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Choon-Quinones M, Zelei T, Németh B, Tóth M, Jia XY, Barnett M, Keown P, Durie B, Harousseau JL, Hose D, Kaló Z. Systematic literature review of health economic models developed for multiple myeloma to support future analyses. J Med Econ 2023; 26:110-119. [PMID: 36346000 DOI: 10.1080/13696998.2022.2144056] [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: 11/11/2022]
Abstract
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.
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Affiliation(s)
| | - Tamás Zelei
- Syreon Research Institute, Budapest, Hungary
| | | | - Manna Tóth
- Syreon Research Institute, Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | | | - Mike Barnett
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Paul Keown
- Syreon Research Institute, Budapest, Hungary
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Brian Durie
- International Myeloma Foundation, North Hollywood, CA, USA
| | | | - Dirk Hose
- Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Zoltán Kaló
- Syreon Research Institute, Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
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Narsipur N, Bulla S, Yoo C, Do B, Tran K, Gu D, Zhong L, Wilson L. Cost-effectiveness of adding daratumumab or bortezomib to lenalidomide plus dexamethasone for newly diagnosed multiple myeloma. J Manag Care Spec Pharm 2021; 27:1691-1702. [PMID: 34818089 PMCID: PMC10391124 DOI: 10.18553/jmcp.2021.27.12.1691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Multiple myeloma survival rates are steadily increasing due to availability of new drug classes used in combination with corticosteroids and chemotherapy. The latest treatments are daratumumab or bortezomib in combination therapy with lenalidomide and dexamethasone (Rd). Daratumumab, a CD38-targeted, human IgG1k monoclonal antibody, and bortezomib, a proteasome inhibitor, are both approved as regimens for transplant-ineligible relapsed/refractory multiple myeloma (RRMM). There have been cost-effectiveness analyses for daratumumab and bortezomib use in RRMM, but there are limited data regarding cost-effectiveness for daratumumab or bortezomib use in newly diagnosed multiple myeloma patients who are ineligible for stem cell transplantation. OBJECTIVE: To compare the cost-effectiveness of 3 separate regimens-(1) daratumumab, lenalidomide, and dexamethasone triple therapy (DRd); (2) bortezomib and lenalidomide plus dexamethasone triple therapy (VRd); and (3) lenalidomide plus dexamethasone (Rd)-in patients with multiple myeloma ineligible for autologous stem cell transplant. METHODS: A 2-state Markov model was developed using a US health system perspective and lifetime time horizon. Transition probabilities were calculated from the latest progression-free survival data reported in two phase 3 randomized controlled trials-MAIA and SWOG S0777-and extrapolated using a Weibull distribution based on the Hoyle Henley method. National data sources were used to obtain costs in 2019 US dollars, discounted by 3%. Health state utilities from available literature were applied to each health state. Utility decrements for adverse events were individualized in each choice branch with utility decrement weighted by the percentage of patients who experienced the adverse event in the MAIA and SWOG S0777 trials. We assumed a treatment would be cost-effective at a willingness to pay (WTP) of $150,000 per progression-free quality-adjusted life-year ($/PFQALY). One-way and probabilistic sensitivity analyses were conducted. RESULTS: Rd standard therapy had the lowest overall cost at $329,867, followed by VRd at $385,434 and DRd with the highest overall total cost at $626,900. Rd was estimated to result in the least amount (1.24) of PFQALYs, followed by VRd at 1.35 PFQALYs and DRd at 1.52 PFQALYs. With a WTP threshold of $150,000 per PFQALY, VRd was not cost-effective compared with Rd standard therapy, with an incremental cost-effectiveness ratio (ICER) of $530,256 per PFQALY. DRd was not cost-effective compared with VRd (ICER = $1,396,318 per PFQALY), nor as compared with Rd standard therapy (ICER = $1060,832). One-way sensitivity analysis showed that our model was sensitive to cost of DRd, VRd, and Rd drugs. Probabilistic sensitivity analysis showed that only at a WTP threshold of $550,000 was VRd cost-effective for 40% of iterations. There were no reasonable WTP thresholds, up to $800,00, where DRd became more cost-effective than VRd. CONCLUSIONS: This study is the first analysis to directly compare the cost-effectiveness of 3 acceptable chemotherapy treatment regimens for patients with multiple myeloma ineligible for autologous stem cell transplant. Neither DRd nor VRd triple therapy were found to be cost-effective vs Rd. Further cost-effectiveness analyses that include overall survival data for daratumumab and bortezomib triple therapies are needed to demonstrate an ICER in QALYs. DISCLOSURES: No funding was received for this study. At the time of this study, Narsipur was a UCSF-Actelion Clinical Research and Medical Communications Fellow, unrelated to this study. The other authors have nothing to disclose.
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Affiliation(s)
- Nihal Narsipur
- UCSF-Actelion Clinical Research and Medical Communications Fellow, University of California, San Francisco
| | - Sabrina Bulla
- PharmD Candidates 2021, University of California, San Francisco
| | - Connie Yoo
- PharmD Candidates 2021, University of California, San Francisco
| | - Brenda Do
- PharmD Candidates 2021, University of California, San Francisco
| | - Kyle Tran
- PharmD Candidates 2021, University of California, San Francisco
| | - Dian Gu
- Institute for Health and Aging, University of California, San Francisco
| | | | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco
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New generation drugs for treatment of multiple myeloma. Drug Discov Today 2019; 25:367-379. [PMID: 31765717 DOI: 10.1016/j.drudis.2019.11.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/08/2019] [Accepted: 11/15/2019] [Indexed: 12/28/2022]
Abstract
Multiple myeloma (MM), a plasma cell malignancy, is characterised by lesions in multiple bones involving transformed, matured post-follicular B cells. The course of the disease involves an initial development of monoclonal gammopathy of undetermined significance (MGUS), followed by smouldering MM, before the full MM disease emerges. Despite novel therapies, MM remains incurable, managed by combination therapies, including proteasome inhibitors (PIs), immunomodulators (IMiDs) and anti-human CD38 (daratumumab). MM patients have an increased risk of thromboembolic events due to combination treatments with IMiDs, PIs and anti-human CD38 antibody, and steroids. This review will examine the efficacy and pro-thrombotic effects of MM therapies.
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Büyükkaramikli NC, Rutten-van Mölken MPMH, Severens JL, Al M. TECH-VER: A Verification Checklist to Reduce Errors in Models and Improve Their Credibility. PHARMACOECONOMICS 2019; 37:1391-1408. [PMID: 31705406 PMCID: PMC6860463 DOI: 10.1007/s40273-019-00844-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND In health economic literature, checklists or best practice recommendations on model validation/credibility always declare verification of the programmed model as a fundamental step, such as 'is the model implemented correctly and does the implementation accurately represent the conceptual model?' However, to date, little operational guidance for the model verification process has been given. In this study, we aimed to create an operational checklist for model users or reviewers to verify the technical implementation of health economic decision analytical models and document their verification efforts. METHODS Literature on model validation, verification, programming errors and credibility was reviewed systematically from scientific databases. An initial beta version of the checklist was developed based on the checklists/tests identified from the literature and from authors' previous modeling/appraisal experience. Next, the first draft checklist was presented to a number of health economists on several occasions and was tested on different models (built in different software, developed by different stakeholders, including drug manufacturers, consultancies or academia), each time leading to an update of the checklist and culminating in the final version of the TECHnical VERification (TECH-VER) checklist, introduced in this paper. RESULTS The TECH-VER necessitates a model reviewer (preferably independent), an executable and transparent model, its input sources, and detailed documentation (e.g. technical report/scientific paper) in which the conceptual model, its implementation, programmed model inputs, and results are reported. The TECH-VER checklist consists of five domains: (1) input calculations; (2) event-state (patient flow) calculations; (3) result calculations; (4) uncertainty analysis calculations; and (5) other overall checks (e.g. validity or interface). The first four domains reflect the verification of the components of a typical health economic model. For these domains, as a prerequisite of verification tests, the reviewer should identify the relevant calculations in the electronic model and assess the provided justifications for the methods used in the identified calculations. For this purpose, we recommend completeness/consistency checks. Afterwards, the verification tests can be conducted for the calculations in each of these stages by checking the correctness of the implementation of these calculations. For this purpose, the following type of tests are recommended in consecutive order: (i) black-box tests, i.e. checking if model calculations are in line with a priori expectations; (ii) white-box testing, i.e. going through the program code details line by line, or cell by cell (recommended for some crucial calculations and if there are some unexpected results from the black-box tests); and (iii) model replication/parallel programming (recommended only in certain situations, and if the issues related to the identified unexpected results from black-box tests could not be resolved through white-box testing). To reduce the time burden of model verification, we suggest a hierarchical order in tests i-iii, where going to the next step is necessary when the previous step fails. CONCLUSIONS The TECH-VER checklist is a comprehensive checklist for the technical verification of decision analytical models, aiming to help identify model implementation errors and their root causes while improving the transparency and efficiency of the verification efforts. In addition to external reviews, we consider that the TECH-VER can be used as an internal training and quality control tool for new health economists, while developing their initial models. It is the authors' aim that the TECH-VER checklist transforms itself to an open-source living document, with possible future versions, or 'bolt-on' extensions for specific applications with additional 'fit-for-purpose' tests, as well as 'tips and tricks' and some demonstrative error examples. For this reason, the TECH-VER checklist and the list of black-box tests created in this paper and a few model verification examples is uploaded to an open access, online platform (github and the website of the institute), where other users will also be able to upload their original verification efforts and tests.
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Affiliation(s)
- Nasuh C Büyükkaramikli
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Maureen P M H Rutten-van Mölken
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Johan L Severens
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Maiwenn Al
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
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Thielen FW, Büyükkaramikli NC, Riemsma R, Fayter D, Armstrong N, Wei CY, Huertas Carrera V, Misso K, Worthy G, Kleijnen J, Corro Ramos I. Obinutuzumab in Combination with Chemotherapy for the First-Line Treatment of Patients with Advanced Follicular Lymphoma : An Evidence Review Group Evaluation of the NICE Single Technology Appraisal. PHARMACOECONOMICS 2019; 37:975-984. [PMID: 30547368 PMCID: PMC6598743 DOI: 10.1007/s40273-018-0740-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The National Institute for Health and Care Excellence (NICE), as part of the institute's single technology appraisal (STA) process, invited the company that makes obinutuzumab (Roche Products Limited) to submit evidence of the clinical and cost effectiveness of the drug in combination with chemotherapy, with or without obinutuzumab as maintenance therapy for adult patients with untreated, advanced follicular lymphoma (FL) in the UK. Kleijnen Systematic Reviews Ltd (KSR), in collaboration with Erasmus University Rotterdam, was commissioned to act as the Evidence Review Group (ERG). This paper describes the company's submission, the ERG review, and NICE's subsequent decisions. The clinical evidence was derived from two phase III, company-sponsored, randomised, open-label studies. Most evidence on obinutuzumab was based on the GALLIUM trial that compared obinutuzumab in combination with chemotherapy as induction followed by obinutuzumab maintenance monotherapy with rituximab in combination with chemotherapy as induction followed by rituximab maintenance monotherapy in previously untreated patients with FL (grades 1-3a). Long-term clinical evidence was based on the PRIMA trial, studying the benefit of two years of rituximab maintenance after first-line treatment in patients with FL. The cost-effectiveness evidence submitted by the company relied on a partitioned survival cost-utility model, implemented in Microsoft® Excel. The base-case incremental cost-effectiveness ratio (ICER) presented in the company submission was <£20,000 per quality-adjusted life-year (QALY) gained. Although the ERG concluded that the economic model met the NICE reference case to a reasonable extent, some errors were identified and several assumptions made by the company were challenged. A new base-case scenario produced by the ERG suggested an ICER that was higher than the company base case, but still below £30,000 per QALY gained. However, some ERG scenario analyses were close to or even above the threshold. This was the case in particular for assuming a treatment effect that did not extend beyond trial follow-up. These results led to an initial negative recommendation by the appraisal committee. Subsequently, the company submitted a revised base case focusing on patients at intermediate or high risk of premature mortality. Simultaneously, a further price discount for obinutuzumab was granted. In addition to the company's revised base case, the ERG suggested a restriction of the treatment effect to 5 years and implemented biosimilar uptake and cheaper prices for rituximab. All of these adjustments did not exceed £30,000 per QALY gained and therefore the use of obinutuzumab for patients with advanced FL and a Follicular Lymphoma International Predictive Index (FLIPI) score of two or more could be recommended.
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Affiliation(s)
- Frederick W Thielen
- Institute of Health Policy and Management/Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
| | - Nasuh C Büyükkaramikli
- Institute of Health Policy and Management/Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | | | | | | | | | | | - Kate Misso
- Kleijnen Systematic Reviews Ltd., York, UK
| | | | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd., York, UK
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Isaac Corro Ramos
- Institute of Health Policy and Management/Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
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Grustam AS, Buyukkaramikli N, Koymans R, Vrijhoef HJM, Severens JL. Value of information analysis in telehealth for chronic heart failure management. PLoS One 2019; 14:e0218083. [PMID: 31220101 PMCID: PMC6586290 DOI: 10.1371/journal.pone.0218083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 05/26/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Value of information (VOI) analysis provides information on opportunity cost of a decision in healthcare by estimating the cost of reducing parametric uncertainty and quantifying the value of generating additional evidence. This study is an application of the VOI methodology to the problem of choosing between home telemonitoring and nurse telephone support over usual care in chronic heart failure management in the Netherlands. METHODS The expected value of perfect information (EVPI) and the expected value of partially perfect information (EVPPI) analyses were based on an informal threshold of €20K per quality-adjusted life-year. These VOI-analyses were applied to a probabilistic Markov model comparing the 20-year costs and effects in three interventions. The EVPPI explored the value of decision uncertainty caused by the following group of parameters: treatment-specific transition probabilities between New York Heart Association (NYHA) defined disease states, utilities associated with the disease states, number of hospitalizations and ER visits, health state specific costs, and the distribution of patients per NYHA group. We performed the analysis for two population sizes in the Netherlands-patients in all NYHA classes of severity, and patients in NYHA IV class only. RESULTS The population EVPI for an effective population of 2,841,567 CHF patients in All NYHA classes of severity over the next 20 years is more than €4.5B, implying that further research is highly cost-effective. In the NYHA IV only analysis, for the effective population of 208,003 patients over next 20 years, the population EVPI at the same informal threshold is approx. €590M. The EVPPI analysis showed that the only relevant group of parameters that contribute to the overall decision uncertainty are transition probabilities, in both All NYHA and NYHA IV analyses. CONCLUSIONS Results of our VOI exercise show that the cost of uncertainty regarding the decision on reimbursement of telehealth interventions for chronic heart failure patients is high in the Netherlands, and that future research is needed, mainly on the transition probabilities.
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Affiliation(s)
- Andrija S. Grustam
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Professional Health Solutions & Services Department, Philips Research, Eindhoven, the Netherlands
- * E-mail:
| | - Nasuh Buyukkaramikli
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute of Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Ron Koymans
- Professional Health Solutions & Services Department, Philips Research, Eindhoven, the Netherlands
| | - Hubertus J. M. Vrijhoef
- Department of Patient & Care, Maastricht UMC, Maastricht, the Netherlands
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussels, Brussels, Belgium
- Panaxea b.v., Amsterdam, the Netherlands
| | - Johan L. Severens
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute of Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Büyükkaramikli NC, de Groot S, Riemsma R, Fayter D, Armstrong N, Portegijs P, Duffy S, Kleijnen J, Al MJ. Ribociclib with an Aromatase Inhibitor for Previously Untreated, HR-Positive, HER2-Negative, Locally Advanced or Metastatic Breast Cancer: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. PHARMACOECONOMICS 2019; 37:141-153. [PMID: 30194622 PMCID: PMC6386053 DOI: 10.1007/s40273-018-0708-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The National Institute for Health and Care Excellence, as part of the institute's single technology appraisal process, invited the manufacturer of ribociclib (Kisqali®, Novartis) to submit evidence regarding the clinical and cost effectiveness of the drug in combination with an aromatase inhibitor for the treatment of previously untreated, hormone receptor-positive, human epidermal growth factor receptor 2-negative, locally advanced or metastatic breast cancer. Kleijnen Systematic Reviews Ltd and Erasmus University Rotterdam were commissioned as the Evidence Review Group for this submission. The Evidence Review Group reviewed the evidence submitted by the manufacturer, corrected and validated the manufacturer's decision analytic model, and conducted exploratory analyses to assess the robustness and validity of the presented clinical and cost-effectiveness results. This article describes the company submission, the Evidence Review Group assessment and National Institute for Health and Care Excellence subsequent decisions. The main clinical effectiveness evidence was obtained from the MONALEESA-2 trial, a randomised controlled trial comparing ribociclib plus letrozole with placebo plus letrozole. Progression-free survival was significantly longer in the ribociclib group (95% confidence interval, 19.3-not reached) vs. 14.7 months (95% confidence interval 13.0-16.5) in the placebo group. To assess the cost effectiveness of ribociclib in combination with an aromatase inhibitor, the company developed an individual patient-level model using a discrete-event simulation approach in Microsoft® Excel. In the model, simulated patients move through a series of three health states until death, i.e. first-line progression-free survival, second-line progression-free survival and progressive disease. The length of progression-free survival during the first line was informed by the MONALEESA-2 trial. The benefit in progression-free survival in the first line was transferred to a benefit in overall survival assuming full progression-free survival to overall survival surrogacy (because of the immaturity of overall survival data from the MONALEESA-2 trial). Patient-level data from the BOLERO-2 trial, evaluating the addition of everolimus to exemestane in the second-line treatment of postmenopausal HR-positive advanced breast cancer, were used to inform the length of progression-free survival during the second line. Costs included in the model were treatment costs (e.g. technology acquisition costs of first, second, third and/or later line treatments), drug administration costs, monitoring costs and health state costs (including terminal care). Additionally, the costs of adverse events associated with the first-line treatment were incorporated. The Evidence Review Group recalculated the incremental cost-effectiveness ratio using data from a different data cut-off date from the MONALEESA-2 trial and by changing some assumptions (e.g. progression-free survival to overall survival surrogacy approach and post-progression third and/or later line treatment-related costs). After two appraisal committee meetings and a revised base case submitted by the company (including a second enhanced patient access scheme discount), the committee concluded that taking into account the uncertainties in the calculation of the cost effectiveness, there were plausible cost-effectiveness estimates broadly in the range that could be considered as a cost-effective use of National Health Service resources. Therefore, ribociclib was recommended as a treatment option for the first-line treatment of hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer, contingent on the company providing ribociclib with the discount agreed in the second enhanced patient access scheme.
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Affiliation(s)
- Nasuh C Büyükkaramikli
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Saskia de Groot
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | | | | | | | - Piet Portegijs
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | | | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Maiwenn J Al
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
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Distelhorst CW. Targeting Bcl-2-IP 3 receptor interaction to treat cancer: A novel approach inspired by nearly a century treating cancer with adrenal corticosteroid hormones. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2018; 1865:1795-1804. [PMID: 30053503 DOI: 10.1016/j.bbamcr.2018.07.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 12/12/2022]
Abstract
Bcl-2 inhibits cell death by at least two different mechanisms. On the one hand, its BH3 domain binds to pro-apoptotic proteins such as Bim and prevents apoptosis induction. On the other hand, the BH4 domain of Bcl-2 binds to the inositol 1,4,5-trisphosphate receptor (IP3R), preventing Ca2+ signals that mediate cell death. In normal T-cells, Bcl-2 levels increase during the immune response, protecting against cell death, and then decline as apoptosis ensues and the immune response dissipates. But in many cancers Bcl-2 is aberrantly expressed and exploited to prevent cell death by inhibiting IP3R-mediated Ca2+ elevation. This review summarizes what is known about the mechanism of Bcl-2's control over IP3R-mediated Ca2+ release and cell death induction. Early insights into the role of Ca2+ elevation in corticosteroid-mediated cell death serves as a model for how targeting IP3R-mediated Ca2+ elevation can be a highly effective therapeutic approach for different types of cancer. Moreover, the successful development of ABT-199 (Venetoclax), a small molecule targeting the BH3 domain of Bcl-2 but without effects on Ca2+, serves as proof of principle that targeting Bcl-2 can be an effective therapeutic approach. BIRD-2, a synthetic peptide that inhibits Bcl-2-IP3R interaction, induces cell death induction in ABT-199 (Venetoclax)-resistant cancer models, attesting to the value of developing therapeutic agents that selectively target Bcl-2-IP3R interaction, inducing Ca2+-mediated cell death.
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Affiliation(s)
- Clark W Distelhorst
- Case Western University School of Medicine, Case Comprehensive Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States of America.
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Büyükkaramikli NC, de Groot S, Fayter D, Wolff R, Armstrong N, Stirk L, Worthy G, Albuquerque de Almeida F, Kleijnen J, Al MJ. Pomalidomide with Dexamethasone for Treating Relapsed and Refractory Multiple Myeloma Previously Treated with Lenalidomide and Bortezomib: An Evidence Review Group Perspective of an NICE Single Technology Appraisal. PHARMACOECONOMICS 2018; 36:145-159. [PMID: 29086363 PMCID: PMC5805808 DOI: 10.1007/s40273-017-0581-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The National Institute for Health and Care Excellence (NICE), as part of the institute's single technology appraisal (STA) process, invited the manufacturer of pomalidomide (POM; Imnovid®, Celgene) to submit evidence regarding the clinical and cost effectiveness of the drug in combination with dexamethasone (POM + LoDEX) for the treatment of relapsed and refractory multiple myeloma (RRMM) after at least two regimens including lenalidomide (LEN) and bortezomib (BOR). Kleijnen Systematic Reviews Ltd (KSR) and Erasmus University Rotterdam were commissioned as the Evidence Review Group (ERG) for this submission. The ERG reviewed the evidence submitted by the manufacturer, validated the manufacturer's decision analytic model, and conducted exploratory analyses in order to assess the robustness and validity of the presented clinical and cost-effectiveness results. This paper describes the company submission, the ERG assessment, and NICE's subsequent decisions. The company conducted a systematic review to identify studies comparing POM with comparators outlined in the NICE scope: panobinostat with bortezomib and dexamethasone (PANO + BOR + DEX), bendamustine with thalidomide and dexamethasone (BTD) and conventional chemotherapy (CC). The main clinical effectiveness evidence was obtained from MM-003, a randomized controlled trial (RCT) comparing POM + LoDEX with high-dose dexamethasone (HiDEX; used as a proxy for CC). Additional data from other studies were also used as nonrandomized observational data sources for the indirect treatment comparison of POM + LoDEX with BTD and PANO + BOR + DEX. Covariate or treatment switching adjustment methods were used for each comparison. The model developed in Microsoft® Excel 2010 using a semi-Markov partitioned survival structure, submitted in the original submission to NICE for TA338, was adapted for the present assessment of the cost effectiveness of POM + LoDEX. Updated evidence from the clinical-effectiveness part was used for the survival modelling of progression-free survival and overall survival. For POM + LoDEX, the patient access scheme (PAS) discount was applied to the POM price. Three separate comparisons were conducted for each comparator, each comparison using a different dataset and adjustment methods. The ERG identified and corrected some errors, and the corrected incremental cost-effectiveness ratios (ICERs) for POM + LoDEX versus each comparator were presented: approximately £45,000 per quality-adjusted life-year (QALY) gained versus BTD, savings of approximately £143,000 per QALY lost versus PANO + BOR + DEX, and approximately £49,000 per QALY gained versus CC. The ERG also conducted full incremental analyses, which revealed that CC, POM + LoDEX and PANO + BOR + DEX were on the cost-effectiveness frontier. The committee's decision on the technology under analysis deemed that POM + LoDEX should be recommended as an option for treating multiple myeloma in adults at third or subsequent relapse of treatments including both LEN and BOR, contingent on the company providing POM with the discount agreed in the PAS.
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Affiliation(s)
- Nasuh C Büyükkaramikli
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Saskia de Groot
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | | | - Lisa Stirk
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Fernando Albuquerque de Almeida
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Maiwenn J Al
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
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