What is the Costliest Therapy for Multiple Myeloma?

A research report published in American Health & Drug Benefits found that among 7 common treatment regimens for relapsed and/or refractory multiple myeloma (RRMM), the highest total costs were associated with regimens combining lenalidomide with a proteasome inhibitor.

Combination therapy with bortezomib was associated with the lowest total costs, coming in under $125,000 per patient. With the increasing use of novel therapies for RRMM, authors noted the need for benchmarks to assess the relative value of therapeutic options.

Their objective was two-fold: (1) to calculate their own cost estimates based on current guidelines from Medicare and commercial insurance perspectives; and (2) to develop the first model that can be used in future budget analyses that considers all the costs of therapy, including drug price, administration, prophylaxis, monitoring, duration, and adverse events.

The 7 treatment regimens for RRMM included in this study, listed in order of total expense from lowest to highest, were:

• Bortezomib + dexamethasone
• Panobinostat + bortezomib + dexamethasone
• Lenalidomide + dexamethasone (Rd)
• Carfilzomib
• Pomalidomide + dexamethasone
• Lenalidomide + bortezomib + dexamethasone (RVD)
• Carfilzomib + lenalidomide + dexamethasone (CRd)

Determining Pharmacy Costs for Multiple Myeloma Treatment

Researchers calculated total pharmacy and medical costs as the sum of expenditures for (1) drugs and their administration (data from published wholesale pricing and labeled dosing schedules); (2) prophylaxis and adverse event monitoring (data from peer-reviewed publications); and (3) treatment of grade 3 or 4 adverse events (data from each regimen’s prescribing information and clinical trials).

All costs were totaled over the duration of therapy specified for each regimen and calculated separately for Medicare and commercial insurance plans. For each regimen, the duration of therapy was determined as the length of time required to obtain 12 months of progression-free survival (PFS) based on duration-of-therapy to PFS ratios published in clinical trials and/or the drug’s labeling.

Cost Comparison of Therapies for Relapsed and/or Refractory Multiple Myeloma

Total cost per patient over the course of 12 months of PFS ranged from approximately $90,600 (bortezomib + dexamethasone) to $260,000 (CRd). The combination of panobinostat + bortezomib + dexamethasone was the second least expensive regimen, at $118,745.

Investigators found that total pharmacy cost was highest for pomalidomide + dexamethasone ($135,774 per patient) and lowest for bortezomib + dexamethasone ($6), followed by panobinostat + bortezomib + dexamethasone ($33,804). All carfilzomib-related costs were medical, so there was no pharmacy cost.

Total medical cost was highest for CRd ($148,326), whereas 2 regimens, Rd and pomalidomide + dexamethasone, incurred no medical costs.

The study authors said that total costs were highest for combination regimens that included lenalidomide (approximate cost range, $126,000 — $256,000).

From the Medicare plan perspective, carfilzomib cost the most per month ($24,293) and bortezomib + dexamethasone cost the least ($8175).

From the commercial plan perspective, CRd cost the most per month ($27,422) and bortezomib + dexamethasone cost the least ($9903).

Conclusion

Going forward, the model framework created by this research project can be used to comprehensively estimate the costs of managing RRMM by comparing all regimens that are currently approved and guideline-recommended in the United States.