Second-Line Chimeric Antigen Receptor T-Cell Therapy in Diffuse Large B-Cell Lymphoma : A Cost-Effectiveness Analysis

Area of Science:

• Oncology
• Health Economics
• Pharmacoeconomics

Background:

• First-line diffuse large B-cell lymphoma (DLBCL) treatment yields durable remission in ~60% of patients.
• Relapsed/refractory DLBCL has poor outcomes with salvage chemoimmunotherapy and autologous stem cell transplantation (ASCT), achieving durable remission in only ~20%.
• Chimeric antigen receptor T-cell (CAR-T) therapies (axicabtagene ciloleucel [axi-cel] and lisocabtagene maraleucel [liso-cel]) show improved event-free survival in high-risk DLBCL compared to ASCT, but at high cost (> $400,000 per infusion).

Purpose of the Study:

• To evaluate the cost-effectiveness of second-line CAR-T therapy versus conventional salvage chemoimmunotherapy and consolidative ASCT for high-risk DLBCL.
• To determine the necessary price reductions for CAR-T to be considered cost-effective within a standard willingness-to-pay threshold.

Main Methods:

• A state-transition microsimulation model was employed for cost-effectiveness analysis.
• Data from ZUMA-7, TRANSFORM trials, and other observational studies were utilized.
• The analysis considered a lifetime time horizon from a healthcare sector perspective.

Main Results:

• Second-line axi-cel and liso-cel demonstrated incremental improvements in overall survival (4 and 1 month, respectively).
• The incremental cost-effectiveness ratios (ICERs) were $684,225/QALY for axi-cel and $1,171,909/QALY for liso-cel.
• Incremental net monetary benefits (iNMBs) were negative for both CAR-T therapies at a $200,000/QALY willingness-to-pay threshold.

Conclusions:

• Neither axi-cel nor liso-cel met the $200,000/QALY cost-effectiveness threshold in second-line high-risk DLBCL.
• Substantial cost reductions for CAR-T therapies are required to achieve cost-effectiveness.
• Implementation of CAR-T in this setting could significantly increase US healthcare spending.