Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Đurđa Vukićević; Ursula Rochau; Aleksandar Savić; Monika Schaffner; Milica Jevđević; Igor Stojkov; Gaby Sroczynski; Wolfgang Willenbacher; Beate Jahn; Uwe Siebert

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Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Slovenian Journal of Public Health

Volume 59 (2020): Issue 2 (June 2020)

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Published Online: Apr 06, 2020

Page range: 83 - 91

Received: Sep 02, 2019

Accepted: Feb 13, 2020

DOI: https://doi.org/10.2478/sjph-2020-0011

Keywords
multiple myeloma, sequential treatment, long-term effectiveness, cost effectiveness

© 2020 Đurđa Vukićević et al., published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Markov health states and state-to-state transitions. Legend: MT, maintenance treatment; Numbers 1, 2, and 3 indicate the treatment line.

Sensitivity analysis - Cost-effectiveness plane. Sequences defined by the combinations of first- and second-line treatment. The thick line is the cost-effectiveness frontier.Legend: BP, bendamustine, prednisone; CTD, cyclophosphamide, thalidomide, dexamethasone; ICER, incremental cost-effectiveness ratio; LY(s), life year(s); MPT, melphalan, prednisone, thalidomide; MPV, melphalan, prednisone, bortezomib; RD, lenalidomide, dexamethasone; VCD, bortezomib, cyclophosphamide, dexamethasone; VD, bortezomib, dexamethasone; €, euro.

Evaluated treatment sequences.

Treatment sequences
First-line Tx; Data source	Second-line Tx; Probability of switching protocol; Data source	Third-line Tx Probability of switching protocol; Data source	Palliative Tx; Data source
MPT (19)	1. VCD, 20% of cases (20)	1. RD, 30% (22)	CP (24, 25)
	2. VD, 70% (21)	2. BTP, 40% (23)
	3. RD, 10% (22)	3. Chemo, 30% ^*
MPV (26)	1. CTD, 90% (27)	1. RD, 30% (22)	CP (24, 25)
	2. RD, 10% (22)	2. BTP, 40% (23)
		3. Chemo, 30% ^*
CTD (28)	1. MPV, 30% (29)	1. RD, 30% (22)	CP (24, 25)
	2. VD, 60% (21)	2. BTP, 40%
	3. RD, 10% (22)	3. Chemo, 30%^*
VCD (30)	1. MPT (31)	1. RD, 30% (22)	CP (24, 25)
	2. RD, 10% (22)	2. BTP, 40% (23)
		3. Chemo, 30% ^*
BP (32)	1. RD, 100% (22)	1. BTP, 50% (23)	CP (24, 25)
BP (32)		2. Chemo, 50% ^*	CP (24, 25)

Sensitivity analysis results – varying probability of switching to the lenalidomide-based treatment options.

Strategy	Without RD options			Probability of switching to RD increased by 20%			Probability of switching to RD increased by 50%			Probability of switching to RD increased by 100% (i.e., doubled)

	Cost (€)	Life expect-ancy (LYs)	ICER (€/LYG)	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)
Starting with MPT	73,000	3.63	-	124,700	3.71	-	137,400	3.73	-	160,300	3.77	-
Starting with CTD	76,900	3.29	Dom	132,800	3.43	Dom	147,300	3.47	Dom	174,200	3.54	Dom
Starting with VCD	82,800	3.89	36,900	136,400	4.00	39,800	151,400	4.03	46,500	178,800	4.09	Ext Dom
Starting with MPV	112,900	4.68	38,000	174,100	4.77	48,700	190,600	4.80	51,000	220,200	4.84	55,800
Starting with BP*	373,400	3.98	Dom	373,400	3.98	Dom	373,400	3.98	Dom	373,400	3.98	Dom

Sensitivity analysis – ranking of the sequences when excluding the third-line chemotherapy.

Strategy	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)
Starting with MPT	210,200	4.40	-
Starting with CTD	223,100	4.16	Dom
Starting with VCD	251,100	4.92	Ext Dom
Starting with MPV	266,000	5.53	55,800
Starting with BP	390,200	4.92	Dom

Variation of annual discount rates.

Discount rate →	1.5% for effectiveness; 3% for costs			5% for effectiveness and costs

Strategy	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)
Starting with MPT	116,500	3.85	-	110,500	3.51	-
Starting with CTD	123,400	3.53	Dom	117,900	3.25	Dom
Starting with VCD	126,700	4.16	32,500	121,800	3.77	43,800
Starting with MPV	163,300	5.01	43,100	156,100	4.47	49,600
Starting with BP	373,400	4.15	Dom	351,800	3.77	Dom

Discounted base-case analysis results.

Strategy	Cost (€)	Life expectancy (LYs)	ICER (€/LYG)
Starting with MPT	116,500	3.70	-
Starting with CTD	123,400	3.41	Dom
Starting with VCD	126,700	3.99	35,300
Starting with MPV	163,300	4.76	47,200
Starting with BP	373,400	3.98	Dom

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Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Article Category: Original scientific article

Published Online: Apr 06, 2020

Page range: 83 - 91

Received: Sep 02, 2019

Accepted: Feb 13, 2020

DOI: https://doi.org/10.2478/sjph-2020-0011

Keywords
multiple myeloma, sequential treatment, long-term effectiveness, cost effectiveness

© 2020 Đurđa Vukićević et al., published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Figure 1

Figure 2

Evaluated treatment sequences.

Sensitivity analysis results – varying probability of switching to the lenalidomide-based treatment options.

Sensitivity analysis – ranking of the sequences when excluding the third-line chemotherapy.

Variation of annual discount rates.

Discounted base-case analysis results.

Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Article Category: Original scientific article

Published Online: Apr 06, 2020

Page range: 83 - 91

Received: Sep 02, 2019

Accepted: Feb 13, 2020

DOI: https://doi.org/10.2478/sjph-2020-0011

Keywordsmultiple myeloma, sequential treatment, long-term effectiveness, cost effectiveness

© 2020 Đurđa Vukićević et al., published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Figure 1

Figure 2

Evaluated treatment sequences.

Sensitivity analysis results – varying probability of switching to the lenalidomide-based treatment options.

Sensitivity analysis – ranking of the sequences when excluding the third-line chemotherapy.

Variation of annual discount rates.

Discounted base-case analysis results.

Keywords
multiple myeloma, sequential treatment, long-term effectiveness, cost effectiveness