Cost-Effectiveness of First-Line Ibrutinib versus Third-Line in Patients with Untreated Chronic Lymphocytic Leukemia
Menée dans un contexte américain, cette étude analyse le rapport coût-efficacité de l’ibrutinib dispensé en traitement de première ou de troisième ligne chez des patients atteints d’une leucémie lymphoïde chronique
The ALLIANCE trial found that continuously administered ibrutinib in the first-line setting significantly prolonged progression-free survival compared to a fixed-duration treatment of rituximab and bendamustine in older adults with CLL. In this study, we created a Markov model to assess the cost-effectiveness of ibrutinib in the first-line setting, compared to a strategy of using ibrutinib in the third-line after failure of time-limited bendamustine and venetoclax-based regimens. 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 from a US payer perspective. First-line ibrutinib was associated with an improvement of 0.26 QALYs and 0.40 life-years compared to using ibrutinib in the third-line setting. However, using ibrutinib in the first-line led to significantly higher healthcare costs (incremental cost of $612,700), resulting in an ICER of $2,350,041/QALY. The monthly cost of ibrutinib would need to be decreased by 72% for first-line ibrutinib therapy to be cost-effective at a willingness-to-pay threshold of $150,000/QALY. In a scenario analysis where ibrutinib was used in the second-line in the delayed ibrutinib arm, first-line ibrutinib had an incremental cost of $478,823, an incremental effectiveness of 0.05 QALYs, and an ICER of $9,810,360/QALY when compared to second-line use. These data suggest that first-line ibrutinib for unselected older adults with CLL is unlikely to be cost-effective under current pricing. Delaying ibrutinib for most patients with CLL until later lines of therapy may be a reasonable strategy to limit healthcare costs without compromising clinical outcomes.
Blood 2020