Cost Effectiveness Analysis for Targeted Therapy in Patients with Acute Myeloid Leukemia

1. Acute myeloid leukemia (AML) is the most common
acute adult leukemia and patients diagnosed with AML have
poor survival. The standard treatment for treating AML is ‘7+3’
regimen, which means 7 days of cytarabine and 3 days of an
anthracycline. But the intensive induction chemotherapy like
‘7+3’ is sometimes unbearable, especially in elderly patients.
Many clinical trials have been designed to use novel agents
for treatment. Since 2017, eight agents have approved for
various indications, including several targeted therapies such
as venetoclax, FLT3 inhibitors and IDH inhibitors.
However, most targeted therapies are expensive and
not covered by Taiwan National Health Insurance. This study
aimed to provide a cost effectiveness analysis for genetic
screening and targeted therapies for treating AML patients.
Based on the decision-analytical modelling, this study is aimed
to evaluate the cost effectiveness of using new treatment like
targeted therapies with ‘7+3’ standard treatment through the
modelling of Markov models for providing quantitative analysis
and considering the uncertain factors during the decision
making process.
Cost Effectiveness Analysis for Targeted Therapy
in Patients with Acute Myeloid Leukemia
Author : Chia-Hsun Lee
Advisor : Hsin-An Hou and Hsiu-Hsi Chen
Background
Conclusion
The first aim for this study is to find a better treatment option for newly diagnosed AML patient, which is ineligible for intensive
chemotherapy. ICER indicates the effectiveness from new treatment could be a treatment alternative.
Regard the 2nd aim is this alternative could it be the target therapy? We took the open data from AML clinical trial called
Beat AML 1.0. There is 47.9% took more than two treatment type in this dataset with 25% FLT3-ITD mutated patients. This needs more
details for each patient characteristics in cohort study in the future analysis.
Materials and methods
Results
Treatment Options for New Diagnostic AML patients
Recently approved drugs provide new treatment
options, include Midostaurin, Gilteritinib for fms-like tyrosine
kinase 3 (FLT3) inhibitor, Venetoclax, Ivosidenib, Enasidenib for
isocitrate dehydrogenase (IDH1/2) inhibitor; CPX-351 for TP53
mutation; Glasdegib for Hedgehog inhibitor; Gemtuzumab
ozogamicin (GO) for newly diagnosed CD-33+ AML.
Meta-analysis for parameters of the effectiveness of new
treatment treating AML patients
We searched the RATIFY trial, Lancet, Cochrane Library
and PubMed for relevant randomised trials and other high-
quality studies, which published in English between Jan 1, 2017
and Mar 31 2022. We used the search terms “acute myeloid
leukaemia” or “AML” in combination with the terms
“genomics”, “outcomes”, “prognosis”, and “treatment”.
Decision Tree for Cost-effectiveness analysis (CEA)
The strategies for comparison are shown in Figure 2.
One is “7+3” standard treatment and the other is the targeted
therapy. The squared symbol is the decision node and the
circle node with pathway strategies inside is the Markov node.
We have Markov cycle follows the disease progression with the
efficacy of treatment to stop the progression. The cycle will
stop until death or the end of our assumed follow-up time.
The key components to construct a decision tree include
demographic distribution, the proportion of unfit from the
prevalence of genetic mutations such as IDH1/2, FLT3 and
CD33+ and the efficacy and costs of the standard treatment
and the targeted therapy.
Survival for AML patients treated with risk stratification for
personalized strategy
Table 1. The result of deterministic Sensitivity Analysis (DSA) and a
probabilistic sensitivity analyses (PSA)
Figure 2. Decision Tree for CEA
Figure 1. Treatment Options by period
CR: Complete remission
AE: Adverse event
D: Death
Figure 3.1Cost-effectiveness plane of Markov model
Figure 3.2Acceptability curves for the choice of treatment strategy
QALY: Quality-adjusted life years
ICER: Incremental cost-effectiveness ratio
SOC: Standard of Care