CAR T-cell Therapy for Diffuse Large B-cell Lymphoma in Canada: A Cost-Utility Analysis

BACKGROUND

Chimeric antigen receptor (CAR) T-cell therapy is a novel cell therapy for treating non-Hodgkin lymphoma. The development of CAR T-cell therapy has transformed oncology treatment by offering a potential cure. However, due to the high cost of these therapies, and the large number of eligible patients, decision makers are faced with difficult funding decisions. Our objective was to assess the cost-effectiveness of tisagenlecleucel for adults with relapsed/refractory diffuse large B-cell lymphoma in Canada using updated survival data from the recent JULIET trial.

METHODS

We developed an individual-simulated discrete event simulation model to assess the costs and quality-adjusted life-years (QALY) of tisagenlecleucel compared with salvage chemotherapy. Survival estimates were obtained from a published clinical trial and retrospective analysis. If patients remained progression free for 5 y, they were assumed to be in long-term remission. Costing and utility data were obtained from reports and published sources. A Canadian health care payer perspective was used, and outcomes were modeled over a lifetime horizon. Costs and outcomes were discounted at 1.5% annually, with costs reported in 2021 Canadian dollars. A probabilistic analysis was used, and model parameters were varied in 1-way sensitivity analyses and scenario analyses.

RESULTS

After we incorporated the latest clinical evidence, tisagenlecleucel led to an additional cost of $503,417 and additional effectiveness of 2.48 QALYs, with an incremental cost-effectiveness ratio of $202,991 compared with salvage chemotherapy. At a willingness-to-pay threshold of $100,000/QALY, tisagenlecleucel had a 0% likelihood of being cost-effective.

CONCLUSIONS

At the current drug price, tisagenlecleucel was not found to be a cost-effective option. These results heavily depend on assumptions regarding long-term survival and the price of CAR T. Real-world evidence is needed to reduce uncertainty.

HIGHLIGHTS

For patients with diffuse large B-cell lymphoma who failed 2 or more lines of systemic therapy, CAR T was not found to be a cost-effective treatment option at a willingness-to-pay threshold of $100,000.These results heavily depend on the expected long-term survival. The uncertainty in the model may be improved using real-world evidence reported in the future.

Exploration of current pharmacy practice in cardio-oncology: Experiences & perspectives

INTRODUCTION

Cardiovascular complications can occur in oncology patients secondary to certain cancer therapies. Pharmacists are involved in the care of oncology patients who are at risk of or experiencing cardiotoxicity related to their cancer therapy. Our study aimed to understand how pharmacists in Canada care to these patients and to explore their experiences, perceptions, and challenges.

METHODS

Canadian pharmacists currently involved in the care of patients receiving cancer treatments and at risk of or experiencing cardiotoxicity were invited to participate in a 30-min telephone interview using an interview guide. A combination of inductive and deductive reasoning was applied using two coders who independently reviewed the transcribed interviews and identified key concepts and themes.

RESULTS

Eight pharmacists were interviewed. Perceived benefits included sharing specialized knowledge and conducting safety assessments. Perceived challenges were the lack of role recognition and resources and fractured continuity of care. Proposed future directions were to play a more substantial role in direct medication management, creation of specific guidance and tools to support the clinical decision-making process, and to understand how pharmacists at other sites were providing care through the creation of a community of practice.

CONCLUSIONS

As patient-focused medication specialists, pharmacists help guide clinical decision-making, assess cardiac risk factors, and offer individualized education to meet the holistic needs of oncology patients at risk of or experiencing cardiotoxicities. The creation of a cardio-oncology community of practice may allow pharmacists with a common interest to connect, share learnings, and collaborate on how to continue to advance the delivery of care.

Clinical Considerations for the Integration of Adjuvant Olaparib into Practice for Early Breast Cancer: A Canadian Perspective

With the recent Health Canada approval of olaparib for high-risk, HER2-negative early breast cancer, physicians are now facing the practical challenges of integrating olaparib into current management of triple-negative breast cancer (TNBC) and HR-positive, HER2-negative (HR+/HER2-) early breast cancer. This review provides perspectives on some of the challenges related to identification of olaparib candidates, with a focus on the latest guidance for germline BRCA testing and considerations regarding high-risk disease definitions. Updated treatment pathways are explored for both disease states, including other adjuvant treatment options such as pembrolizumab, capecitabine, and abemaciclib. Gaps in the current literature regarding the sequential or combined use of these adjuvant therapies are noted and future, potentially informative, studies are briefly examined.

Understanding the Feasibility of Implementing CAR T-Cell Therapies from a Canadian Perspective

In Canada, chimeric antigen receptor (CAR) T-cell therapy was recommended for funding for the treatment of select hematological cancers. Canadian hospitals have limited experience and capacity in administrating this therapy. We conducted a qualitative interview-based study with stakeholders in Canada. Questions were asked related to the development, administration, implementation and logistical planning of CAR T-cell therapy. Results were summarized into four main themes: (i) novel; (ii) patient characteristics and the delivery of care; (iii) processes from "bench-to-bedside"; and (iv) the future state, including both challenges and recommendations to ensure sustainability. Valuable perspectives from stakeholders highlight some of the unique challenges to implementing a highly personalized and expensive-to-deliver therapy.

Impact of Increasing Wait Times on Overall Mortality of Chimeric Antigen Receptor T-Cell Therapy in Large B-Cell Lymphoma: A Discrete Event Simulation Model

PURPOSE

The development of chimeric antigen receptor (CAR) T cells has transformed oncology treatment, with the potential to cure certain cancers. Although shown to be effective in selected populations and studies, CAR T-cell technology requires considerable health care resources, which may lead to additional wait times to access this type of treatment in future. The objective of our study was to estimate the potential impact of increasing wait times on CAR T-cell therapy effectiveness compared with standard chemotherapy for patients with relapsed/refractory diffuse large B-cell lymphoma.

METHODS

A health system-level discrete event simulation model was developed to project the potential impact of wait times on CAR T-cell therapy for patients with relapsed/refractory diffuse large B-cell lymphoma. Waiting queues and health states related to treatment and clinical progression were implemented. Using data from the literature, we evaluated nine scenarios of using CAR T-cell therapy with wait times ranging from 1 to 9 months. The outcome of interest was 1-year all-cause mortality.

RESULTS

Increasing the wait time of receiving CAR T-cell therapy from 1 to 9 months increased the predicted 1-year mortality rate from 36.1% to 76.3%. Baseline 1-year mortality was 34.0% in patients receiving CAR T-cell therapy with no wait times and 75.1% in patients treated with chemotherapy. This resulted in an increased relative mortality rate of 6.2% to 124.5% over a 1- to 9-month wait time compared with no wait time.

CONCLUSION

We found that modest delays in CAR T-cell therapy significantly hinder its effectiveness. Because CAR T-cell therapy offers a potential cure, it is expected that the uptake rate will be substantially increased once the therapy is regularly funded by a health care system. Wait times may be prolonged if system resource availability does not match the demand. Strategies must be developed to minimize the impact of delays and reduce complications during waiting.

Weight-related other evaluation in eating disorders

Weight-related self-evaluation has been described as the fundamental maladaptive cognitive feature of disordered eating. It is not clear, however, whether the process of determining personal-worth based on an evaluation of body size is specific to the self, or whether it is relevant to the evaluation of people in general. Thirty-three eating disordered patients and 54 undergraduates read an article about a woman who was described as either overweight or slender and evaluated the woman on several dimensions. Both undergraduates and eating disordered patients rated the heavy woman as less attractive than the thin woman. However, the patients' evaluation of the overweight target's attractiveness was significantly more negative than the undergraduates'. Patients also rated the overweight woman as less popular and claimed that they liked the overweight woman less than the thin woman. These effects were not present among the undergraduate students. Finally, the eating disorder participants rated the overweight woman as more overweight and less intelligent than did the undergraduate students. The results suggest that weight-related evaluation in eating disorders extends beyond the self to include the evaluation of other people.

Postmenopausal bleeding due to chronic DIC

'Bleeding disorders' are listed as a cause of postmenopausal bleeding even though there appear to be no reported cases. We present a case of postmenopausal bleeding, because of chronic DIC, which resulted from aortic aneurysm and was managed with replacement blood products and tranexamic acid.

Weight-related and shape-related self-evaluation in eating-disordered and non-eating-disordered women

OBJECTIVE

Weight- and shape-related self-evaluation refers to the process whereby an individual determines her self-worth based on an evaluation of her body weight and shape. This is a hallmark feature of both anorexia and bulimia nervosa, as specified in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. The purpose of this study was to further our understanding of weight-related self-evaluation in eating-disordered women.

METHOD

Eating-disordered patients, restrained eaters, and unrestrained eaters completed an experimenter-designed questionnaire that examines different dimensions of weight-related self-evaluation (i.e., the Multidimensional Weight-Related Self-Evaluation Inventory).

RESULTS

Results revealed that weight-related self-evaluation is a feature shared, to some extent, by both eating-disordered patients and restrained eaters. However, eating-disordered patients extend weight-related self-evaluation to include more domains of self-esteem than did restrained eaters.

DISCUSSION

These findings support a multidimensional approach to weight-related self-evaluation and further our understanding of the process of weight-related self-evaluation in eating-disordered patients.

Eating disorders, dieting, and the accuracy of self-reported weight

OBJECTIVE

This study investigated the accuracy of self-reported weight and height in individuals with an eating disorder (i.e., anorexia nervosa [AN] and bulimia nervosa [BN]) and in individuals without an eating disorder (i.e., dieters and nondieters).

METHOD

Self-reported and measured weights and heights were obtained from the eating disorder sample (n = 81) and the college student sample (n = 163) and were compared within and between the groups.

RESULTS

Eating disorder patients were extremely accurate at self-reporting their weight. However, there was a significant difference in accuracy between AN and BN patients. AN patients slightly overreported their weight, whereas BN patients slightly underreported their weight. Both dieters and nondieters significantly underreported their weight. However, dieters significantly underreported their weight to a greater degree than did the nondieters.

DISCUSSION

The implications of these subgroup differences and their specificity to weight reporting are discussed with reference to the accuracy of self-reported height.

Effects of false weight feedback on mood, self-evaluation, and food intake in restrained and unrestrained eaters

Restrained and unrestrained eaters were weighted 5 lb (2.27 kg) heavier or 5 lb lighter than their actual weight or were not weighed at all. Unrestrained eaters and restrained eaters who were told they weighed 5 lb less were not affected by the false weight feedback. However, restrained eaters who were informed that they weighted 5 lb more reported lower self-esteem, less positive moods, and more negative moods than did restrained eaters in the other 2 conditions. Furthermore, restrained eaters who were led to believe that they weighed heavier ate significantly more food during a subsequent "taste test" than did each of the other groups. Restrained eaters who believed that they were heavier experienced lowered self-worth and a worsening of mood that led them to relinquish their dietary restraint and overindulge in available food. Implications for patients with eating disorders are discussed.

Effects of false weight feedback on mood, self-evaluation, and food intake in restrained and unrestrained eaters

Restrained and unrestrained eaters were weighted 5 lb (2.27 kg) heavier or 5 lb lighter than their actual weight or were not weighed at all. Unrestrained eaters and restrained eaters who were told they weighed 5 lb less were not affected by the false weight feedback. However, restrained eaters who were informed that they weighted 5 lb more reported lower self-esteem, less positive moods, and more negative moods than did restrained eaters in the other 2 conditions. Furthermore, restrained eaters who were led to believe that they weighed heavier ate significantly more food during a subsequent "taste test" than did each of the other groups. Restrained eaters who believed that they were heavier experienced lowered self-worth and a worsening of mood that led them to relinquish their dietary restraint and overindulge in available food. Implications for patients with eating disorders are discussed.

Increasing willingness to taste novel foods: effects of nutrition and taste information

This study was designed to examine the effects of various kinds of information on willingness to ingest novel foods in individuals varying in the extent to which they reported that nutritional concerns affected their food choices. Male and female volunteers ranging in age from 10 to 79 (N = 401), saw six familiar and six novel foods, and received no information, taste likability information, general nutrition information, or specific nutrition information about the whole set of foods. They rated their willingness to taste each food, with the clear implication that their willingness ratings would determine which foods they would taste later in the study. On a separate questionnaire, they also rated the factors influencing their food everyday choices, and these ratings were used to compute an "importance of nutrition" score for each individual. Results indicated that older subjects were generally more willing to try novel foods than younger ones, that general nutrition information was effective for high school and college students, and that specific nutrition information was influential for young adults. It was also found that general nutrition information increased willingness to taste novel food in subjects for whom nutrition is important and decreased such willingness in subjects for whom nutrition is not important.

Effects of anxiety on eating: does palatability moderate distress-induced overeating in dieters?

When confronted with an anxiety-producing threat to self-esteem, restrained eaters (dieters) increase their food consumption. The functional explanation suggests that increased eating temporarily counteracts or masks dysphoria for the restrained eater; externality or stimulus sensitivity theories propose that distress shifts the dieter's attention to external stimulus properties (e.g., taste) and to activities stimulated by such external cues. In an attempt to distinguish between these two explanations, anxious and nonanxious restrained and unrestrained eaters were given palatable and unpalatable foods, and consumption was measured. Results support the functional explanations: Distressed dieters increased their intake of food regardless of taste properties. Theoretical and practical implications for both restrained eating and the behavior of eating disorder patients are discussed.

Effects of anxiety on eating: does palatability moderate distress-induced overeating in dieters?

When confronted with an anxiety-producing threat to self-esteem, restrained eaters (dieters) increase their food consumption. The functional explanation suggests that increased eating temporarily counteracts or masks dysphoria for the restrained eater; externality or stimulus sensitivity theories propose that distress shifts the dieter's attention to external stimulus properties (e.g., taste) and to activities stimulated by such external cues. In an attempt to distinguish between these two explanations, anxious and nonanxious restrained and unrestrained eaters were given palatable and unpalatable foods, and consumption was measured. Results support the functional explanations: Distressed dieters increased their intake of food regardless of taste properties. Theoretical and practical implications for both restrained eating and the behavior of eating disorder patients are discussed.