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Tsutsué S, Makita S, Asou H, Matsuda H, Yamaura R, Taylor TD. Cost-effectiveness analysis 3L of axicabtagene ciloleucel vs tisagenlecleucel and lisocabtagene maraleucel in Japan. Future Oncol 2024. [PMID: 38597742 DOI: 10.2217/fon-2023-1114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Aim: Cost-effectiveness analysis (CEA) was performed to compare axicabtagene ciloleucel (axi-cel) with tisagenlecleucel (tisa-cel) and lisocabtagene (liso-cel) for treatment of relapsed or refractory large B-cell lymphoma in adult patients after ≥2 lines of therapy in Japan. Materials & methods: Cost-effectiveness analysis was conducted using the partition survival mixture cure model based on the ZUMA-1 trial and adjusted to the JULIET and TRANSCEND trials using matching-adjusted indirect comparisons. Results & conclusion: Axi-cel was associated with greater incremental life years (3.13 and 2.85) and incremental quality-adjusted life-years (2.65 and 2.24), thus generated lower incremental direct medical costs (-$976.29 [-¥137,657] and -$242.00 [-¥34,122]), compared with tisa-cel and liso-cel. Axi-cel was cost-effective option compared with tisa-cel and liso-cel from a Japanese payer's perspective.
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Affiliation(s)
- Saaya Tsutsué
- Gilead Sciences Japan,1-9-2 Marunouchi, Chiyoda-ku, Tokyo, 100-6616, Japan
| | - Shinichi Makita
- National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroya Asou
- Gilead Sciences Japan,1-9-2 Marunouchi, Chiyoda-ku, Tokyo, 100-6616, Japan
| | - Hiroyuki Matsuda
- IQVIA Solutions, Japan, 4-10-18 Takanawa Minato-ku, Tokyo, 108-0074, Japan
| | - Reiko Yamaura
- IQVIA Solutions, Japan, 4-10-18 Takanawa Minato-ku, Tokyo, 108-0074, Japan
| | - Todd D Taylor
- IQVIA Solutions, Japan, 4-10-18 Takanawa Minato-ku, Tokyo, 108-0074, Japan
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2
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Bouttell J, Fraser H, Goodlad JR, Hopkins D, McKay P, Oien KA, Seligmann B, von Delft S, Hawkins N. Adding a Gene Expression Profile Test to Aid Differential Diagnosis and Treatment in Aggressive Large B-Cell Lymphoma: An Early Exploratory Economic Evaluation. Appl Health Econ Health Policy 2024; 22:243-254. [PMID: 38017318 DOI: 10.1007/s40258-023-00845-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Adding gene expression profiles (GEPs) to the current diagnostic work-up of aggressive large B-cell lymphomas may lead to the reclassification of patients, treatment changes and improved outcomes. A GEP test is in development using TempO-Seq® technology to distinguish Burkitt lymphoma (BL) and primary mediastinal large B-cell lymphoma (PMBCL) from diffuse large B-cell lymphoma (DLBCL), and to classify patients with DLBLC and to predict the benefit of (e.g.) adding bortezomib to R-CHOP therapy (RB-CHOP). This study aims to estimate the potential impact of a GEP test on costs and health outcomes to inform pricing and evidence generation strategies. METHODS Three decision models were developed comparing diagnostic strategies with and without GEP signatures over a lifetime horizon using a UK health and social care perspective. Inputs were taken from a recent clinical trial, literature and expert opinion. We estimated the maximum price of the test using a threshold of Great Britain Pound (GBP) 30,000 per quality-adjusted life-year (QALY). Sensitivity analyses were conducted. RESULTS The estimated maximum threshold price for a combined test to be cost effective is GBP 15,352. At base-case values, the BL signature delivers QALY gains of 0.054 at an additional cost of GBP 275. This results in a net monetary benefit at a threshold of GBP 30,000 per QALY of GBP 1345. For PMBCL, the QALY gain was 0.0011 at a cost saving of GBP 406 and the net monetary benefit was GBP 437. The hazard ratio for the impact of treating BL less intensively must be at least 1.2 for a positive net monetary benefit. For identifying patients with the DLBCL subtype responsive to bortezomib, QALY gain was 0.2465 at a cost saving of GBP 6175, resulting in a net monetary benefit of GBP 13,570. In a probabilistic sensitivity analysis using 1000 simulations, a testing strategy was superior to a treat all with R-CHOP strategy in 81% of the simulations and with a cost saving in 92% assuming a cost price of zero. CONCLUSIONS Our estimates show that the combined test has a high probability of being cost effective. There is good quality evidence for the benefit of subtyping DLBCL but the evidence on the number of patients reclassified to or from BL and PMBCL and the impact of a more precise diagnosis and the cost of treatment is weak. The developers can use the price estimate to inform a return on investment calculations. Evidence will be required of how well the TempO-Seq® technology performs compared to the testing GEP technology used for subtyping in the recent clinical trial. For BL and PMBCL elements of the test, evidence would be required of the number of patients reclassified and improved costing information would be useful. The diagnostic and therapeutic environment in haematological malignancies is fast moving, which increases the risk for developers of diagnostic tests.
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Affiliation(s)
- Janet Bouttell
- Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Health Economics and Health Technology Assessment, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow, G12 8TB, UK.
| | - Heather Fraser
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - John R Goodlad
- NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, Glasgow, UK
| | - David Hopkins
- NHS Greater Glasgow and Clyde, Gartnavel General Hospital, Glasgow, UK
| | - Pam McKay
- NHS Greater Glasgow and Clyde, Gartnavel General Hospital, Glasgow, UK
| | - Karin A Oien
- School of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Stephan von Delft
- Adam Smith Business School, University of Glasgow, Glasgow, UK
- Reach Euregio Start-up Center, University of Münster, Münster, Germany
| | - Neil Hawkins
- Health Economics and Health Technology Assessment, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow, G12 8TB, UK
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Oluwole OO, Ray MD, Davies N, Bradford R, Jones C, Patel AR, Locke FL. Cost-effectiveness of axicabtagene ciloleucel versus tisagenlecleucel for the treatment of 3L + relapsed/refractory large B-cell lymphoma in the United States: incorporating longer survival results. J Med Econ 2024; 27:230-239. [PMID: 38240256 DOI: 10.1080/13696998.2024.2305558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024]
Abstract
AIMS To provide an update on the cost-effectiveness of the chimeric antigen receptor (CAR) T-cell therapies axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) for the treatment of relapsed/refractory (r/r) large B-cell lymphoma (LBCL) among patients who have previously received ≥2 lines of systemic therapy using more mature clinical trial data cuts (60 months for axi-cel overall survival [OS] and 45 months for tisa-cel OS and progression-free survival [PFS]). METHODS A partitioned survival model consisting of three health states (pre-progression, post-progression and death) was used to estimate quality-adjusted life years (QALYs) and costs associated with axi-cel and tisa-cel over a lifetime horizon. PFS and OS inputs for axi-cel and tisa-cel were based on a previously published matching-adjusted indirect treatment comparison (MAIC). Long-term OS and PFS were extrapolated using parametric survival mixture cure models (PS-MCMs). Costs of CAR-T cell therapy drug acquisition and administration, conditioning chemotherapy, apheresis, CAR T-specific monitoring, stem cell transplant, hospitalization, adverse events, routine care, and terminal care were sourced from US cost databases. Health state utilities were derived from previous publications. Model inputs were varied using a range of sensitivity and scenario analyses. RESULTS Compared with tisa-cel, axi-cel resulted in 2.51 additional QALYs and $50,185 additional costs (an incremental cost-effectiveness ratio [ICER] of $19,994 per QALY gained). In probabilistic sensitivity analysis (PSA), the ICER for axi-cel versus tisa-cel was ≤$50,000/QALY in 99.4% of simulations and ≤$33,500 in 99% of simulations. Axi-cel remained cost-effective versus tisa-cel (assuming a willingness-to-pay threshold of $150,000 per QALY) across a range of scenarios. CONCLUSIONS With longer-term survival data, axi-cel continues to represent a cost-effective option versus tisa-cel for treatment of r/r LBCL among patients who have previously received ≥2 lines of systemic therapy, from a US payer perspective.
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Rho H, Jeong IJH, Prica A. Ibrutinib Plus RCHOP versus RCHOP Only in Young Patients with Activated B-Cell-like Diffuse Large B-Cell Lymphoma (ABC-DLBCL): A Cost-Effectiveness Analysis. Curr Oncol 2023; 30:10488-10500. [PMID: 38132398 PMCID: PMC10742773 DOI: 10.3390/curroncol30120764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/29/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
The standard treatment for Diffuse Large B-Cell Lymphoma (DLBCL) is rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP). However, many patients require subsequent treatment after relapsed disease. The ABC subtype of DLBCL (ABC-DLBCL) has a worse prognosis, and the PHOENIX trial explored adding ibrutinib to RCHOP for this patient population. The trial showed favorable outcomes for younger patients, and our study aimed to inform clinical decision-making via a cost-effectiveness model to compare RCHOP with and without ibrutinib (I-RCHOP). A Markov decision analysis model was designed to compare the treatments for patients younger than 60 years with ABC-DLBCL. The model considered treatment pathways, adverse events, relapses, and death, incorporating data on salvage treatments and novel therapies. The results indicated that I-RCHOP was more cost-effective, with greater quality-adjusted life years (QALY, 15.48 years vs. 14.25 years) and an incremental cost-effectiveness ratio (ICER) of CAD 34,111.45/QALY compared to RCHOP only. Sensitivity analyses confirmed the model's robustness. Considering the high market price for ibrutinib, I-RCHOP may be more costly. However, it is suggested as the preferred cost-effective strategy for younger patients due to its benefits in adverse events, overall survival, and quality of life. The decision analytic model provided relevant and robust results to inform clinical decision-making.
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Affiliation(s)
- Hayeong Rho
- Department of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada (A.P.)
| | - Irene Joo-Hyun Jeong
- Department of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada (A.P.)
| | - Anca Prica
- Department of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada (A.P.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, ON M5G 1V7, Canada
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Vijenthira A, Kuruvilla J, Crump M, Jain M, Prica A. Cost-Effectiveness Analysis of Frontline Polatuzumab-Rituximab, Cyclophosphamide, Doxorubicin, and Prednisone and/or Second-Line Chimeric Antigen Receptor T-Cell Therapy Versus Standard of Care for Treatment of Patients With Intermediate- to High-Risk Diffuse Large B-Cell Lymphoma. J Clin Oncol 2023; 41:1577-1589. [PMID: 36315922 DOI: 10.1200/jco.22.00478] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Recent studies of polatuzumab vedotin and CD19 chimeric antigen receptor T-cell therapy (CAR-T) have shown significant improvements in progression-free survival over standard of care (SOC) for patients with diffuse large B-cell lymphoma. However, they are costly, and it is unclear whether these strategies, alone or combined, are cost-effective over SOC. METHODS A Markov model was constructed to compare four strategies for patients with newly diagnosed intermediate- to high-risk diffuse large B-cell lymphoma: strategy 1: polatuzumab-rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP) plus second-line CAR-T for early relapse (< 12 months); strategy 2: polatuzumab-R-CHP plus second-line salvage therapy ± autologous stem-cell transplant; strategy 3: rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus second-line CAR-T for early relapse; strategy 4: SOC (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus second-line salvage therapy ± autologous stem-cell transplant). Transition probabilities were estimated from trial data. Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated from US and Canadian payer perspectives. Willingness-to-pay (WTP) thresholds of $150,000 US dollars (USD) or Canadian dollars (CAD)/QALY were used. RESULTS In probabilistic analyses (10,000 simulations), each strategy was incrementally more effective than the previous strategy, but also more costly. Adding polatuzumab-R-CHP to the SOC had an ICER of $546,956 (338,797-1,199,923) USD/QALY and $245,381 (151,671-573,250) CAD/QALY. Adding second-line CAR-T to the SOC had an ICER of $309,813 (190,197-694,200) USD/QALY and $303,163 (221,300-1,063,864) CAD/QALY. Simultaneously adding both polatuzumab-R-CHP and second-line CAR-T to the SOC had an ICER of $488,284 (326,765-840,157) USD/QALY and $267,050 (182,832-520,922) CAD/QALY. CONCLUSION Given uncertain incremental benefits in long-term survival and high costs, neither polatuzumab-R-CHP frontline, CAR-T second-line, nor a combination are likely to be cost-effective in the United States or Canada at current pricing compared with the SOC.
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Affiliation(s)
- Abi Vijenthira
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - John Kuruvilla
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael Crump
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Anca Prica
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Syal G, Melmed GY, Almario CV, Spiegel BMR. Azathioprine Withdrawal Is Cost-Effective in Patients with Crohn's Disease in Remission on Infliximab and Azathioprine. Dig Dis Sci 2023; 68:404-413. [PMID: 36512266 DOI: 10.1007/s10620-022-07789-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/05/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND In Crohn's disease, combination therapy with infliximab and azathioprine is more effective than either drug alone but is associated with a higher risk of therapy-related complications. Though therapy de-escalation can reduce risks and save costs, it is associated with a risk of Crohn's disease relapse. AIMS We aimed to study the cost-effectiveness of de-escalation strategies in Crohn's disease patients in remission on infliximab and azathioprine. METHODS We constructed a decision tree with Markov models for continuation of infliximab and azathioprine, discontinuation of azathioprine followed by its re-introduction in case of relapse, discontinuation of azathioprine followed by infliximab dose intensification without azathioprine reintroduction in case of relapse and discontinuation of infliximab. Third-party payers' perspective with a willingness-to-pay threshold of $100,000/quality-adjusted life years was used. Markov cycle length was 3 months, and the study period was 5 years. A 35-year-old patient with Crohn's disease in clinical remission on azathioprine 150 mg daily and infliximab 5 mg/kg every 8 weeks was used for base-case analysis. RESULTS Azathioprine withdrawal followed by its reintroduction upon relapse was the dominant strategy as it was the most effective and least expensive approach on base-case analysis. It was also cost-effective in 99.3% of Monte Carlo trial simulations. AZA withdrawal without IFX dose intensification upon relapse was the least effective and the most expensive strategy. CONCLUSION Azathioprine withdrawal is the most effective and least costly de-escalation strategy in CD patients in remission on combination therapy if AZA re-introduction is performed upon CD relapse.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology, University of California at San Diego, 9452 S Medical Ctr Dr, La Jolla, San Diego, CA, 92037, USA.
| | - Gil Y Melmed
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
| | - Brennan M R Spiegel
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
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Kambhampati S, Saumoy M, Schneider Y, Pak S, Budde LE, Mei MG, Siddiqi T, Popplewell LL, Wen YP, Zain J, Forman SJ, Kwak LW, Rosen ST, Danilov AV, Herrera AF, Thiruvengadam NR. Cost-effectiveness of polatuzumab vedotin combined with chemoimmunotherapy in untreated diffuse large B-cell lymphoma. Blood 2022; 140:2697-2708. [PMID: 35700381 PMCID: PMC10653095 DOI: 10.1182/blood.2022016624] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 12/30/2022] Open
Abstract
In patients with treatment-naive diffuse large B-cell lymphoma (DLBCL), the POLARIX study (A Study Comparing the Efficacy and Safety of Polatuzumab Vedotin With Rituximab-Cyclophosphamide, Doxorubicin, and Prednisone [R-CHP] Versus Rituximab-Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone [R-CHOP] in Participants With Diffuse Large B-Cell Lymphoma) reported a 6.5% improvement in the 2-year progression-free survival (PFS), with no difference in overall survival (OS) or safety using polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin, and prednisone (pola-R-CHP) compared with standard rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). We evaluated the cost-effectiveness of pola-R-CHP for DLBCL. We modeled a hypothetical cohort of US adults (mean age, 65 years) with treatment-naive DLBCL by developing a Markov model (lifetime horizon) to model the cost-effectiveness of pola-R-CHP and R-CHOP using a range of plausible long-term outcomes. Progression rates and OS were estimated from POLARIX. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $150 000 per quality-adjusted life-year (QALY). Assuming a 5-year PFS of 69.6% with pola-R-CHP and 62.7% with R-CHOP, pola-R-CHP was cost-effective at a WTP of $150 000 (incremental cost-effectiveness ratio, $84 308/QALY). pola-R-CHP was no longer cost-effective if its 5-year PFS was 66.1% or lower. One-way sensitivity analysis revealed that pola-R-CHP is cost-effective up to a cost of $276 312 at a WTP of $150 000. pola-R-CHP was the cost-effective strategy in 56.6% of the 10 000 Monte Carlo iterations at a WTP of $150 000. If the absolute benefit in PFS is maintained over time, pola-R-CHP is cost-effective compared with R-CHOP at a WTP of $150 000/QALY. However, its cost-effectiveness is highly dependent on its long-term outcomes and costs of chimeric antigen receptor T-cell therapy. Routine usage of pola-R-CHP would add significantly to health care expenditures. Price reductions or identification of subgroups that have maximal benefit would improve cost-effectiveness.
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Affiliation(s)
- Swetha Kambhampati
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, NJ
| | | | - Stacy Pak
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Lihua Elizabeth Budde
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Matthew G. Mei
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Tanya Siddiqi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Leslie L. Popplewell
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Yi-Ping Wen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Jasmine Zain
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Larry W. Kwak
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Steven T. Rosen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Alexey V. Danilov
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Alex F. Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
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Cummings Joyner AK, Snider JT, Wade SW, Wang ST, Buessing MG, Johnson S, Gergis U. Cost-Effectiveness of Chimeric Antigen Receptor T Cell Therapy in Patients with Relapsed or Refractory Large B Cell Lymphoma: No Impact of Site of Care. Adv Ther 2022; 39:3560-3577. [PMID: 35689726 PMCID: PMC9309131 DOI: 10.1007/s12325-022-02188-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
Introduction Cost-effectiveness data on chimeric antigen receptor (CAR) T cell therapies for relapsed/refractory large B cell lymphoma (R/R LBCL), accounting for inpatient/outpatient site of care (site), are sparse. Methods This payer model compares lifetime costs/benefits for CAR T cell-treated (axicabtagene ciloleucel [axi-cel], lisocabtagene maraleucel [liso-cel], tisagenlecleucel [tisa-cel]) patients with R/R LBCL in the USA. Three-month post-infusion costs were derived from unit costs and real-world all-payer (RW) site-specific utilization data for 1175 patients with diffuse R/R LBCL (CAR T cell therapy October 2017–September 2020). Therapy- and site-specific grade 3+ cytokine release syndrome (CRS) and neurologic event (NE) incidences were imputed from published trials. Lifetime quality-adjusted life-years (QALYs) and long-term costs were calculated from therapy-specific overall and progression-free survival data, adjusted for differences in trial populations. The base case used 17% outpatient site (RW) for all therapies. ZUMA-1 trial cohorts 1/2 informed other axi-cel base case inputs; ZUMA-1 cohorts 4/6 data (updated safety management) supported scenario analyses. Results Base case total costs for axi-cel exceeded liso-cel ($637 K versus $621 K) and tisa-cel ($631 K versus $577 K) costs. Three-month post-infusion costs were $57 K to $59 K across all therapies. Total QALYs for axi-cel also exceeded those for liso-cel (7.7 versus 5.9) and tisa-cel (7.2 versus 5.0) with incremental costs per QALY gained of $9 K versus liso-cel and $25 K versus tisa-cel. Base case incremental net monetary benefit was $255 K (95% confidence interval (CI) $181–326 K) for axi-cel versus liso-cel, and $280 K (95% CI $200–353 K) versus tisa-cel. Longer survival with axi-cel conferred higher lifetime costs. In all scenarios (e.g., varied outpatient proportions, CRS/NE incidence), axi-cel was cost-effective versus both comparators at a maximum willingness-to-pay of under $26 K/QALY as a result of axi-cel’s higher incremental survival gains and quality-of-life. Conclusions Axi-cel is a cost-effective CAR T cell therapy for patients with R/R LBCL compared to tisa-cel and liso-cel. Site of care does not impact the cost-effectiveness of CAR T cell therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02188-0.
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Affiliation(s)
| | | | - Sally West Wade
- Wade Outcomes Research and Consulting, 136 U Street, Salt Lake City, UT, 84103, USA
| | - Si-Tien Wang
- Medicus Economics, LLC, 2 Stonehill Lane, Milton, MA, 02186, USA
| | | | - Scott Johnson
- Medicus Economics, LLC, 2 Stonehill Lane, Milton, MA, 02186, USA
| | - Usama Gergis
- Thomas Jefferson University Hospital, 925 Chestnut Street, Suite 420A, Philadelphia, PA, 19107, USA
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Hogervorst MA, Vreman RA, Mantel-Teeuwisse AK, Goettsch WG. Reported Challenges in Health Technology Assessment of Complex Health Technologies. Value Health 2022; 25:992-1001. [PMID: 35667787 DOI: 10.1016/j.jval.2021.11.1356] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/06/2021] [Accepted: 11/09/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES With complex health technologies entering the market, methods for health technology assessment (HTA) may require changes. This study aimed to identify challenges in HTA of complex health technologies. METHODS A survey was sent to European HTA organizations participating in European Network for HTA (EUnetHTA). The survey contained open questions and used predefined potentially complex health technologies and 7 case studies to identify types of complex health technologies and challenges faced during HTA. The survey was validated, tested for reliability by an expert panel, and pilot tested before dissemination. RESULTS A total of 22 HTA organizations completed the survey (67%). Advanced therapeutic medicinal products (ATMPs) and histology-independent therapies were considered most challenging based on the predefined complex health technologies and case studies. For the case studies, more than half of the reported challenges were "methodological," equal in relative effectiveness assessments as in cost-effectiveness assessments. Through the open questions, we found that most of these challenges actually rooted in data unavailability. Data were reported as "absent," "insufficient," "immature," or "low quality" by 18 of 20 organizations (90%), in particular data on quality of life. Policy and organizational challenges and challenges because of societal or political pressure were reported by 8 (40%) and 4 organizations (20%), respectively. Modeling issues were reported least often (n = 2, 4%). CONCLUSIONS Most challenges in HTA of complex health technologies root in data insufficiencies rather than in the complexity of health technologies itself. As the number of complex technologies grows, the urgency for new methods and policies to guide HTA decision making increases.
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Affiliation(s)
- Milou A Hogervorst
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands.
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10
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Vu M, Degeling K, Thompson ER, Blombery P, Westerman D, IJzerman MJ. Health economic evidence for the use of molecular biomarker tests in hematological malignancies: A systematic review. Eur J Haematol Suppl 2022; 108:469-485. [PMID: 35158410 PMCID: PMC9310724 DOI: 10.1111/ejh.13755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 12/01/2022]
Abstract
Objectives Molecular biomarker tests can inform the clinical management of genomic heterogeneous hematological malignancies, yet their availability in routine care largely depends on the supporting health economic evidence. This study aims to systematically review the economic evidence for recent molecular biomarker tests in hematological malignancies. Methods We conducted a systematic search in five electronic databases for studies published between January 2010 and October 2020. Publications were independently screened by two reviewers. Clinical study characteristics, economic methodology, and results were extracted, and reporting quality was assessed. Results Fourteen studies were identified, of which half (n = 7; 50%) were full economic evaluations examining both health and economic outcomes. Studies were predominantly conducted in a first‐line treatment setting (n = 7; 50%) and adopted a non‐lifetime time horizon to measure health outcomes and costs (n = 7; 50%). Five studies reported that companion diagnostics for associated therapies were likely cost‐effective for acute myeloid leukemia, chronic myeloid leukemia, diffuse large B‐cell lymphoma, and multiple myeloma. Four studies suggested molecular biomarker tests for treatment monitoring in chronic myeloid leukemia were likely cost‐saving. Conclusions Although there is initial confirmation of the promising health economic results, the present research for molecular biomarker tests in hematological malignancies is sparse with many applications of technological advances yet to be evaluated.
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Affiliation(s)
- Martin Vu
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Koen Degeling
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Ella R Thompson
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Piers Blombery
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, Australia
| | - David Westerman
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, Australia
| | - Maarten J IJzerman
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia.,Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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11
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Li N, Zheng B, Cai H, Yang T, Hong Y, Liu M, Hu J. Cost-effectiveness analysis of axicabtagene ciloleucel vs. salvage chemotherapy for relapsed or refractory adult diffuse large B-cell lymphoma in China. Support Care Cancer 2022; 30:6113-6121. [PMID: 35419735 DOI: 10.1007/s00520-022-07041-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Axicabtagene ciloleucel (Axi-Cel, 2 × 106 CAR-T cells/kg, single intravenous injection) is a chimeric antigen receptor cell immunotherapy that exhibits favorable clinical efficacy and safety in patients with relapsed or refractory diffuse large B-cell lymphoma (R/R DLBCL). However, this treatment is expensive in China. This study aimed to evaluate the cost-effectiveness of Axi-Cel versus salvage chemotherapy for the treatment of R/R DLBCL from the perspective of the Chinese healthcare system. METHODS A decision analysis model containing a short-term decision tree and long-term semi-Markov partitioned survival model was developed. The time horizon was 40 years and the period from 10 to 40 years was included in sensitivity analysis. The model was developed based on data from the ZUMA-1 and SCHOLAR-1 trials. Life years, quality-adjusted life years (QALYs), overall costs, and the incremental cost-effectiveness ratio (ICER) were estimated at a willingness to pay (WTP) threshold of US $31,320 per QALY, which is three times the gross domestic product per capita. RESULTS The base case analysis revealed that treatment with Axi-Cel is associated with an increased overall cost of US $175,380 and improved effectiveness of 3.43 LYs and 2.61 QALYs compared to salvage chemotherapy, leading to an ICER of US $51,190 per LY and US $67,250 per QALY. The developed model is sensitive to the discount rate, utility of progression-free survival (PFS), and cost of Axi-Cel. The ICER of Axi-Cel was greater than the WTP threshold in the sensitivity and scenario analyses. To achieve cost-effectiveness, the price of Axi-Cel must be reduced by 59.19% to US $71,000. CONCLUSION At its current price, Axi-Cel is not likely to be a cost-effective option compared to salvage chemotherapy for adult patients with R/R DLBCL.
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Affiliation(s)
- Na Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Bin Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Hongfu Cai
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Ting Yang
- Department of Hematology, Fujian Provincial Key Laboratory On Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yunda Hong
- Department of Hematology, Fujian Provincial Key Laboratory On Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.
- The School of Pharmacy, Fujian Medical University, Fuzhou, China.
| | - Jianda Hu
- Department of Hematology, Fujian Provincial Key Laboratory On Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China.
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12
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Snider JT, McMorrow D, Song X, Diakun D, Wade SW, Cheng P. Burden of Illness and Treatment Patterns in Second-line Large B-cell Lymphoma. Clin Ther 2022; 44:521-538. [PMID: 35241295 DOI: 10.1016/j.clinthera.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/23/2021] [Accepted: 02/05/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE This study examined real-world treatment patterns with curative intent, adverse events, and health care resource utilization and costs in patients with relapsed or refractory large B-cell lymphoma (LBCL) to understand the unmet medical need in the United States. METHODS Adult patients with ≥2 LBCL diagnoses between January 1, 2012, and March 31, 2019, were identified (index date was the date of the earliest LBCL diagnosis) from MarketScan® Commercial and Medicare Supplemental Databases. Patients had ≥1 claim for any LBCL treatment, ≥6 months of data before (baseline) and ≥12 months of data after (follow-up period) the index date, and no baseline LBCL diagnosis. Treatment patterns, adverse events, and all-cause and LBCL-related health care resource utilization and costs were examined. All patients had received first-line therapy of cyclophosphamide, doxorubicin, vincristine, and prednisone with or without rituximab; etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin hydrochloride with or without rituximab; or regimens with anthracycline and second-line therapy with stem cell transplant (SCT)-intended intensive therapy or platinum-based chemotherapy. Patients who received an SCT-intended second-line regimen or received an SCT regardless of second-line regimen were considered SCT eligible. FINDINGS A total of 188 patients met the criteria of eligibility for SCT. Among the 119 patients who received a second-line regimen intended for SCT, only 22.7% received an SCT. Patients eligible for SCT started first-line therapy within 1 month of their LBCL index date, and the mean duration of first-line therapy was 4.1 months. The mean gap in therapy between first- and second-line therapy was 6.6 months, and the mean duration of second-line therapy was 3.0 months. During the second-line therapy treatment window (mean duration with SCT, 12.4 months; mean duration without SCT, 4.8 months), the most common regimens for patients eligible for SCT were ifosfamide, carboplatin, and etoposide with or without rituximab and gemcitabine and oxaliplatin with or without rituximab; the top 4 most common treatment-related adverse events were febrile neutropenia (56.4%), anemia (49.5%), thrombocytopenia (42.6%), and nausea and vomiting (36.2%), which were similar regardless of receipt of SCT; mean (SD) per-patient-per-month all-cause costs were $46,174 ($49,057) for patients with SCT and $45,780 ($52,813) for patients without SCT. IMPLICATIONS Treatment patterns among patients with relapsed or refractory LBCL eligible for SCT were highly varied. Only 22.7% of patients who received an SCT-preparative regimen ultimately received SCT, which highlights the magnitude of unmet needs in this population. The occurrence of treatment-related adverse events was similar regardless of SCT status. Per-patient-per-month all-cause costs were also similar with upfront SCT costs averaged during a longer follow-up.
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Affiliation(s)
| | | | - Xue Song
- IBM Watson Health, Cambridge, Massachusetts
| | | | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, Utah
| | - Paul Cheng
- Kite, A Gilead Company, Santa Monica, California
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13
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Regier DA, Chan B, Costa S, Scott DW, Steidl C, Connors JM, Karsan A, Marra MA, Kridel R, Cromwell I, Pollard S. Cost-Effectiveness of Molecularly Guided Treatment in Diffuse Large B-Cell Lymphoma (DLBCL) in Patients under 60. Cancers (Basel) 2022; 14:908. [PMID: 35205656 PMCID: PMC8870002 DOI: 10.3390/cancers14040908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Classifying diffuse large B-cell lymphoma (DLBCL) into cell-of-origin (COO) subtypes could allow for personalized cancer control. Evidence suggests that subtype-guided treatment may be beneficial in the activated B-cell (ABC) subtype of DLBCL, among patients under the age of 60. Methods: We estimated the cost-effectiveness of age- and subtype-specific treatment guided by gene expression profiling (GEP). A probabilistic Markov model examined costs and quality-adjusted life-years gained (QALY) accrued to patients under GEP-classified COO treatment over a 10-year time horizon. The model was calibrated to evaluate the adoption of ibrutinib as a first line treatment among patients under 60 years with ABC subtype DLBCL. The primary data source for efficacy was derived from published estimates of the PHOENIX trial. These inputs were supplemented with patient-level, real-world data from BC Cancer, which provides comprehensive cancer services to the population of British Columbia. Results: We found the cost-effectiveness of GEP-guided treatment vs. standard care was $77,806 per QALY (24.3% probability of cost-effectiveness at a willingness-to-pay (WTP) of $50,000/QALY; 53.7% probability at a WTP of $100,000/QALY) for first-line treatment. Cost-effectiveness was dependent on assumptions around decision-makers’ WTP and the cost of the assay. Conclusions: We encourage further clinical trials to reduce uncertainty around the implementation of GEP-classified COO personalized treatment in this patient population.
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14
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Bastos-oreiro M, de las Heras A, Presa M, Casado MA, Pardo C, Martín-escudero V, Sureda A. Cost-Effectiveness Analysis of Axicabtagene Ciloleucel vs. Tisagenlecleucel for the Management of Relapsed/Refractory Diffuse Large B-Cell Lymphoma in Spain. Cancers (Basel) 2022; 14:538. [PMID: 35158805 PMCID: PMC8833685 DOI: 10.3390/cancers14030538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/17/2022] Open
Abstract
The study aimed to assess the cost-effectiveness of axicabtagene ciloleucel (axi-cel) vs. tisagenlecleucel (tisa-cel) for the treatment of relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) after ≥2 lines of systemic therapy in Spain. A lifetime partitioned survival mixture cure model, which comprises pre-progression, post-progression, and death health states, was used to estimate the accumulated costs and outcomes in terms of life years gained (LYG) and quality-adjusted life years (QALY). A matching-adjusted indirect comparison was used to reweight patient-level data from ZUMA-1, the pivotal clinical trial for axi-cel, to aggregate-level data from the pivotal tisa-cel trial, JULIET. The analysis was performed from the National Health System perspective, thus only direct costs were included. Sensitivity analyses (SA) were performed. Axi-cel yielded 2.74 incremental LYG and 2.31 additional QALY gained per patient compared to tisa-cel. Total incremental lifetime costs for axi-cel versus tisa-cel were €30,135/patient. The incremental cost-effectiveness ratio of axi-cel versus tisa-cel resulted in €10,999/LYG and the incremental cost-utility ratio in €13,049/QALY gained. SA proved robustness of the results. Considering the frequently assumed willingness-to-pay thresholds in Spain (€22,000/QALY and €60,000/QALY), axi-cel is a cost-effective treatment vs. tisa-cel for adult patients with R/R DLBCL in Spain.
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15
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Gye A, Goodall S, De Abreu Lourenco R. A Systematic Review of Health Technology Assessments of Chimeric Antigen Receptor T-Cell Therapies in Young Compared With Older Patients. Value Health 2022; 25:47-58. [PMID: 35031099 DOI: 10.1016/j.jval.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/06/2021] [Accepted: 07/16/2021] [Indexed: 05/05/2023]
Abstract
OBJECTIVES The objective of this review was to identify sources of variability in cost-effectiveness analyses of chimeric antigen receptor T-cell (CAR-T) therapies, tisagenlecleucel and axicabtagene ciloleucel, evaluated by health technology assessment (HTA) agencies, focusing on young compared with older patients. METHODS HTA evaluations in pediatric acute lymphoblastic leukemia (ALL) and adult diffuse large B-cell lymphoma (DLBCL) were included from Australia, Canada, England, Norway, and the United States. Key clinical evidence, economic approach, and outcomes (costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratios) were summarized. RESULTS Fourteen HTA evaluations were identified (5 ALL, 9 DLBCL [4 tisagenlecleucel, 5 axicabtagene]). Analyses were naive comparisons of prospective single-arm studies for the CAR-Ts with retrospective cohort studies for the comparators. Key clinical evidence and economic model approaches were generally consistent by CAR-T and indication, although outcomes varied. Notably, incremental QALYs varied substantially in ALL (3.67-10.6 QALYs gained), whereas variation in DLBCL was less (1.21-1.97 [tisagenlecleucel], 1.97-3.40 [axicabtagene]). Discounting of costs and outcomes varied, with the highest QALYs generated for tisagenlecleucel in ALL (10.95) associated with the lowest discount rate (1.5%) and vice versa (4.97 QALYs; 5% discount rate). The approach to extrapolation of overall survival data varied, even where the same empirical data were used. CONCLUSION Modeled, long-term treatment benefit in young patients may be associated with greater uncertainty compared with adults because of potential life-long benefits with cell and gene therapies. This reflects the methodological challenges identified by HTA agencies associated with single-arm, short-term studies.
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Affiliation(s)
- Amy Gye
- Novartis Pharmaceuticals Australia, Macquarie Park, Australia; Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia.
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
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16
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Oluwole OO, Liu R, Diakite I, Feng C, Patel A, Nourhussein I, Snider JT, Locke FL. Cost-effectiveness of axicabtagene ciloleucel versus lisocabtagene maraleucel for adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in the US. J Med Econ 2022; 25:541-551. [PMID: 35443867 DOI: 10.1080/13696998.2022.2065787] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIMS This study evaluated from a US payer perspective the cost-effectiveness of two chimeric antigen receptor T (CAR T) cell therapies, axicabtagene ciloleucel (axi-cel) versus lisocabtagene maraleucel (liso-cel), for the treatment of adult patients with relapsed or refractory (r/r) large B-cell lymphoma (LBCL) following two or more systemic therapy lines. METHODS We developed a 3-state (i.e., pre-progression, post-progression, death) partitioned survival model to estimate patients' lifetime outcomes. Mixture cure models were used for survival extrapolation to account for long-term remission. Survival inputs were based on a matching-adjusted indirect comparison (MAIC) that reweighted the ZUMA-1 population (receiving axi-cel) to match patient characteristics in TRANSCEND-NHL-001 (assessing liso-cel). Costs included apheresis, drug acquisition, and administration for conditioning chemotherapy and CAR T therapies, monitoring, transplant, hospitalization, adverse events, routine care, and terminal care, per published literature and databases. Utilities were derived from ZUMA-1 and literature. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS In the base case, axi-cel was associated with more QALYs (7.76 vs. 5.94) and greater costs overall ($611,440 vs. $597,174) than liso-cel, at $7,843/QALY gained. The incremental costs (+$14,266) were largely driven by higher routine care costs (+$18,596) due to longer survival and hospitalization (+$10,993) but partially offset by reduced costs of CAR T acquisition (‒$11,300) and terminal care (‒$4,025). Sensitivity analyses consistently suggested robustness of base-case results. LIMITATIONS This study relied on an MAIC in which trial design differences and unobserved confounders could not be accounted for. Future real-world studies for recently approved CAR T are warranted to validate our results. Due to a lack of data, we assumed equivalent use of transplants and treatment for B-cell aplasia between the two therapies based on clinicians' opinions. CONCLUSIONS In the US, axi-cel is a potentially cost-effective treatment option compared with liso-cel for adult patients with r/r LBCL after two or more systemic therapy lines.
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Affiliation(s)
| | | | | | | | - Anik Patel
- Kite, A Gilead Company, Santa Monica, CA, USA
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Qi CZ, Bollu V, Yang H, Dalal A, Zhang S, Zhang J. Cost-Effectiveness Analysis of Tisagenlecleucel for the Treatment of Patients With Relapsed or Refractory Diffuse Large B-Cell Lymphoma in the United States. Clin Ther 2021; 43:1300-1319.e8. [PMID: 34380609 DOI: 10.1016/j.clinthera.2021.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/03/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the cost-effectiveness and cost-effective price of tisagenlecleucel, a novel, effective chimeric antigen receptor T-cell therapy, versus salvage chemotherapy (SC) for the treatment of relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) using a willingness-to-pay (WTP) threshold of $150,000 per quality-adjusted life year (QALY) gained from a US third-party payer's perspective. METHODS A three-state (progression-free survival, progressive disease, and death), responder-based partitioned survival model with a lifetime horizon and 3% annual discount rate was developed. Overall survival (OS) and progression-free survival of tisagenlecleucel were estimated separately for patients with and without an overall response (OR), using data from JULIET ( Study of Efficacy and Safety of CTL019 in Adult DLBCL Patients). OS of SC was informed by SCHOLAR-1 (Retrospective Non-Hodgkin Lymphoma Research). Mixture cure models were used to inform the survival of tisagenlecleucel responders, supported by JULIET. The median OS was 11.1 months in all tisagenlecleucel-treated patients but not reached for responders; no progression or death occurred among responders since month 22 of treatment. For tisagenlecleucel nonresponders and SC, survival was based on standard parametric models until month 60and the survival of DLBCL long-term survivors thereafter. The model prediction validated well against the observed trial data. Costs and utilities were from the literature; utilities depended on health states and were used to estimate QALYs. Total costs, QALYs, and incremental cost per QALY gained were estimated. A cost-effective price range was estimated for all tisagenlecleucel-treated patients, OR responders, and complete response (CR) responders. Deterministic sensitivity and scenario analyses and a probabilistic sensitivity analysis were performed. All costs were reported in or inflated to 2020 US dollars. FINDINGS Tisagenlecleucel was associated with 3.35 QALYs gained versus SC.,The estimated incremental costs per QALY gained versus SC were $78,652 using the wholesale acquisition cost of $373,000 for tisagenlecleucel. The estimated cost-effective price of tisagenlecleucel in all treated patients was $612,270 at the WTP threshold of $150,000. Tisagenlecleucel OR and CR responders had an increase of 7.82 and 9.34 QALYs versus SC, with cost-effective prices estimated at $1,281,456 and $1,551,974, respectively. Sensitivity analysis results supported the base case findings. IMPLICATIONS Tisagenlecleucel is a cost-effective treatment versus SC for r/r DLBCL from the perspective of a US third-party payer. The estimated cost-effective prices ranged from $612,270 (all tisagenlecleucel-treated patients) to up to $1.5 million (patients achieving CR). Limitations include the use of single-arm trials due to data availability. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
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Affiliation(s)
| | - Vamsi Bollu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Anand Dalal
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Su Zhang
- Analysis Group, Inc, Boston, MA, USA
| | - Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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18
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Chen Z, Cheng Y, DeRemer D, Diaby V. Cost-effectiveness and drug wastage of immunotherapeutic agents for hematologic malignancies: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2021; 21:923-941. [PMID: 33934691 DOI: 10.1080/14737167.2021.1913056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Novel immunotherapeutic agents (e.g. monoclonal antibodies, antibody-drug conjugates, bispecific T-cell engagers) as treatment options for hematologic malignancies continue to emerge. These agents have been used as the standard of care in specific disease states and are associated with high costs. Value assessment of these therapies is of critical importance for coverage and reimbursement decision-making.Areas covered: We identified 15 immunotherapeutic agents through the U.S. FDA approvals for hematologic malignancies until 2018 and systematically reviewed related cost-effectiveness studies. Additionally, we examined whether drug wastage was accounted for in these studies.Expert opinion: We reviewed 51 studies for 14 identified immunotherapeutic agents that met the inclusion criteria for this systematic review. Three studies were observational-based, one study was model-based and incorporated observational data. The remaining studies were model-based with the majority of the model parameters extracted from randomized control trials (RCTs). Among 43 model-based economic evaluations, 13 studies accounted for drug wastage. Most of the studies showed favorable incremental cost-effectiveness ratios of immunotherapeutic agents-containing regimens when compared with no immunotherapeutic agents-containing regimens. Alemtuzumab, brentuximab vedotin, and daratumumab were not considered cost-effective across all the studies. Further investigations are warranted to establish the value of recent immunotherapeutic agents for hematologic malignancies.
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Affiliation(s)
- Ziyan Chen
- Department of Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, University of Florida, Gainesville, Florida, United States
| | - Yue Cheng
- Institute for Pharmaceutical Outcomes & Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, United States
| | - David DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, United States
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, University of Florida, Gainesville, Florida, United States
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Wakase S, Teshima T, Zhang J, Ma Q, Fujita T, Yang H, Chai X, Qi CZ, Liu Q, Wu EQ, Igarashi A. Cost Effectiveness Analysis of Tisagenlecleucel for the Treatment of Adult Patients with Relapsed or Refractory Diffuse Large B Cell Lymphoma in Japan. Transplant Cell Ther 2021; 27:506.e1-506.e10. [PMID: 33823168 DOI: 10.1016/j.jtct.2021.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/04/2021] [Accepted: 03/02/2021] [Indexed: 12/31/2022]
Abstract
There are limited treatment options and substantial unmet needs for adult patients with relapsed or refractory diffuse large B cell lymphoma (r/r DLBCL) in Japan. In 2019, tisagenlecleucel, a CD19-directed chimeric antigen receptor T cell therapy, was approved for r/r DLBCL in Japan. The efficacy and safety of tisagenlecleucel were demonstrated in the pivotal phase II single-arm JULIET trial. The objective of the current study was to assess the cost-effectiveness of tisagenlecleucel treatment strategy versus current standard of care (salvage chemotherapy treatment strategy) for the treatment of patients with r/r DLBCL in Japan. A three-state partitioned survival model was constructed from a Japanese public healthcare payer's perspective, with the following three health states: progression-free survival, progressive/relapsed disease, and death. Because the tisagenlecleucel arm included patients who did or did not receive the infusion, a decision-tree structure was used to partition patients based on their infusion status. Treatment efficacy and costs were based on tisagenlecleucel-infused patients for those who received the infusion; for non-infused patients, they were based on standard salvage chemotherapy. The efficacy inputs for tisagenlecleucel-infused patients and salvage chemotherapy were based on observed data in the JULIET trial and the international SCHOLAR-1 meta-analysis, respectively, before year 3. Afterward, all patients were assumed to have no further progression and to incur the mortality risk of long-term DLBCL survivors. The base case analysis explored a lifetime horizon (44 years), with costs and effectiveness discounted 2.0% annually, and it used a monthly model cycle. Direct costs were considered in the base case, composed of pretreatment costs, treatment costs, adverse events management costs, follow-up costs before progression, subsequent SCT costs, post-progression costs, and terminal care costs. Total incremental costs, life years (LYs), and quality-adjusted life years (QALYs) were compared for tisagenlecleucel versus salvage chemotherapy. The incremental cost-effectiveness ratio (ICER) was estimated as the costs per QALY gained, and a threshold of ¥7.5 million was used to assess whether tisagenlecleucel is cost effective. Deterministic and probabilistic sensitivity analyses were performed. The total LYs (discounted) for tisagenlecleucel and salvage chemotherapy were 7.24 and 4.35 years, respectively; the corresponding QALYs were 5.42 and 2.57 years, respectively. The discounted incremental LYs and QALYs comparing tisagenlecleucel to salvage chemotherapy were estimated as 2.89 and 2.85 years, respectively. Over a lifetime horizon, the model estimated that tisagenlecleucel had a total incremental cost of ¥15,590,335 (discounted) versus salvage chemotherapy. Tisagenlecleucel was associated with an ICER of ¥5,476,496 per QALY gained compared to salvage chemotherapy. Extensive sensitivity analyses supported the base-case findings. Tisagenlecleucel is a cost-effective treatment strategy for r/r DLBCL compared to salvage chemotherapy treatment strategy from a Japanese public healthcare payer's perspective.
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Wang XJ, Wang YH, Li SCT, Gkitzia C, Lim ST, Koh LP, Lim FLWI, Hwang WYK. Cost-effectiveness and budget impact analyses of tisagenlecleucel in adult patients with relapsed or refractory diffuse large B-cell lymphoma from Singapore's private insurance payer's perspective. J Med Econ 2021; 24:637-653. [PMID: 33904359 DOI: 10.1080/13696998.2021.1922066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients experiencing relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) have limited treatment options and poor prognosis. Tisagenlecleucel (TIS) has shown improved clinical outcomes, but at a high upfront cost. Singapore has a multi-payer healthcare system where private insurance is one of the major payers. This study evaluated the cost-effectiveness and budget impact of TIS against salvage chemotherapy regimen (SCR) for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapy from Singapore's private insurance payer's perspective. METHODS Over a life-time horizon, a partitioned survival model with three health-states was developed to evaluate the cost-effectiveness of TIS vs. SCR with or without hematopoietic stem cell transplantation (HSCT). Efficacy inputs for TIS and SCR were based on 43 months of observation data from pooled JULIET and UPenn trials, and CORAL extension studies respectively. Direct costs for pre-treatment, treatment, adverse events, follow-up, subsequent-HSCT, relapse, and terminal care were included. Incremental cost-effectiveness ratios (ICERs) were calculated as the total incremental costs per quality-adjusted life-year (QALY) gained. Additionally, the financial implication of introducing TIS in Singapore from a private payer's perspective was analyzed, comparing the current treatment pathway (without TIS) with a future scenario (with TIS) over 5 years. RESULTS Compared with SCR, TIS was the dominant option, with cost savings of S$8,477 alongside an additional gain of 2.78 QALYs in privately insured patients who shifted from private to public hospitals for TIS treatment. Scenario analyses for patients starting in public hospitals show ICERs of S$99,623 (no subsidy) and S$133,261 (50% subsidy for SCR treatment, no subsidy for TIS), supporting the base case. The projected annual budget impact ranges from S$850,000 to S$3.4 million during the first 5 years. CONCLUSIONS TIS for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapies, is likely to be cost effective with limited budget impact.
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Affiliation(s)
| | - Yi-Ho Wang
- Novartis Singapore Pte Ltd., Singapore, Singapore
| | | | | | - Soon Thye Lim
- National Cancer Centre Singapore, Singapore, Singapore
| | - Liang Piu Koh
- National University Cancer Institute, Singapore, Singapore
| | | | - William Ying Khee Hwang
- National University Cancer Institute, Singapore, Singapore
- Singapore General Hospital, Singapore, Singapore
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21
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Liu R, Oluwole OO, Diakite I, Botteman MF, Snider JT, Locke FL. Cost effectiveness of axicabtagene ciloleucel versus tisagenlecleucel for adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in the United States. J Med Econ 2021; 24:458-468. [PMID: 33691581 DOI: 10.1080/13696998.2021.1901721] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS To assess from a US payer perspective the cost-effectiveness of the chimeric antigen receptor T (CAR T)-cell therapies axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) to treat relapsed or refractory (r/r) large B-cell lymphoma (LBCL) following ≥2 systemic therapy lines. METHODS A three-state (i.e. pre-progression, post-progression, and death) partitioned survival model was used to estimate the quality-adjusted life-years (QALYs) and costs for patients on each treatment over a lifetime horizon. Progression-free survival (PFS) and overall survival (OS) were based on a matching-adjusted indirect treatment comparison (MAIC) that accounted for differences in trial population baseline characteristics. Mixture cure models (MCMs) were used to account for long-term survivors. Costs included drug acquisition and administration for the CAR T-cell therapies and conditioning chemotherapy, apheresis, CAR T-specific monitoring, transplant, hospitalization, adverse events, routine care, and terminal care. Health state utilities were derived from trial and published data. Sensitivity analyses included probabilistic sensitivity analyses (PSAs) and an analysis of extremes that assessed the results across a vast array of combinations of parametric OS and PFS curves across the two therapies. RESULTS Compared to tisa-cel, axi-cel resulted in 2.31 QALYs gained and a cost reduction of $1,407 in the base case. In the PSA, the cost per QALY gained was ≤$31,500 in 95% of the 1,000 simulations. In the analysis of extremes, the cost per QALY gained was ≤$7,500 in 99% of the 1,296 combinations of MCMs and ≤$40,000 in 95% of the 1,296 combinations of standard models. LIMITATIONS In absence of head-to-head comparative data, we relied on a MAIC, which cannot account for all possible confounders. Moreover, some outcomes (i.e. transplantations, hospitalizations, adverse events (AEs)) were not adjusted in the MAIC. CONCLUSIONS In this simulation, axi-cel was a superior treatment option as it is predicted to achieve better outcomes at lower or minimal incremental costs versus tisa-cel.
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Affiliation(s)
- Rongzhe Liu
- Pharmerit - an OPEN Health Company, Bethesda, MD, USA
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22
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Patel KK, Isufi I, Kothari S, Foss F, Huntington S. Cost-effectiveness of polatuzumab vedotin in relapsed or refractory diffuse large B-cell lymphoma. Leuk Lymphoma 2020; 61:3387-3394. [PMID: 32835553 DOI: 10.1080/10428194.2020.1808208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A recent phase II trial showed that use of polatuzumab vedotin in combination with bendamustine plus rituximab (Pola-BR) in transplant-ineligible patients with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) resulted in longer progression-free survival and overall survival compared to bendamustine plus rituximab (BR) alone. In this study, we constructed a Markov model to assess the cost-effectiveness of Pola-BR versus BR in transplant-ineligible R/R DLBCL. We calculated the incremental cost-effectiveness ratio (ICER) of each treatment strategy from a US payer perspective, using a lifetime horizon and a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY). Use of Pola-BR was associated with an incremental cost of $92,641 compared to BR alone ($200,905 vs $108,265, respectively), an incremental effectiveness of 1.76 QALYs (2.35 vs 0.59 QALYs, respectively), and an ICER of $52,519/QALY. These data suggest that use of Pola-BR for R/R DLBCL is likely to be cost-effective compared to BR alone.
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Affiliation(s)
- Kishan K Patel
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Iris Isufi
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Shalin Kothari
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Francine Foss
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Scott Huntington
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT, USA.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, USA
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23
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Abstract
Introduction: Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma and is a clinically heterogeneous disease. Treatment pathways for DLBCL are diverse and integrate established and novel therapies.Areas covered: We review the cost burden of DLBCL and the cost-effectiveness of DLBCL management including precision and cellular medicine. We utilized Medical Subject Heading (MeSH) terms and keywords to search the National Library of Medicine online MEDLINE database (PubMed) for articles related to cost, cost burden, and cost-of-illness of DLBCL and cost-effectiveness of DLBCL management strategies published in English as of June 2019.Expert commentary: Available and developing DLBCL therapies offer improved outcomes and often curative treatment at considerable financial expense, and the total cost burden for DLBCL management is substantial for patients and the healthcare system. In the era of personalized medicine, CAR T cells and targeted therapies provide exciting avenues for current and future DLBCL care and can further increase treatment cost. Determinations of cost and cost-effectiveness in DLBCL treatment pathways should continue to guide care providers and systems in identifying cost reduction strategies to provide appropriate therapies to the greatest number of patients in treating DLBCL.
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Affiliation(s)
- R Andrew Harkins
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sharvil P Patel
- Department of Quantitative Theories and Methods, Emory University, Atlanta, GA, USA
| | - Christopher R Flowers
- Department of Hematology and Oncology, Winship Research Informatics Shared Resource Emory University School of Medicine Winship Cancer Institute, Atlanta, GA, USA
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Costa S, Scott DW, Steidl C, Peacock SJ, Regier DA. Real-world costing analysis for diffuse large B-cell lymphoma in British Columbia. ACTA ACUST UNITED AC 2019; 26:108-113. [PMID: 31043812 DOI: 10.3747/co.26.4565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Diffuse large B-cell lymphoma (dlbcl) accounts for 30%-40% of all non-Hodgkin lymphomas. Approximately 60% of patients are cured with standard treatment. Targeted treatments are being investigated and might improve disease outcomes; however, their effect on cancer drug budgets will be significant. For the present study, we conducted an analysis of real-world costs for dlbcl patients treated in British Columbia, useful for health care system planning. Methods Patient records from a retrospective cohort of patients diagnosed with dlbcl in British Columbia during 2004-2013 were anonymously linked across multiple administrative data sources: systemic therapy, radiotherapy, hospitalizations, oncologist services, outpatient medications, and fee-for-service physician services. Using generalized linear modelling regression, time-dependent costs (in 2015 Canadian dollars) were estimated in 6-month intervals over a 5-year period. The inverse probability weighting method was applied to account for censored observations. Nonparametric bootstrapping was used to estimate standard errors for the mean cost at each time interval. Results The cohort consisted of 678 patients (5-year overall survival: 67%). Mean age at diagnosis was 64 ± 14 years; median follow-up was 3.2 years. Mean total cost of care was highest in the first 6 months after diagnosis ($29,120; 95% confidence interval: $28,986 to $29,170) and after disease progression ($18,480; 95% confidence interval: $15,187 to $24,772). Systemic therapy and hospitalization costs were the largest cost drivers. At each time interval, costs were observed to be positively skewed. Conclusions Our results depict real-world costs for the treatment of dlbcl patients with standard chop-r therapy. Cost-model parameters are also provided for economic modelling of dlbcl interventions.
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Affiliation(s)
- S Costa
- Canadian Centre for Applied Research in Cancer Control, Vancouver, BC.,Cancer Control Research, BC Cancer, Vancouver, BC
| | - D W Scott
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC.,Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC
| | - C Steidl
- Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC.,Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC
| | - S J Peacock
- Canadian Centre for Applied Research in Cancer Control, Vancouver, BC.,Cancer Control Research, BC Cancer, Vancouver, BC.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
| | - D A Regier
- Canadian Centre for Applied Research in Cancer Control, Vancouver, BC.,Cancer Control Research, BC Cancer, Vancouver, BC.,School of Population and Public Health, University of British Columbia, Vancouver, BC
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Shi Q, Schmitz N, Ou FS, Dixon JG, Cunningham D, Pfreundschuh M, Seymour JF, Jaeger U, Habermann TM, Haioun C, Tilly H, Ghesquieres H, Merli F, Ziepert M, Herbrecht R, Flament J, Fu T, Coiffier B, Flowers CR. Progression-Free Survival as a Surrogate End Point for Overall Survival in First-Line Diffuse Large B-Cell Lymphoma: An Individual Patient-Level Analysis of Multiple Randomized Trials (SEAL). J Clin Oncol 2018; 36:2593-2602. [PMID: 29975624 DOI: 10.1200/jco.2018.77.9124] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Purpose Overall survival (OS) is the definitive and best-established primary efficacy end point to evaluate diffuse large B-cell lymphoma (DLBCL) therapies, but it requires prolonged follow-up. An earlier end point assessed post-treatment would expedite clinical trial conduct and accelerate patient access to effective new therapies. Our objective was to formally evaluate progression-free survival (PFS) and PFS at 24 months (PFS24) as surrogate end points for OS in first-line DLBCL. Patients and Methods Individual patient data were analyzed from 7,507 patients from 13 multicenter randomized controlled trials of active treatment in previously untreated DLBCL, published after 2002, with sufficient PFS data to predict treatment effects on OS. Trial-level surrogacy examining the correlation of treatment effect estimates of PFS/PFS24 and OS was evaluated using both linear regression ( R2WLS) and Copula bivariable ( R2Copula) models. Prespecified criteria for surrogacy required either R2WLS or R2Copula ≥ 0.80 and neither < 0.7, with lower-bound 95% CI > 0.60. Results Trial-level surrogacy for PFS was strong ( R2WLS = 0.83; R2Copula = 0.85) and met the predefined criteria for surrogacy. At the patient level, PFS strongly correlated with OS. The surrogate threshold effect had a hazard ratio of 0.89. Surrogacy was consistent across comparisons with or without rituximab and with rituximab maintenance trials. Trial-level surrogacy for PFS24 was relatively strong ( R2WLS = 0.77; R2Copula = 0.78) but did not meet prespecified criteria. At the patient level, PFS24 significantly correlated with OS. The surrogate threshold effect had an odds ratio of 1.51. Conclusion This large pooled analysis of individual patient data supports PFS as a surrogate end point for OS in future randomized controlled trials evaluating chemoimmunotherapy in DLBCL. Use of this end point may expedite therapeutic development with the intent of bringing novel therapies to this patient population years before OS results are mature.
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Affiliation(s)
- Qian Shi
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Norbert Schmitz
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Fang-Shu Ou
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Jesse G Dixon
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - David Cunningham
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Michael Pfreundschuh
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - John F Seymour
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Ulrich Jaeger
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Thomas M Habermann
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Corinne Haioun
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Hervé Tilly
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Hervé Ghesquieres
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Francesco Merli
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Marita Ziepert
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Raoul Herbrecht
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Jocelyne Flament
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Tommy Fu
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Bertrand Coiffier
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
| | - Christopher R Flowers
- Qian Shi, Fang-Shu Ou, Jesse G. Dixon, and Thomas M. Habermann, Mayo Clinic, Rochester, MN; Norbert Schmitz, University of Muenster, Muenster; Michael Pfreundschuh, Universität des Saarlandes, Homburg; Marita Ziepert, University of Leipzig, Leipzig, Germany; David Cunningham, The Royal Marsden Hospital, Surrey, United Kingdom; John F. Seymour, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia; Ulrich Jaeger, Medical University of Vienna, Vienna, Austria; Corinne Haioun, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil; Hervé Tilly, Institut National de la Santé et de la Recherche Médicale U1245, Université de Rouen, Rouen; Hervé Ghesquieres and Bertrand Coiffier, Centre Hospitalier Lyon-Sud, Pierre-Benite; Raoul Herbrecht, Hôpital de Hautepierre, Strasbourg, France; Francesco Merli, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; Jocelyne Flament, Celgene, Boudry, Switzerland; Tommy Fu, Celgene, Summit, NJ; and Christopher R. Flowers, Emory University, Atlanta, GA
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Affiliation(s)
- Pamela B Allen
- a Department of Hematology and Medical Oncology , Winship Cancer Institute, Emory University School of Medicine , Atlanta , GA , USA
| | - Christopher R Flowers
- a Department of Hematology and Medical Oncology , Winship Cancer Institute, Emory University School of Medicine , Atlanta , GA , USA
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Affiliation(s)
- Piers Blombery
- a Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Sir Peter MacCallum Department of Oncology , University of Melbourne , Melbourne , VIC , Australia
| | | | - Michael Dickinson
- a Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Sir Peter MacCallum Department of Oncology , University of Melbourne , Melbourne , VIC , Australia
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