Adult Cord Blood Transplantation (CBT) Vs. Unrelated Donor Transplantation: A Cost Comparison
Authors: Gutman Jonathan A , Olson Amy L , Lee Stephanie J. , Storb Rainer F. , Sandmaier Brenda M. , Appelbaum Frederick R. , Delaney Colleen 
Published: April 2020

Abstract
The number of adult CBTs is increasing. However, delayed engraftment and immune reconstitution remain important issues in CBT frequently resulting in significant resource utilization. To evaluate the relative cost of adult CBT, waiver of consent was obtained from the IRB, and we compared costs of all adult CBTs (n=25) performed at our center since February 2006 (when our current CBT protocols opened) to cohorts of adult unrelated (URD) (n=88) transplants performed during the same period. Twelve patients, median age 30 (range 20–42), underwent myeloablative CBT following conditioning with 120 mg/kg cyclophosphamide (CY), 75 mg/m2 fludarabine (FLU), and 13.2 Gy total body irradiation (TBI) and were compared to 51 consecutive URD( n=27 matched URD (MURD) and n=24 mismatched (MMURD)) patients, median age 44 (range 20–67), undergoing transplant on our center’s standard myeloablative treatment plan with either CY/TBI or busulfan (BU)/CY conditioning. Thirteen patients, median age 55 (range 24–68), underwent CBT following reduced intensity conditioning (RIC) with 200mg/m2 FLU, 50mg/kg CY, 2 Gy TBI, +/− 90 mg/kg anti-thymocyte globulin (ATG) and were compared to 37 URD (n=20 matched URD (MURD) and n=17 mismatched (MMURD)) patients, median age 56 (range 22−75) undergoing non-myeloablative RIC with 90 mg/m2 FLU/2 Gy TBI (an outpatient regimen). Ten additional patients undergoing tandem autologous/non-myeloablative URD transplant for multiple myeloma and 4 additional patients undergoing non-myeloablative URD transplant for primary graft failure were excluded. Administrative cost data were obtained for the following functional areas: inpatient bed, laboratory, pharmacy (outpatient prescriptions and home infusions excluded), outpatient clinic, radiology, radiation oncology, infusion, endoscopy, surgery, and other. Only charge data was available for the supplies functional area (which includes blood bank services), and these data were included in the analysis as charges rather than costs. Costs were totaled from arrival date on the center’s transplant service to date of discharge to primary providers or date of death. Thirteen patients were found to have relapsed disease upon arrival on the transplant service and underwent induction chemotherapy prior to transplant; these costs were excluded. Costs of cord blood units and unrelated donor products were excluded. Results are presented in Table 1. Results include cost breakdown by all functional areas with median CBT cost greater than $10,000. Myeloablative CBT was more expensive than myeloablative MURD transplant (p=0.003) and trended toward more expensive than MMURD transplant (p=0.097). RIC CBT was more expensive than both MURD and MMURD non-myeloablative RIC transplant (p=0.0002 and 0.024 respectively). Cost comparisons were performed using the Wilcoxon-Mann-Whitney test. The increased costs of CBT reflect the increased supportive care required by CBT patients; CBT patients required more inpatient days (except versus MMURD myeloablative transplants), required more laboratory testing, required more costly in-hospital and outpatient clinic drug administration, and needed more frequent transfusions. Strategies to decrease time to engraftment, to enhance immune reconstitution, and to further decrease the intensity of RIC regimens may result in significant CBT cost reductions.
Table 1: CBT vs URD transplant: Cost comparison