| ==== Front | |
| J Manag Care Spec Pharm | |
| J Manag Care Spec Pharm | |
| jmcsp | |
| Journal of Managed Care & Specialty Pharmacy | |
| 2376-0540 | |
| 2376-1032 | |
| Academy of Managed Care Pharmacy | |
| 10.18553/jmcp.2018.24.7.711 | |
| Letters | |
| Reframing the Value of Treatments for Relapsed/Refractory Multiple Myeloma | |
| Ailawadhi Sikander MD 1 | |
| Panjabi Sumeet PhD 2 | |
| Campioni Marco PhD 3 | |
| Majer Istvan PhD 3 | |
| Jakubowiak Andrzej MD, PhD 4 | |
| 1 Division of Hematology/Oncology, Department of Medicine, Mayo Clinic, Jacksonville, Florida | |
| 2 Amgen, South San Francisco, California | |
| 3 Amgen, Zug, Switzerland | |
| 4 Myeloma Program, University of Chicago, Chicago, Illinois | |
| Ailawadhi reports research support from Pharmacyclics and consulting relationships with Takeda, Amgen, and Celgene. Jakubowiak reports consulting and advisory board relationships with AbbVie, Amgen, BMS, Celgene, Karyopharm, SkylineDX, and Takeda. Panjabi, Campioni, and Majer are employees of and stockholders in Amgen. | |
| 7 2018 | |
| 24 7 10.18553/jmcp.2018.24.7.711Copyright © 2018, Academy of Managed Care Pharmacy. All rights reserved. | |
| 2018 | |
| https://creativecommons.org/licenses/by/4.0/ This article is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use and redistribution provided that the original author and source are credited. | |
| ==== Body | |
| pmcIn the article “Cost-effectiveness of Drugs to Treat Relapsed/Refractory Multiple Myeloma in the United States,” published in the JMCP January 2018 issue, Carlson et al. seek to identify the most cost-effective therapy for relapsed/refractory multiple myeloma (R/RMM).1 Instead, for MM, a chronic, progressive, and heterogenous disease, the decision problem is to identify the regimen sequences that maximize benefit for patients longitudinally over their disease course. Optimal treatment varies by patient at each relapse, since stakeholders need to consider prognostic factors, previous therapies, and associated response (duration/depth); residual adverse events; and, of course, individual patient preferences. In this letter, we discuss limitations of the Carlson et al. analysis that significantly affect the results and conclusions. Inaccurate statements that warrant correction are also identified. | |
| A major limitation stems from the network meta-analysis (NMA), which yields estimates of relative efficacy that are not reliable and valid and lack face validity: lenalidomide (LEN) plus dexamethasone (DEX) is estimated to be less effective than bortezomib (BOR) + DEX, even though all listed trials (Appendix A) show that LEN + DEX achieved double the progression-free survival (PFS) than BOR + DEX1; panobinostat (PAN) + BOR + DEX is estimated to be more effective than LEN + DEX (PFS hazard ratio of 0.54), even though the appraisal committee for the National Institute of Clinical Excellence (NICE) concluded that there is no difference in effectiveness between PAN + BOR + DEX and LEN + DEX in third-line treatment.2 | |
| Trials included in the NMA are not comparable due to differences in clinical trial designs, populations, and end-points. In CASTOR,3 BOR + DEX duration was capped at 6 months and in ENDEAVOR was used to treat-to-progression (TTP),4 and a majority of patients (> 50%) received BOR + DEX beyond 6 months in ENDEAVOR. In its appraisal, the NICE committee concluded that capping treatment duration instead of TTP would reduce BOR + DEX efficacy.5 | |
| Carfilzomib (CFZ) + DEX, an NCCN preferred category 1 regimen for previously treated MM with proven PFS and overall survival (OS) superiority over BOR + DEX, was not even considered in the Carlson et al. analysis. The cost-effectiveness of CFZ + DEX versus BOR + DEX has been unequivocally established.6 For CFZ + LEN + DEX, Carlson et al. appear to overestimate treatment costs by possibly not capping CFZ dosing at 18 cycles per the ASPIRE trial and label, not considering discontinuation of treatments due to reasons other than progression, and by overestimating wastage. Accounting for these corrections would confirm that CFZ + LEN + DEX is cost-effective versus LEN + DEX.7 | |
| The Jakubowiak et al. (2017) study,4 which concluded that CFZ + LEN + DEX is cost-effective versus LEN + DEX, was cited inaccurately in several instances. Carlson et al. misreported an odds ratio as a hazards ratio. In Jakubowiak et al., PFS curves for CFZ + LEN + DEX generated by the model aligned very well with the PFS curves observed in the ASPIRE trial (Figure 2),4 yet Carlson et al. stated that there is a mismatch between “modeled” and “ASPIRE trial-observed” results probably because they compare a “mean” estimate from the model to the “median” from the ASPIRE trial. Jakubowiak et al. report postprogression survival and costs to be greater for CFZ + LEN + DEX (Table 8),4 yet Carlson et al. inaccurately state the opposite. | |
| We strongly recommend that Carlson et al. undertake a reanalysis to address cited limitations and withdraw inaccurate statements. By publishing this letter, JMCP will serve patients well in its mission to present balanced information that contributes to improving the quality of care for patients. | |
| ==== Refs | |
| REFERENCES | |
| 1. Carlson JJ, Guzauskas GF, Chapman RH, et al . Cost-effectiveness of drugs to treat relapsed/refractory multiple myeloma in the United States. J Manag Care Spec Pharm. 2018;24 (1 ):29-38. Available at: https://www.jmcp.org/doi/10.18553/jmcp.2018.24.1.29.29290170 | |
| 2. National Institute for Health and Care Excellence. Panobinostat for treating multiple myeloma for a least 2 previous treatments. Technology Appraisal Guidance 380. January 27, 2016. Available at: www.nice.org.uk/guidance/ta380. Accessed June 6, 2018. | |
| 3. Palumbo A, Chanan-Khan A, Weisel K, et al . Daratumumab, bortezomib, and dexamethasone for multiple myeloma. N Engl J Med. 2016;375 (8 ):754-66.27557302 | |
| 4. Dimopoulos MA, Goldschmidt H, Niesvizky R, et al . Carfilzomib or bortezomib in relapsed or refractory multiple myeloma (ENDEAVOR): an interim overall survival analysis of an open-label, randomised, phase 3 trial. Lancet Oncol. 2017;18 (10 ):1327-37.28843768 | |
| 5. National Institute for Health for Care Excellence. Carfilzomib for previously treated multiple myeloma. June 2017. Available at: https://www.nice.org.uk/guidance/ta457/documents/final-appraisal-determination-document. Accessed June 6, 2018. | |
| 6. Jakubowiak AJ, Houisse I, Májer I, et al . Cost-effectiveness of carfilzomib plus dexamethasone compared with bortezomib plus dexamethasone for patients with relapsed or refractory multiple myeloma in the United States. Expert Rev Hematol. 2017;10 (12 ):1107-19.29027825 | |
| 7. Jakubowiak AJ, Campioni M, Benedict Á, et al . Cost-effectiveness of adding carfilzomib to lenalidomide and dexamethasone in relapsed multiple myeloma from a U.S. perspective. J Med Econ. 2016;19(11 ):1061-74.27471948 | |