Cost-effectiveness of Tyrosine Kinase Inhibitor Treatment Strategies for Chronic Myeloid Leukemia in Chronic Phase After Generic Entry of Imatinib in the United States

• Published in: JNCI : Journal of the National Cancer Institute 2016-07, Vol.108 (7), p.djw003
• Main Authors: Padula, William V, Larson, Richard A, Dusetzina, Stacie B, Apperley, Jane F, Hehlmann, Rudiger, Baccarani, Michele, Eigendorff, Ekkehard, Guilhot, Joelle, Guilhot, Francois, Mahon, Francois-Xavier, Martinelli, Giovanni, Mayer, Jiri, Müller, Martin C, Niederwieser, Dietger, Saussele, Susanne, Schiffer, Charles A, Silver, Richard T, Simonsson, Bengt, Conti, Rena M
• Format: Article
• Language: English
• Subjects: Adult; Aged; Antineoplastic Agents - economics; Antineoplastic Agents - therapeutic use; Cost-Benefit Analysis; Drugs, Generic - economics; Drugs, Generic - therapeutic use; Female; Humans; Imatinib Mesylate - economics; Imatinib Mesylate - therapeutic use; Leukemia, Myelogenous, Chronic, BCR-ABL Positive - drug therapy; Leukemia, Myelogenous, Chronic, BCR-ABL Positive - economics; Leukemia, Myelogenous, Chronic, BCR-ABL Positive - mortality; Male; Markov Chains; Middle Aged; Models, Econometric; Practice Patterns, Physicians' - standards; Practice Patterns, Physicians' - trends; Protein Kinase Inhibitors - economics; Protein Kinase Inhibitors - therapeutic use; Protein-Tyrosine Kinases - antagonists & inhibitors; Quality-Adjusted Life Years; Survival Analysis; Treatment Outcome; United States - epidemiology
• ISSN: 0027-8874; 1460-2105; 1460-2105
• DOI: 10.1093/jnci/djw003

We analyzed the cost-effectiveness of treating incident chronic myeloid leukemia in chronic phase (CML-CP) with generic imatinib when it becomes available in United States in 2016. In the year following generic entry, imatinib's price is expected to drop 70% to 90%. We hypothesized that initiating treatment with generic imatinib in these patients and then switching to the other tyrosine-kinase inhibitors (TKIs), dasatinib or nilotinib, because of intolerance or lack of effectiveness ("imatinib-first") would be cost-effective compared with the current standard of care: "physicians' choice" of initiating treatment with any one of the three TKIs. We constructed Markov models to compare the five-year cost-effectiveness of imatinib-first vs physician's choice from a US commercial payer perspective, assuming 3% annual discounting ($US 2013). The models' clinical endpoint was five-year overall survival taken from a systematic review of clinical trial results. Per-person spending on incident CML-CP treatment overall care components was estimated using Truven's MarketScan claims data. The main outcome of the models was cost per quality-adjusted life-year (QALY). We interpreted outcomes based on a willingness-to-pay threshold of $100 000/QALY. A panel of European LeukemiaNet experts oversaw the study's conduct. Both strategies met the threshold. Imatinib-first ($277 401, 3.87 QALYs) offered patients a 0.10 decrement in QALYs at a savings of $88 343 over five years to payers compared with physician's choice ($365 744, 3.97 QALYs). The imatinib-first incremental cost-effectiveness ratio was approximately $883 730/QALY. The results were robust to multiple sensitivity analyses. When imatinib loses patent protection and its price declines, its use will be the cost-effective initial treatment strategy for CML-CP.