patients underwent transplantation. Median overall survival from diagnosis in those who underwent transplantation was significantly longer than in patients who did not (58 months versus 37 months, P < .001). For patients living longer than 2 years, the median monthly cost during the first year was significantly different, but the middle and last year of life costs were similar. The median cost of the first 100 days after transplantation was $60,000 (range, $37,000 to $85,000). The resultant ICER was $72,852 per life-year gained. Survival after transplantation was comparable to that in those who underwent transplantation patients under 65 years and significantly longer than older patients who did not undergo transplantation. With an ICER less than $100,000/life-year gained, Auto HSCT is cost-effective when compared with nontransplantation care in the era of novel agents and should be considered, where clinically indicated, for patients over the age of 65.

Financial toxicity in insured patients with multiple myeloma: a cross-sectional pilot study

BACKGROUND

Financial toxicity is increasingly recognised as adversely affecting the quality of life and medication adherence in patients with cancer in the USA. Patients with multiple myeloma might be particularly vulnerable because of high use of novel treatments and extended treatment duration.

METHODS

Between Aug 18, 2014, and Jan 7, 2015, we did a cross-sectional survey of individuals receiving at least 3 months of ongoing treatment for multiple myeloma at a tertiary academic medical centre in the USA. The survey was derived from previous reported studies and included the 11-item COST measure (financial toxicity score range 0-44). A paper survey was offered to eligible patients on arrival for routine follow-up visits, and participants were asked to complete the survey before or after their visit to the clinic. Insurance and treatment data were obtained from patients' electronic health records.

FINDINGS

Of 111 patients approached for the study, 100 individuals completed the survey. 59 (59%) of 100 patients reported that treatment costs were higher than expected, 70 (71%) of 99 had at least minor financial burden, and 36 (36%) of 100 reported applying for financial assistance. Use of savings to pay for myeloma treatment was common (43 [46%] of 94 patients) and 21 (21%) of 98 individuals borrowed money to pay for medications. COST scores were highly correlated with patient-reported use of strategies to cope with myeloma treatment expenses. On multivariable analysis, younger age (correlation coefficient β 0·36, 95% CI 0·15 to 0·56, p=0·00092), non-married status (5·6, 1·5 to 9·6, p=0·0074), longer duration since diagnosis (-4·8, -9·3 to -0·2, p=0·042), and lower household income (US$40 000-79 999: 7·8, 2·7 to 12·9, p=0·0031; ≥$80 000: 11·8, 7·1 to 16·4, p<0·0001) were associated with higher financial burden as measured with the COST score.

INTERPRETATION

Patient-reported financial toxicity and use of coping mechanisms were common in our insured population with multiple myeloma. Additional attention to rising treatment costs and cost sharing is needed to address the increasing evidence of financial toxicity affecting patients with cancer.

FUNDING

University of Pennsylvania Perelman School of Medicine.

Decision-analytic modeling studies: An overview for clinicians using multiple myeloma as an example

PURPOSE

The purpose of this study was to provide a clinician-friendly overview of decision-analytic models evaluating different treatment strategies for multiple myeloma (MM).

METHODS

We performed a systematic literature search to identify studies evaluating MM treatment strategies using mathematical decision-analytic models. We included studies that were published as full-text articles in English, and assessed relevant clinical endpoints, and summarized methodological characteristics (e.g., modeling approaches, simulation techniques, health outcomes, perspectives).

RESULTS

Eleven decision-analytic modeling studies met our inclusion criteria. Five different modeling approaches were adopted: decision-tree modeling, Markov state-transition modeling, discrete event simulation, partitioned-survival analysis and area-under-the-curve modeling. Health outcomes included survival, number-needed-to-treat, life expectancy, and quality-adjusted life years. Evaluated treatment strategies included novel agent-based combination therapies, stem cell transplantation and supportive measures.

CONCLUSION

Overall, our review provides a comprehensive summary of modeling studies assessing treatment of MM and highlights decision-analytic modeling as an important tool for health policy decision making.

Cost-effectiveness analysis of early vs. late autologous stem cell transplantation in multiple myeloma

BACKGROUND

Autologous stem cell transplant (ASCT) is the current standard of care for most patients with multiple myeloma (MM) who are transplant eligible, yet the timing of ASCT is disputed due to a similar overall (OS) and progression-free survival with an early ASCT (eASCT) or a delayed ASCT (dASCT) approach.

OBJECTIVE

We developed a decision analytic model to perform cost-effectiveness analysis of the two commonly used treatment strategies for MM.

METHODS

Data on disease progression and treatment effectiveness came from 2001 to 2008 cohort treated at the Mayo Clinic and from published studies. Cost analysis was performed from a third-party payer perspective.

RESULTS

The Consumer Price Index adjusted 2012 costs of eASCT and dASCT were $249 236 and $262 610, respectively. eASCT cohort had a benefit of 1.96 quality-adjusted life years (QALYs), 0.23 QALYs more than dASCT, implying that eASCT is preferred (dominant) over dASCT. The most critical variables in one-way sensitivity analysis were treatment-related mortality and OS associated with eASCT strategy.

CONCLUSIONS

We conclude that eASCT could potentially be a relatively cost-effective treatment option for appropriate patients with MM, and these results would help patients, providers, and payers in decision making for timing of ASCT.

Medical decision analysis for first-line therapy of chronic myeloid leukemia

Several tyrosine kinase inhibitors (TKIs) are approved for the treatment of chronic myeloid leukemia (CML). Our goal was to develop a clinical decision-analytic model for evaluation of the long-term effectiveness of different therapy regimens. We developed a Markov cohort model with a lifelong time horizon for first-line treatment with imatinib, dasatinib or nilotinib. Seven strategies including combinations of TKIs, chemotherapy and stem cell transplant were evaluated. The model was parameterized using published trial data, the Austrian CML registry and practice patterns estimated by experts. Health outcomes evaluated were life-years (LYs) and quality-adjusted LYs (QALYs). Based on our decision analysis, dasatinib following nilotinib failure was the most effective treatment in terms of LYs (19.8 LYs) and QALYs (16.1 QALYs). Sensitivity analyses showed that the ranking of strategies was mostly influenced by the duration of first- and second-line therapies. Our results may support decision-making regarding the sequential application of TKIs.

Effect of thalidomide on the proliferation of hepatoma cells assessed by osteopontin levels in nude mice

The aim of the present study was to investigate the inhibitory effects of thalidomide in the hepatocellular carcinoma nude mouse model in order to provide new insights into a comprehensive clinical intervention for hepatocellular carcinoma. MHCC97 cells were routinely cultured, passaged and adjusted to a single cell suspension with a concentration of 2×10⁷/ml. Six-week-old, BALB/C male nude mice were anesthetized and fixed in the prone position, then a subcapsular injection of the single cell suspension was administered into the spleen and their abdomens were closed. A laparotomy and left hepatic lobectomy was performed 14 days later and the abdomens were closed once again. Subsequent to the establishment of the hepatocellular carcinoma model, the nude mice were randomly divided into three groups, each consisting of 12 mice. The early intervention group were immediately provided with the post-operative thalidomide intervention, the late intervention group were provided with the post-operative thalidomide intervention one week subsequent to the surgery, and the negative control group were provided with a placebo intervention (0.9% physiological saline). Each intervention was continuously administered once per day for one week. The osteopontin (OPN) content of the liver tumors was detected using immunohistochemistry. The data were analyzed using an analysis of variance (ANOVA) test. There were significant differences in the OPN levels of the tumors among the early intervention, late intervention and negative control groups. Thalidomide may inhibit the generation of OPN and thereby inhibit the infiltration and metastasis of tumors; the immediate use of thalidomide following hepatectomy in the present study may block the invasion and metasis for liver cancer more effectively.