Cost Offsets in the Treatment Journeys of Patients with Relapsed/Refractory Multiple Myeloma (RRMM)

Background

Multiple new regimens combining different mechanisms of action and routes of administration are available for the treatment of RRMM. It is increasingly important to understand the differential costs of these regimens, including patient and caregiver burden of treatment and associated indirect costs. The objectives of this study were to determine the costs associated with treating RRMM with 2^nd-line therapy and cost offsets associated with frequently used regimens in this setting.

Methods

A 12-month (mo) treatment journey for RRMM was developed to reflect real-world clinical practice based on current treatment guidelines and input from hematologists/oncologists. Regimens used as 2^nd- or 3^rd-line therapy were included, incorporating thalidomide (T), lenalidomide (R), pomalidomide (Pom), bortezomib (V), carfilzomib (K), ixazomib (I), elotuzumab (E), daratumumab (D), panobinostat (Pa), cyclophosphamide (C), melphalan-prednisone (MP), and dexamethasone (d/dex). Specific regimens were: Rd, Vd, VRd, VCd, Pom-dex, Kd, MPT, VMP, KRd, IRd, ERd, DVd, and PaVd. Data on DRd were not available when the model was developed. A cost model was constructed to determine costs associated with 2^nd-line treatment with these regimens, including direct (medical/laboratory [lab], drug, administration, pre-medication, prophylaxes, adverse event [AE]-related) and indirect (productivity loss, transportation, caregiving) costs incurred at the initiation of and during 2^nd-line therapy, and for a subsequent line of therapy among patients who discontinued 2^nd-line therapy due to disease progression or AEs.

Results

Drug cost represented the primary cost component of the total cost of 2^nd-line therapy across all regimens; analyses excluding these costs highlight additional direct and indirect drivers of treatment journey costs. Total costs excluding drug costs (Fig 1) appeared highest with regimens with substantial rates of discontinuation due to AEs, such as MPT, and with triplet regimens in which one or more of the agents was administered by intravenous (IV) or subcutaneous (SC) infusion, such as DVd, KRd, PaVd, VRd, and ERd. Compared to other recently approved doublet or triplet regimens, excluding drug costs, IRd appeared less expensive than Kd, KRd, ERd, DVd, and PaVd, driven by lower administration costs, AE-related costs, and indirect costs. Direct medical costs, including medical visits, lab tests, administration costs, and costs for prophylaxes, were $140.97 for the all-oral regimens IRd, Rd, and Pom-dex (12-mo cost: $1,691.61). Direct medical costs were higher for V-containing regimens, such as Vd ($707.75; 12-mo cost: $8,493.01), VRd ($708.29; 12-mo cost: $8,499.50), and VCd ($561.72; 12-mo cost: $6,740.69), compared to all-oral regimens, driven by higher administration and lab test costs. Similarly, compared to all-oral regimens, direct medical costs were higher for regimens containing novel drugs requiring clinic administration, such as Kd ($1,009.65; 12-mo cost: $12,115.75), KRd ($1,010.19; 12-mo cost: $12,122.24), ERd ($795.00; 12-mo cost: $9,539.99), DVd ($1,122.63; 12-mo cost: $13,471.61), and PaVd ($707.75; 12-mo cost: $8,493.01). AE management costs were estimated on average (all regimens) to be $243.37 per 28-day cycle (12-mo cost: $2,920.42), and were lower with Vd ($103.58; 12-mo cost: $1242.91) and higher with Pom-dex ($395.58; 12-mo cost: $4,747.00) and PaVd ($306.02; 12-mo cost: $3,672.20). Indirect costs (Fig 2) were higher for regimens requiring more frequent or longer drug administration, such as DVd ($702.78; 12-mo cost: $8,433.33), Kd, and KRd ($511.26; 12-mo cost: $6,135.06), and lowest for all-oral regimens ($78.19; 12-mo cost: $938.30). Adjusted cost offsets will be reported for subgroups with high unmet need, including frail patients, patients with barriers to physician access, and patients with pre-existing cardiac disease or other comorbidities.

Conclusions

Excluding drug acquisition costs, differences in total costs between regimens for RRMM were driven primarily by administration costs, AE-related costs, and indirect costs. The results of this study of costs accrued over 12 mos for specified regimens demonstrate the lower treatment burden (direct medical costs) and indirect costs associated with administering all-oral regimens compared to the specified regimens requiring frequent and/or lengthy IV or SC administration.

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