Artikel
Sequential Treatment of Chronic Myeloid Leukemia Patients: A Decision-analytic Cost-effectiveness Study
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Veröffentlicht: | 10. März 2014 |
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Gliederung
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Purpose: The introduction of the tyrosine kinase inhibitor (TKI) imatinib dramatically extended the overall survival of chronic myeloid leukemia (CML) patients. Currently, there are several different TKIs approved and recommended for CML therapy. The aim of our study was to evaluate the long-term cost-effectiveness of different therapy regimens for CML within the Austrian health care context.
Methods: We performed a cost-effectiveness analysis using a state-transition Markov model. The model evaluates seven treatment strategies of differential sequencing of TKIs as well as chemotherapy or stem cell transplantation. For model parameters, we used published trial data, data from the Austrian CML registry, statistical and economic databases. We performed a cohort simulation over a lifelong time horizon, adopted a societal perspective with an annual 3% discount rate. Evaluated outcomes included life expectancy, quality-adjusted life years (QALYs), life-time costs, and discounted incremental cost-effectiveness/utility ratios (ICER/ICUR). We performed extensive univariate, and multivariate probabilistic sensitivity analyses (PSA) as well as a scenario analysis for generic drug pricing of imatinib.
Results: In the base-case efficiency frontier, nilotinib yielded an ICUR of 120,400 €/QALY (1) and an ICER of 107,000 €/LY compared to the baseline strategy imatinib without 2nd-line TKI. Imatinib followed by nilotinib after failure resulted in 129,500 €/QALY (2) and was dominated in terms of LY/€ compared to nilotinib without 2nd-line TKI. Nilotinib followed by dasatinib yielded an ICUR of 151,500 €/QALY (3) compared to imatinib followed by nilotinib after failure and an ICER of 192,400 €/LY compared to nilotinib without 2nd-line TKI. The remaining three strategies were excluded due to dominance. The PSA resulted in mean ICURs of 122,400 (1), 132,900 (2) and 153,300 €/QALYs (3). Deviations of the mean PSA results from the deterministic analysis range from 1.2% (3) to 2.6% (2).
Conclusions: Our analysis revealed high ICERs for the treatment of CML with TKIs. In Austria, the sequential application of TKIs is standard of care and withholding a 2nd-line TKI would not be acceptable. Therefore, based on our analysis we recommend imatinib followed by nilotinib as the most cost-effective treatment strategy. Mean results from PSA show only small deviation from the base-case analysis. When new path to cure treatment strategy data are available, results will need to be updated.