A model for analysing the cost of autologous peripheral blood progenitor cell (PBPC) transplantation

Outcomes of Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Performed in the Inpatient versus Outpatient Setting

Allogeneic hematopoietic cell transplantation (allo-HCT) with reduced-intensity conditioning (RIC) is commonly performed as an inpatient procedure. The feasibility and outcomes of RIC allo-HCT in the outpatient setting is not known. We performed a single-center retrospective cohort study of patients aged ≥ 18years with hematologic malignancies who underwent RIC allo-HCT either in the inpatient or outpatient setting. Donor types included HLA-matched sibling and well-matched unrelated donors. The objectives were to compare the survival, complications, charges, and incidences of relapse, nonrelapse mortality (NRM), and acute and chronic graft-versus-host disease (GVHD) between the 2 groups. Between 2014 and 2017, 151 eligible patients were included, with 116 undergoing RIC allo-HCT in the inpatient setting and 35 patients undergoing RIC allo-HCT in the outpatient setting. Baseline characteristics were comparable between the 2 groups except for a higher proportion of patients with myeloma in the outpatient cohort (inpatient 15.5% versus outpatient 37.1%). The cumulative incidence of grades II to IV acute GVHD (inpatient 25.2% versus outpatient 25.7%), grades III to IV acute GVHD (inpatient 10.4% versus outpatient 8.5%), chronic GVHD (inpatient 38.3% versus outpatient 51.6%), NRM at 1 year (inpatient 10.8% versus outpatient 3.2%), and relapse (inpatient 24.8% versus outpatient 33.2%) did not significantly differ between the 2 cohorts. One-year progression-free survival (inpatient 64.4% versus outpatient 63.6%, P = .39) and overall survival (inpatient 73.8% versus outpatient 82.8%, P = .93) were also not significantly different between the 2 groups. The proportion of patients who developed neutropenic fever (inpatient 25.8% versus outpatient 8.5%, P = .03) and mucositis (inpatient 50.8% versus outpatient 8.5%, P < .001) and who required total parenteral nutrition (inpatient 20.6% versus outpatient 5.7%, P = .04) were more frequent in the inpatient cohort. About 51.5% of the outpatient cohort never required hospital admission in the first 100days. Outpatient HCT resulted in significantly lower charges than inpatient HCT in the first 100days (median charges: inpatient $339,621 versus outpatient $247,334; P < .001). On multivariate analysis the site of the HCT (outpatient versus inpatient) was not a significant predictor of either overall or progression-free survival. Outpatient RIC allo-HCT is feasible and safe with daily outpatient evaluation and aggressive supportive care resulting in outcomes comparable with those who received the transplant in the inpatient setting.

A Comparative Assessment of Quality of Life in Patients with Multiple Myeloma Undergoing Autologous Stem Cell Transplantation Through an Outpatient and Inpatient Model

Outpatient autologous stem cell transplantation (ASCT) has proven to be feasible in terms of physical morbidity and mortality outcomes, but little data exist on the impact of this procedure on quality of life (QoL). The purpose of this prospective, observational, longitudinal cohort study was to compare the effects of inpatient (n = 76) and outpatient (n = 64) modes of care on QoL in patients with multiple myeloma who underwent ASCT. Patients were treated according to their preference for the inpatient or outpatient model. QoL was assessed using the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) at baseline (7 days before ASCT; T1) and at days +7 (T2) and +30 (T3) after ASCT. Overall, inpatients achieved higher mean values at each time point (86.05 ± 15.54 at T1, 89.23 ± 19.19 at T2, and 87.96 ± 13.6 at T3) compared with outpatients (85.62 ± 14.51 at T1, 87.42 ± 23.41 at T2, and 83.98 ± 20.2 at T3), although the differences did not reach statistical significance. Inpatients showed higher mean scores than outpatients in physical well-being (7.67 ± 5.7, 15.44 ± 6.34, and 12.96 ± 6.03, respectively, versus 5.89 ± 4.33, 13.92 ± 7.05, and 8.84 ± 6.33, respectively; P < .05). Mean scores on social/family well-being were significantly higher in the outpatient group compared with the inpatient group (22.93 ± 13.29, 21.14 ± 5.31, and 21.64 ± 4.58, respectively, versus 20.59 ± 3.79, 19.52 ± 5.12, and 20.01 ± 3.97, respectively; P = .003). There were no significant between-group differences with respect to functional well-being and emotional status. Among adults at a single institution undergoing ASCT for MM, the use of outpatient care compared with standard transplantation care did not result in improved QoL during transplantation. Further research is needed for replication and to assess longer-term outcomes and implications.

Very low rate of readmission after an early discharge outpatient model for autografting in multiple myeloma patients: an Italian multicenter retrospective study

We analyzed the main modalities and clinical outcomes of the early discharge outpatient model in autologous stem cell transplantation (EDOM-ASCT) for multiple myeloma in Italy. EDOM-ASCT was employed in 382 patients, for a total of 522 procedures, between 1998 and 2012. Our study showed high homogeneity among centers in terms of inclusion criteria, supportive care, and in hospital readmission criteria. Overall, readmissions during the aplastic phase occurred in 98 of 522 transplantations (18.8%). The major extrahematological complication was neutropenic fever in 161 cases (30.8%), which required readmission in 76 cases. The incidence of severe World Health Organization grade 3 to 4 mucositis was 9.6%. By univariate analysis, fever, mucositis, altered renal function at diagnosis, second transplantation, and transplantation performed late in the course of the disease were significantly correlated with readmission, whereas fever, mucositis, altered renal function, and timing of transplantation remained the only independent predictors by multivariate analysis. Overall, transplantation-related mortality was 1.0%. No center effect was observed in this study (P = .36). The safety and low rate of readmission of the EDOM-ASCT in myeloma trial suggest that this strategy could be extended to other transplantation centers if a stringent patient selection and appropriate management are applied.

The costs of mobilisation and collection of peripheral blood stem cells in multiple myeloma and lymphoma in an European country: results from The Gruppo Italiano Trapianto Midollo Osseo (GITMO) and Società Italiana di Emaferesi e Manipolazione Cellulare (SIdEM) survey

Scarce information is available about the cost of mobilisation/collection of peripheral blood stem cells for patients undergoing autologous transplant for relapsed Lymphoma or Multiple Myeloma. This paper reports the consumption of resources and costs collected through a survey among Italian Centres who adhere to the GITMO and SIdEM scientific societies. General transplant information was extracted from the European Promise database. Resources used alongside the phases of mobilisation/collection were retrieved. Resources for each of the process phases were quantified and averaged across centres and a unit cost value was attributed, based on administrative data from 3 centres, tariffs and market values. 25/89 Centres (34% of 2009 Promise transplants) provided data according to their standard practice. The mean cost/patient of the process of cell mobilisation/collection was € 6830 ± 1802 for Multiple Myeloma and € 7304 ± 1542 for Lymphoma. The organisational path for PBSC mobilisation/collection appears complex and cumbersome, spread amongst different treatment settings, with many different healthcare professionals being involved and considerable amounts of time and resources being currently dedicated to the management of patients requiring autologous transplantation.

Critical issues on high-dose chemotherapy with autologous hematopoietic progenitor cell transplantation in breast cancer patients

INTRODUCTION

High-dose chemotherapy (HDC) with autologous hematopoietic progenitor cell transplantation (AHPCT) for high-risk (HR) or metastatic breast cancer (MBC) is no longer an option.

AREAS COVERED

An expert panel including medical oncologists and hematologists produce an opinion paper on the use of HDC and AHPCT in BC patients and they explain why they believe that; despite inconclusive results thus far, this treatment should have an ongoing role in breast cancer management under clinical trials.

EXPERT OPINION

HDC with AHPCT has become a safe treatment modality and an advantage in disease-free survival has been observed in most of the studies with HDC, with the caveat that today, even a limited relapse-free survival and progression-free survival benefit is sufficient for the approval of new antineoplastic agents. Moreover, in HRBC, an overall survival benefit by HDC could be achieved in the HER2-ve and triple-negative populations and, in this setting, HDC with AHPCT represents a therapeutic option that can be proposed to well-informed patients. In MBC, the HDC approach should be investigated further in selected patients with HER2-ve, chemosensitive disease. This paper is not intended to give any conclusion, but rather to open a debate on the value of HDC in HR and MBC.

Healthcare costs of multiple myeloma: an Italian study

Few economic evaluations are currently available on multiple myeloma (MM) and they address treatment-related rather than disease-related costs. We estimated resource utilisation and costs associated with MM in an Italian haematology department. This was a single-centre observational study which followed retrospectively for 2 years 90 patients with MM stages II-III. To investigate the association between costs and age as a prognostic factor for treatment eligibility, patients were classified in two age groups (under 65 or >65). The annual average cost per patient was very similar in the two subgroups. Drugs and hospitalisations were the largest cost components. Differences between the two age groups were significant only for drugs, hospital admissions and day hospital (DH) days. Autologous stem-cell transplantation (ASCT) accounted for more than 80% of the non-pharmacological therapy costs, being nearly double in the younger patients. Cost of elderly patients is comparable with that of younger ones who generally receive expensive procedures such as ASCT. The higher hospital costs of younger patients were counterbalanced by supportive pharmaceutical care and DH days for older patients, mainly in the group treated with new immunomodulatory agents. Further multi-centre studies on larger samples of patients are needed.

Economic assessment in the management of non-Hodgkin’s lymphoma

An increasing need for economic evaluations of non-Hodgkin's lymphoma (NHL) treatments exists. We performed a literature review on the currently available NHL economic evaluations, using PubMed and the Cochrane database. English and Dutch language papers on treatment in adults were selected. A total of 88 publications were found, 44 of which were included. Of these, 6 economic evaluation-specific methodological items are evaluated (study perspective, overhead costs, data sources, charges or prices, sensitivity analysis, presentations of resource use and unit costs), enabling readers to judge the value of these studies. The 11 subjects covered by the economic evaluations are discussed. Many NHL treatments remain to be studied in economic evaluations. Future publications should report on the six methodological items in more detail, and preferably tackle them in the recommended way.

[Economic cost of peripheral blood progenitor cell transplantation in Spain]

BACKGROUND AND OBJECTIVE

Peripheral blood hematopoietic progenitor cell transplantation (PCT), both autologous and allogeneic, has been consolidated in the last decades as an important tool in the treatment of a number of oncohematologic malignancies. Nevertheless, there are scarce data about the real cost of the autologous procedure in our setting, and to date the economic impact of allogeneic PCT in our health system is unknown.

PATIENTS AND METHOD

In the present study a comparative analysis of the economic cost of both methods of PCT was carried out in a series of 67 consecutive patients who were eligible for autologous PCT (n = 48), or allogeneic PCT (n = 19) in a 2 year study period. The expenses derived from pretransplant studies, from the collection and processing of hematopoietic progenitors, and from the transplantation procedure itself were evaluated.

RESULTS

The collection of hematopoietic progenitors was significantly more expensive in autologous than in allogeneic PCT (p = 0.0001), owing both to the difficulty in the mobilization of such cells in patients who have been treated for the underlying disease and to the higher costs derived from the criopreservation of the collected material. Nevertheless, the costs of the pretransplant studies were significantly higher in allogeneic PCT due to the expenses of histocompatibility studies (p = 0.0001). Similarly, the costs derived from the transplantation procedure itself were significantly higher in allogeneic procedures (p = 0.0002) as those patients required a longer hospitalization, and also because of the higher number of patients requiring conditioning regimens including total body irradiation.

CONCLUSIONS

From these data we conclude that the real cost of PCT in our setting is 24,000 Euros for the autologous procedure, while it is 34,000 Euros in the context of allogeneic transplantation.

Aggressive non-Hodgkin's lymphoma: economics of high-dose therapy

High-intermediate grade non-Hodgkin's lymphoma (NHL) is an aggressive form of the disease, which can respond well to combination chemotherapy, with long-term survival seen in 40-50% of patients. When NHL relapses following standard treatment, high-dose chemotherapy with peripheral blood stem cell or bone marrow support may still cure a significant proportion of patients. Despite a significant rise in the incidence of NHL over recent years, there remains only limited published economic study concerning the overall lifetime cost of treatment, the cost effectiveness of specific treatments or the overall societal cost burden of the disease. The majority of studies identified for the purposes of this review considered the cost of alternative forms of chemotherapy and bone marrow support strategies for patients with advanced disease. Data from these studies suggest that there is a definite trend towards reduced costs for high-dose therapy, possibly reflecting increasing technical experience and improved bone marrow recovery through the use of stem cell transplantation and growth factors. The limited number of cost-effectiveness evaluations suggest that high-dose therapy, following a chemosensitive relapse, is likely to be considered favourable against commonly quoted cost-effectiveness thresholds. Cost effectiveness is becoming an increasingly important factor to consider in the formal assessment of new interventions conducted by groups such as the UK National Institute for Clinical Excellence. In light of the increasing incidence of NHL and the extended use of high-dose treatments in other subgroups of patients, there is a need for increased research into the economics of new interventions for NHL.

Economic aspects of high-dose chemotherapy: a clinician's perspective review

Over the last 15 years, the increased use of high-dose chemotherapy (HDC) has led to a considerable increase in the cost of cancer treatments. After making a general economic analysis of the benefits and costs of healthcare initiatives, this paper considers all of the different phases and elements of HDC, as well as the strategies for reducing basic, indirect and out-of-pocket costs. The cost of HDC has decreased by 40-60% over the last decade and its cost-effectiveness ratios are now similar or only slightly higher than those of other widely accepted medical interventions. However, except in the case of some hematological and paediatric neoplasms, the efficacy of the treatment has not yet been clearly defined and so it should only be used in well-designed clinical trials that should also include prospective cost evaluation measures.

Costs of high-dose chemotherapy and peripheral blood progenitor cell autograft for breast cancer

The aim of the study was to analyze the real cost of single or tandem high-dose chemotherapy (HDC) and peripheral blood progenitor cell autologous transplant (PBPCT) in patients with breast cancer. We analyzed the costs of 40 PBPCT performed in 20 patients. Tandem transplant was planned for each patient. Resources used and direct costs were identified for each patient. The study was carried out using the hospital perspective and monetary values were reported in 1999 Euro. The mean cost of whole procedure for single transplant was 20,816.63 Euro, while the mean cost of tandem transplant was 38,770.83 Euro. The cost distribution in the two groups was similar: the most expensive phase of procedure was the supportive phase post transplant (about 60% of total cost), with the categories of cost most represented being professional fees (about 28%) and pharmacy (about 35%). Awaiting more convincing trials of the clinical advantage of HDC in breast cancer, our analytical evaluation of transplant costs for different therapeutic options, single or tandem, permits identification of the most expensive categories in order to intervene for cost savings.