Cost associated with hematopoietic stem cell transplantation: a retrospective claims data analysis in Germany

Epidemiology and Real-World Treatment of Incident Diffuse Large B-cell Lymphoma (DLBCL): A German Claims Data Analysis

INTRODUCTION

The objective of this study was to investigate the prevalence, incidence, and treatment patterns (treatment regimens, switches, duration) for diffuse large B-cell lymphoma (DLBCL) in a real-world setting.

METHODS

This was a retrospective German claims data analysis of patients with DLBCL diagnosed between January 1, 2012, and December 31, 2020. The prevalence and cumulative incidence of DLBCL were found for 2019/2020. Line of treatment  (LOT) and treatment setting from first DLBCL diagnosis to end of follow-up were described. Kaplan-Meier overall survival (OS) estimates since DLBCL diagnosis and start of treatment lines were calculated.

RESULTS

Overall, 2633 incident DLBCL cases were identified (median age 75 years, 51% male). Of these, 2119 patients received at least one DLBCL-related treatment (LOT1), and 1567 patients died during follow-up. In 2019/2020, the prevalence and cumulative incidence of DLBCL was 34.8/36.7 per 100,000 patients and 14.0/12.7 per 100,000 patients, respectively. For LOT1, 1922 patients were given a chemotherapy-based regimen (1530 with CD20 antibodies). A total of 403 patients were administered a second line (LOT2), of which 183 patients received a CD20 antibody-containing chemotherapy regimen and 100 patients received stem cell transplantation or chimeric antigen receptor (CAR)-T therapy. Of the 136 LOT3+ treatments, 74 were chemotherapy regimens (54 with CD20 antibodies) and 18 were kinase inhibitors. The median time between treatment lines was less than 6 months. Among patients with at least LOT2, approximately 50% received more than one LOT during the first year after diagnosis. Approximately 25% of treated patients died within 6 months of treatment initiation. Of the 2633 included patients, the median OS from diagnosis was 31.0 months (treated patients: 46.8 months, untreated patients: 3.0 months).

CONCLUSIONS

Despite advances in the field, high unmet medical need in DLBCL remains. The treatment landscape is very heterogeneous, particularly in second- or later-line treatments, with few patients receiving potentially curative treatment beyond the first line. Treatment for DLBCL, particularly for transplant-ineligible patients, remains challenging.

Delayed diagnosis of ocular graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

PURPOSE

To investigate the delayed diagnosis of chronic ocular graft-versus-host disease (coGVHD) after allogeneic hematopoietic stem cell transplantation (alloHCT), and further analyze potential confounding factors.

METHODS

This cross-sectional study included 118 patients newly diagnosed as coGVHD after alloHCT at Zhongshan Ophthalmic Center, Sun Yat-sen University. All participants finished the flow path of medical history taking, detailed ophthalmological examination and questionnaire-based survey. coGVHD was diagnosed and graded by International Chronic Ocular GVHD Consensus Group (ICOGCG) criteria. Lag time of diagnosis was defined as interval between noting of ocular symptoms and confirmed diagnosis of coGVHD (TN-D). We further compared the clinical parameters between groups categorized by the median TN-D as medium and long delay groups.

RESULTS

The median TN-D was 6.3 [IQR 2.8-14.5] months. Most coGVHD patients underwent delayed diagnosis of coGVHD longer than 3 months (70 %, 83 of 118), with 90 of 118 diagnosed as severe coGVHD (76 %). The long delay group exhibited higher ICOGCG scores (10 [IQR 9-10.5] vs. 9 [IQR 8-10], P = 0.039) and more pronounced ocular signs, including conjunctival injection, meibomian gland loss, fibrotic tarsal conjunctiva, symblepharon, and corneal complications (all P < 0.05). Delayed diagnosis was strikingly correlated with seeking ophthalmic medical care twice or more prior to diagnosis (adjusted OR = 5.42, 95%CI: 1.40-21.06, P = 0.015) and accurate knowledge of ocular discomfort symptoms in coGVHD (adjusted OR = 0.29, 95%CI: 0.08-1.00, P = 0.050).

CONCLUSIONS

Delayed diagnosis of coGVHD, associated with disease severity, was common among alloHCT recipients in southern China. Improving patient education and the awareness of ophthalmologists may facilitate early diagnosis of coGVHD.

Healthcare Resource Utilization and Cost Associated with Allogeneic Hematopoietic Stem Cell Transplantation: A Scoping Review

This scoping review summarizes the evidence regarding healthcare resource utilization (HRU) and costs associated with allogeneic hematopoietic stem cell transplantation (allo-HSCT). This study was conducted in accordance with the Joanne Briggs Institute methodology for scoping reviews. The PubMed, Embase, and Health Business Elite Electronic databases were searched, in addition to grey literature. The databases were searched from inception up to November 2022. Studies that reported HRU and/or costs associated with adult (≥18 years) allo-HSCT were eligible for inclusion. Two reviewers independently screened 20% of the sample at each of the 2 stages of screening (abstract and full text). Details of the HRU and costs extracted from the study data were summarized, based on the elements and timeframes reported. HRU measures and costs were combined across studies reporting results defined in a comparable manner. Monetary values were standardized to 2022 US Dollars (USD). We identified 43 studies that reported HRU, costs, or both for allo-HSCT. Of these studies, 93.0% reported on costs, 81.4% reported on HRU, and 74.4% reported on both. HRU measures and cost calculations, including the timeframe for which they were reported, were heterogeneous across the studies. Length of hospital stay was the most frequently reported HRU measure (76.7% of studies) and ranged from a median initial hospitalization of 10 days (reduced-intensity conditioning [RIC]) to 73 days (myeloablative conditioning). The total cost of an allo-HSCT ranged from $63,096 (RIC) to $782,190 (double umbilical cord blood transplantation) at 100 days and from $69,218 (RIC) to $637,193 at 1 year (not stratified). There is heterogeneity in the reporting of HRU and costs associated with allo-HSCT in the literature, making it difficult for clinicians, policymakers, and governments to draw definitive conclusions regarding the resources required for the delivery of these services. Nevertheless, to ensure that access to healthcare meets the necessary high cost and resource demands of allo-HSCT, it is imperative for clinicians, policymakers, and government officials to be aware of both the short- and long-term health resource requirements for this patient population. Further research is needed to understand the key determinants of HRU and costs associated with allo-HSCT to better inform the design and delivery of health care for HSCT recipients and ensure the quality, safety, and efficiency of care.

Hematopoietic cell transplants in resource-poor countries: challenges and opportunities

INTRODUCTION

Numbers of hematopoietic cell transplants continue to increase globally but most of this activity is in resource-rich countries. Limitations to increasing transplant activity in resource-poor countries include lack of sophisticated personnel and infrastructure, complexity in identifying and accessing donors, unavailability of some new drugs and high cost.

AREAS COVERED

We searched the biomedical literature for hematopoietic cell transplants and resource-rich and resource-poor countries. Recent advances which potentially make transplants more accessible in resource-poor countries include: (1) outpatient transplants; (2) grafts stored at 4°C; (3) less intensive pretransplant conditioning; (4) use of generic drugs; (5) less complex and costly donor access; and (6) increased collaboration with transplant centers in resource-rich countries.

EXPERT OPINION

We reviewed publications on the limitations and solutions discussed above. Paradoxically, most data we analyzed originate from resource-rich countries. We found no convincing epidemiological data to support a recent increased transplant rate in resource-poor countries yet but hope to see increases soon.

Cost analysis of childhood hematopoietic stem cell transplantation in Sichuan, China

Objective

To analyze the inpatient cost of hematopoietic stem cell transplantation (HSCT) in children, so as to support clinical decision-making.

Methods

Study population were children who received HSCT in a tertiary children's hospital (Sichuan, China) between 1st January 2020 and 31st December 2021. The median and interquartile range (IQR) of total cost at 100 days post transplantation were calculated. Subgroup analyses were conducted based on age, gender, transplantation types, and post-transplant complications. The cost differences between subgroups were analyzed to determine whether it had an impact on the total costs.

Results

A total of 142 pediatric patients were included in the study with a total cost of 250721.78 yuan (197019.16-315740.52, 1 yuan equals to around 0.15 US dollars). Drug costs accounted for 51.85% of the total cost, followed by medical service costs (12.57%) and treatment expenses (12.24%). In terms of transplantation types, the cost of autologous transplantation was lower than that of allogeneic transplantation (115722.98 yuan vs. 256043.99 yuan, p < 0.05), and the cost of human leukocyte antigen (HLA) complete matched was lower compared with that of partial matched (213760.88 yuan vs. 294044.84 yuan, p < 0.05). As for post-transplant complications, cases with <3 types of complications cost less than those with ≥3 types (212893.25 yuan vs. 286064.60 yuan, p < 0.05), and those with severity ≤ grade 2 cost less than those > grade 2 (235569.37 yuan vs. 280061.58 yuan, p < 0.05). Age and gender of patients did not lead to statistical differences in the total cost, while the transplantation types and post-transplant complications influenced the total cost.

Conclusion

The total cost at 100 days post transplantation associated with HSCT treatment were substantial for pediatric patients. The HLA compatibility between donors and recipients, and post-transplant complications were important factors affecting the total cost.

Inpatient treatment of relapsed/refractory diffuse large B-cell lymphoma (r/r DLBCL): A health economic perspective

INTRODUCTION

Patients with relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) require highly individualized therapies. Limited information exists regarding inpatient treatment patterns, outcomes, resource-use, and costs from the perspective of third-party payers in Germany. The aim of this study was to collect and evaluate routine inpatient care data to fill aforementioned gaps.

METHODS

Retrospective single center observational study in a German tertiary teaching hospital. Data were collected from patient records, the hospital-pharmacy database, and claims data.

RESULTS

Eighty-four patients (47 male; mean age at initial diagnosis, 59 years) were identified and grouped by treatment line (L): 2L (n = 78), 3L (n = 32), and >3L (n = 12). Prescribed treatments in 2L were chemotherapy 56%, auto-SCT 31%, allo-SCT 1%, other 12%; 3L: 50%, 16%, 6%, 28%, respectively, and >3L: 42%, 0%, 33%, 25%, respectively. Mean number of hospital admissions and length of inpatient stay (days) were: 2L (4, 44), 3L (2, 26), and >3L (5, 63). Average cost/patient: 2L = 44,750€, 3L = 32,589€ and >3L = 88,668€. Mean treatment costs per patient for stem-cell-transplanted patients were 55,468€ for autologous SCT (n = 28) and 131,264€ for allogeneic SCT (n = 7). Documented death was 21%, 28%, and 41% for 2L, 3L, and >3L, respectively.

CONCLUSION

Individualized DLBCL treatment in patients ≥ 2L is costly and results in a huge variability in resource consumption. The number of documented deaths and length of hospitalization signal a high economic burden on patients and families. A multicenter comprehensive evaluation of health and economic burdens of r/r DLBCL and linkage with other data sources (eg, registries, payers' claims data) is essential.

CRISPR/Cas-Based Gene Editing Strategies for DOCK8 Immunodeficiency Syndrome

Defects in the DOCK8 gene causes combined immunodeficiency termed DOCK8 immunodeficiency syndrome (DIDS). DIDS previously belonged to the disease category of autosomal recessive hyper IgE syndrome (AR-HIES) but is now classified as a combined immunodeficiency (CID). This genetic disorder induces early onset of susceptibility to severe recurrent viral and bacterial infections, atopic diseases and malignancy resulting in high morbidity and mortality. This pathological state arises from impairment of actin polymerization and cytoskeletal rearrangement, which induces improper immune cell migration-, survival-, and effector functions. Owing to the severity of the disease, early allogenic hematopoietic stem cell transplantation is recommended even though it is associated with risk of unintended adverse effects, the need for compatible donors, and high expenses. So far, no alternative therapies have been developed, but the monogenic recessive nature of the disease suggests that gene therapy may be applied. The advent of the CRISPR/Cas gene editing system heralds a new era of possibilities in precision gene therapy, and positive results from clinical trials have already suggested that the tool may provide definitive cures for several genetic disorders. Here, we discuss the potential application of different CRISPR/Cas-mediated genetic therapies to correct the DOCK8 gene. Our findings encourage the pursuit of CRISPR/Cas-based gene editing approaches, which may constitute more precise, affordable, and low-risk definitive treatment options for DOCK8 deficiency.

Improved Therapeutic Approaches are Needed to Manage Graft-versus-Host Disease

Allogeneic haematopoietic stem cell transplantation (alloHSCT) offers a potentially curative therapy for patients suffering from diseases of the haematopoietic system but requires a high level of expertise and is both resource intensive and expensive. A frequent and life-threatening complication is graft-versus-host disease (GvHD). Acute GvHD (aGvHD) generally causes skin, gastrointestinal and liver symptoms, but chronic GvHD (cGvHD) has a different pathophysiology and may affect nearly every organ or tissue of the body. In Europe, GvHD prophylaxis is generally a calcineurin inhibitor in combination with methotrexate, with high-dose systemic steroids used for advanced GvHD treatment. Between 39% and 59% of alloHSCT patients will develop aGvHD and around 36–37% will develop cGvHD. Steroid response decreases with increasing disease severity, which in turn leads to an increase in non-relapse mortality. GvHD imposes a financial burden on healthcare systems, significantly increasing post-alloHSCT costs. Increased GvHD disease severity magnifies this. Balancing immunosuppression to control the GvHD whilst maintaining a degree of immunocompetence against infection is critical. European GvHD guidelines acknowledge the lack of evidence to support a standard second-line therapy, and improved long-term outcomes and quality-of-life (QoL) remain an unmet need. Evidence generation for potential treatments is challenging. Issues to overcome include choice of comparator (extensive off-label usage); blinding; selection of relevant patient-reported outcome measures (PROMs); and rarity of the condition, which may infeasibly increase timescales to achieve clinical and statistical relevance.

Concepts in immuno-oncology: tackling B cell malignancies with CD19-directed bispecific T cell engager therapies

The B cell surface antigen CD19 is a target for treating B cell malignancies, such as B cell precursor acute lymphoblastic leukemia and B cell non-Hodgkin lymphoma. The BiTE® immuno-oncology platform includes blinatumomab, which is approved for relapsed/refractory B cell precursor acute lymphoblastic leukemia and B cell precursor acute lymphoblastic leukemia with minimal residual disease. Blinatumomab is also being evaluated in combination with other agents (tyrosine kinase inhibitors, checkpoint inhibitors, and chemotherapy) in various treatment settings, including frontline protocols. An extended half-life BiTE molecule is also under investigation. Patients receiving blinatumomab may experience cytokine release syndrome and neurotoxicity; however, these events may be less frequent and severe than in patients receiving other CD19-targeted immunotherapies, such as chimeric antigen receptor T cell therapy. We review BiTE technology for treating malignancies that express CD19, analyzing the benefits and limitations of this bispecific T cell engager platform from clinical experience with blinatumomab.