Modeling First-Line Daratumumab Use for Newly Diagnosed, Transplant-Ineligible, Multiple Myeloma: A Cost-Effectiveness and Risk Analysis for Healthcare Payers

Diana Beatriz Bayani; Yihao Clement Lin; Chandramouli Nagarajan; Melissa G Ooi; Allison Ching Yee Tso; John Cairns; Hwee Lin Wee

doi:10.1007/s41669-024-00503-9

Modeling First-Line Daratumumab Use for Newly Diagnosed, Transplant-Ineligible, Multiple Myeloma: A Cost-Effectiveness and Risk Analysis for Healthcare Payers

Pharmacoecon Open. 2024 Sep;8(5):651-664. doi: 10.1007/s41669-024-00503-9. Epub 2024 Jun 20.

Authors

Diana Beatriz Bayani¹, Yihao Clement Lin², Chandramouli Nagarajan³, Melissa G Ooi⁴, Allison Ching Yee Tso², John Cairns⁵, Hwee Lin Wee⁶

Affiliations

¹ Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, Singapore, 117549, Republic of Singapore. dbayani@u.nus.edu.
² Department of Hematology, Tan Tock Seng Hospital, Singapore, Singapore.
³ Department of Haematology, Singapore General Hospital, Singapore, Singapore.
⁴ Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.
⁵ Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
⁶ Saw Swee Hock School of Public Health, Department of Pharmacy, National University of Singapore, Singapore, Singapore.

Abstract

Background and objective: This study aimed to assess the cost-effectiveness of two regimens regarded as the standard of care for the treatment of newly diagnosed, transplant-ineligible multiple myeloma in Singapore: (1) daratumumab, lenalidomide, and dexamethasone and (2) bortezomib, lenalidomide, and dexamethasone. Additionally, it aimed to explore potential strategies to manage decision uncertainty and mitigate financial risk.

Methods: A cost-effectiveness analysis from the healthcare system perspective was conducted using a partitioned survival model to estimate lifetime costs and quality-adjusted life years (QALYs) associated with daratumumab-based treatment and the bortezomib-based regimen. The analysis used data from the MAIA and SWOG S0777 trials and incorporated local real-world data where available. Sensitivity analyses were performed to evaluate the robustness of the findings, and a risk analysis was conducted to analyze various payer strategies in terms of their payer strategy and uncertainty burden (P-SUB), which account for the decision uncertainty and the additional cost of choosing a suboptimal intervention.

Results: The incremental cost-effectiveness ratio (ICER) for daratumumab, lenalidomide, and dexamethasone (DRd) compared with bortezomib, lenalidomide, and dexamethasone (VRd) was US $90,364 per QALY gained. The results were sensitive to variations in survival for DRd, postprogression treatment costs, cost of hospice care, and hazard ratio for progression-free survival. The scenarios explored indicated that structural assumptions, such as the time horizon of the analysis, significantly influenced the results due to uncertainties arising from immature trial data and treatment efficacy over time. Among the various payer strategies compared, an upfront price discount for daratumumab emerged as the best approach with the lowest P-SUB at US $14,708.

Conclusion: In conclusion, this study finds that daratumumab as a first-line treatment for myeloma exceeds the cost-effectiveness threshold considered in this evaluation. An upfront price reduction is the recommended strategy to manage uncertainties and mitigate financial risks. These findings highlight the importance of targeted payer strategies to address specific types and sources of uncertainty.