Decitabine Is Superior to Cytotoxic Chemotherapy in Elderly Acute Myeloid Leukemia Patients in Terms of Medical Source Utilization and Cost-Effectiveness without Negatively Impacting Survival Outcomes

Introduction

Decitabine is a drug commonly used drug in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). The efficacy of decitabine compared to best supportive care or low dose cytarabine has been shown in previous studies. However, no comparison has been made between decitabine and intensive chemotherapy in fit elderly patients. Hence, in this study, we tried to uncover the cost-effectiveness of decitabine compared to cytotoxic chemotherapy in elderly AML patients using a big database, called the Korean National Health Insurance (KNHI) Claims Database.

Methods

Records from elderly (>=65 years) patients with AML who received chemotherapy were retrieved from the KNHI claims database between July 1st, 2010 and December 31st, 2014. We investigated survival outcome within 1 year after the administration of the first line chemotherapy, utilization of the emergency room, utilization of the intensive care unit (ICU), visit to out-patient clinics and in-patient units, and total medical cost (1USD=1,000KRW) within 6 months after the initial chemotherapy. Overall survival (OS) following chemotherapy was calculated using the Kaplan-Meier method. The log-rank test was carried out to compare survival curves.

Results

A total of 1,151 records from elderly patients who received chemotherapy for AML were retrieved from the database. Decitabine was administered as the first line therapy in 239 patients, while low dose cytarabine and cytarabine combination chemotherapy were given as the first line therapy in 258 and 654 patients, respectively.

In older patients (age 65-74 years, n=821), the majority of patients received cytarabine combination chemotherapy (n=560), while 130 patients received decitabine as the first line therapy. In these patients, OS was not different between decitabine group (median OS 43.0 weeks) and cytarabine combination group (median OS 46.2 weeks). Patients who received cytarabine single agent showed significantly poorer survival with a median OS of 7.7 weeks compared to patients receiving other treatments (decitabine or cytarabine combination) (p<0.0001).

In elderly patients (age over 75 years, n=330), one-third of patients received decitabine (n=109), and 127 patients received cytarabine single treatment as the first line therapy. In these patients, OS was not different between decitabine group (median OS 37.9 weeks) and cytarabine combination group (median OS 47.9 weeks). Patients who received cytarabine single agent showed significantly poorer survival with median OS of 6.3 weeks compared to patients receiving other treatments (decitabine or cytarabine combination) (p=0.0002).

Although a similar survival outcome was observed between decitabine treatment and cytarabine combination treatment, decitabine treatment was associated with less need for intravenous antibiotic treatment (p=0.01) and less utilization of the ICU (p=0.02).

The total medical cost per person was similar to decitabine arm (40,568 USD/person) and cytarabine combination arm (44,506 USD/person) (p=0.26).

Decitabine treatment, however, was related to more frequent outpatient clinic visits (p<0.0001). Blood transfusion requirements (p=0.09), need for in-patient care (p=0.12), and utilization of the emergency room (p=0.22) were similar between the two groups.

Conclusion

In conclusion, in elderly AML patients decitabine is a reasonable first line treatment regimen with less medical source utilization and better cost-effectiveness without negatively impacting survival outcomes.

This study is funded by Janssen Korea Ltd.