Cost-Effectiveness of First-Line Versus Second-Line Use of Daratumumab in Older, Transplant-Ineligible Patients With Multiple Myeloma
Cost-Effectiveness of First-Line Versus Second-Line Use of Daratumumab in Older, Transplant-Ineligible Patients With Multiple Myeloma
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DOI：
10.1200/jco.20.01849
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发表时间：
2021-04-01
影响因子：
45.3
通讯作者：
Huntington, Scott F.
中科院分区：
文献类型：
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作者：
Patel, Kishan K.;Giri, Smith;Huntington, Scott F.
马亚试验发现，与来那度胺和地塞米松单药治疗（Rd）相比，来那度胺和地塞米松联合达雷妥尤单抗治疗（DRd）可显著延长不符合移植条件的新诊断多发性骨髓瘤患者的无进展生存期。然而，达雷妥尤单抗是一种昂贵的治疗方法，并且无限期给药直至疾病进展。因此，目前尚不清楚达雷妥尤单抗在一线治疗中使用与将其保留至后期治疗相比是否具有成本效益。我们创建了一个马尔可夫模型来比较一线环境中接受达雷妥尤单抗治疗的不符合移植条件的患者的医疗成本和临床结局，与将达雷妥尤单抗保留到二线的策略相比。我们使用参数生存模型估计随机试验的转移概率。从美国支付者的角度计算一线达雷妥尤单抗与二线达雷妥尤单抗的终生直接医疗保健成本、质量调整生命年（QER）和增量成本效果比（ICER）。结果：与二线达雷妥尤单抗相比，一线达雷妥尤单抗与0.52 Qs和0.66折扣生命年的改善相关。虽然这两种治疗策略都与相当大的终身支出相关（1，434，937美元vs 1，112，101美元），但一线达雷妥尤单抗的增量成本为322，836美元，导致ICER为618，018美元/QALY。达雷妥尤单抗的成本需要降低67%，一线达雷妥尤单抗才具有成本效益，支付意愿阈值为每QALY 150，000美元。结论：在目前的价格下，在不符合移植条件的患者中使用达雷妥尤单抗进行一线治疗可能不具有成本效益。将daratumumab延迟至后续治疗线可能是一种合理的策略，可以在不显著影响临床结局的情况下限制医疗费用。成熟的总生存数据是必要的，以更充分地评估在这种情况下的成本效益。
PURPOSE The MAIA trial found that addition of daratumumab to lenalidomide and dexamethasone (DRd) significantly prolonged progression-free survival in transplant-ineligible patients with newly diagnosed multiple myeloma, compared with lenalidomide and dexamethasone alone (Rd). However, daratumumab is a costly treatment and is administered indefinitely until disease progression. Therefore, it is unclear whether it is cost-effective to use daratumumab in the first-line setting compared with reserving its use until later lines of therapy. METHODS We created a Markov model to compare healthcare costs and clinical outcomes of transplant-ineligible patients treated with daratumumab in the first-line setting compared with a strategy of reserving daratumumab until the second-line. We estimated transition probabilities from randomized trials using parametric survival modeling. Lifetime direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for first-line daratumumab versus second-line daratumumab from a US payer perspective. RESULTS First-line daratumumab was associated with an improvement of 0.52 QALYs and 0.66 discounted life-years compared with second-line daratumumab. While both treatment strategies were associated with considerable lifetime expenditures ($1,434,937 v $1,112,101 in US dollars), an incremental cost of $322,836 for first-line daratumumab led to an ICER of $618,018 per QALY. The cost of daratumumab would need to be decreased by 67% for first-line daratumumab to be cost-effective at a willingness-to-pay threshold of $150,000 per QALY. CONCLUSION Using daratumumab in the first-line setting for transplant-ineligible patients may not be cost-effective under current pricing. Delaying daratumumab until subsequent lines of therapy may be a reasonable strategy to limit healthcare costs without significantly compromising clinical outcomes. Mature overall survival data are necessary to more fully evaluate cost-effectiveness in this setting.