Cost-effectiveness analysis of mosunetuzumab for treatment of relapsed or refractory follicular lymphoma after two or more lines of systemic therapy in the United States

Figures & data

Figure 1. Model structure. Note: Patients’ distribution among health states over time were estimated using the fitted PFS and OS curves. At each model cycle, the proportion of patients remaining alive and discontinuing treatment were estimated by means of TTOT data from the GO29871 study for mosunetuzumab whereas for all other treatments, the TTOT is set equal to the selected parametric distribution for PFS, capped at the treatment-specific maximum number of cycles ascertained from US PIs. Abbreviations. OS, overall survival; PIs, package inserts; PFS, progression-free survival; PPS, post-progression disease; TTOT, time-to-off treatment.

Table 1. Model parameters.

Parameter	Base case value	Low value	High value	PSA distribution	Reference/Note
Baseline patient characteristics
Age (years)	60.0	48.0	72.0	Not varied	GO29781 study
Body surface area (m^2)	1.96	1.56	2.35	Not varied	GO29781 study
Body weight (kg)	81.4	65.1	97.7	Not varied	GO29781 study
Proportion male	61.1%	48.9%	73.3%	Not varied	GO29781 study
Treatment efficacy, OS, PH method (if PH assumption was not violated)
HR, mosunetuzumab vs. Taz	0.16	0.07	0.41	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. Axi-cel	0.61	0.14	1.68	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. Tisa-cel	0.86	0.15	1.93	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. RW	0.43	0.19	0.94	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. O-Benda	0.70	0.28	1.58	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. R-Benda	N/A	N/A	N/A	N/A	N/A
HR, mosunetuzumab vs. R-Len	N/A	N/A	N/A	N/A	N/A
Treatment efficacy, PFS, PH method (if PH assumption was not violated)
HR, mosunetuzumab vs. Taz	0.35	0.19	0.57	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. Axi-cel	2.09	1.30	3.12	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. Tisa-cel	1.73	1.10	2.75	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. RW	0.82	0.53	1.27	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. O-Benda	2.10	1.19	3.87	Bootstrapped	Data on file^a
HR, mosunetuzumab vs. R-Benda	N/A	N/A	N/A	N/A	N/A
HR, mosunetuzumab vs. R-Len	N/A	N/A	N/A	N/A	N/A
Utilities
PFS	0.8373	0.8073	0.8657	Beta	GO29781 study
PPS	0.7650	0.7197	0.8117	Beta	GO29781 study
Drug acquisition costs
Mosunetuzumab, 1 mg/1 mL (1 mL)	$594.06	Not varied	Not varied	Not varied	AnalySource^29
Mosunetuzumab, 1 mg/1 mL (30 mL)	$17,821.78	$14,257.42	$21,386.14	Not varied	AnalySource^29
Tazemetostat, 200 mg (240s ea)	$18,850.00	$15,080.00	$22,620.00	Not varied	AnalySource^29
Axicabtagene ciloleucel	$424,000.00	$339,200.00	$508,800.00	Not varied	AnalySource^29
Tisagenlecleucel	$427,047.70	$341,638.16	$512,457.24	Not varied	AnalySource^29
Obinutuzumab, 25 mg/mL (40 mL)	$7,775.32	$6,220.26	$9,330.38	Not varied	AnalySource^29
Bendamustine, 25 mg (ea)	$400.00	$320.00	$480.00	Not varied	AnalySource^29
Bendamustine, 100 mg (ea)	$1,600.00	$1,280.00	$1,920.00	Not varied	AnalySource^29
Rituximab, 10 mg/mL (10 mL)	$824.24	$659.39	$989.09	Not varied	AnalySource^29^,b
Rituximab, 50 mg/mL (10 mL)	$4,121.21	$3,296.96	$4,945.45	Not varied	AnalySource^29^,b
Lenalidomide, 20 mg (21s ea)	$17,497.73	$13,998.18	$20,997.28	Not varied	AnalySource^29
Administration costs
CPT code 96413	$140	$112	$168	Gamma	CMS^30
CPT code 96415	$30	$24	$36	Gamma	CMS^30
CPT code 96417	$68	$55	$82	Gamma	CMS^30
CPT code 96374	$40	$32	$48	Gamma	CMS^30
CPT code 96375	$16	$13	$20	Gamma	CMS^30
CPT code 36511	$110	$88	$132	Gamma	CMS^30
Axi-cel, excl. LD chemo drug costs	$30,778	$24,623	$36,934	Gamma	Calculated^c
Tisa-cel, excl. LD chemo drug costs	$25,436	$20,349	$30,523	Gamma	Calculated^c
Axi-cel, LD chemo drug costs	$1,357	$1,086	$1,629	Gamma, Beta^d	Calculated^c
Tisa-cel, LD chemo drug costs	$1,999	$1,600	$2,399	Gamma, Beta^d	Calculated^c
AE costs
Mosunetuzumab	$9,591	$7,673	$11,509	Gamma, Beta^d	Lin et al. 2023^31
Taz	$448	$359	$538	Gamma, Beta^d	Lin et al. 2023^31
Axi-cel	$16,512	$13,210	$19,815	Gamma, Beta^d	Lin et al. 2023^31
Tisa-cel	$10,160	$8,128	$12,192	Gamma, Beta^d	Lin et al. 2023^31
RW	$9,591	$7,673	$11,509	Gamma, Beta^d	Assumption, same as Mosunetuzumab
O-Benda	$6,099	$4,879	$7,318	Gamma, Beta^d	Lin et al. 2023^31
R-Benda	$8,913	$7,130	$10,695	Gamma, Beta^d	Lin et al. 2023^31
R-Len	$9,771	$7,816	$11,725	Gamma, Beta^d	Lin et al. 2023^31
CRS costs
Mosunetuzumab	$7,136	$5,708	$8,563	Gamma, Beta^d	Calculated^e
Axi-cel	$28,987	$23,189	$34,784	Gamma, Beta^d	Calculated^e
Tisa-cel	$7,913	$6,330	$9,495	Gamma, Beta^d	Calculated^e
Routine care costs
CAR T-cell therapies, weeks 0-26	$44	$35	$53	Gamma	Expert opinion, CMS^30^,^32
CAR T-cell therapies, subsequent weeks	$22	$17	$26	Gamma	Expert opinion, CMS^30^,^32
Other therapies, weekly costs	$22	$17	$26	Gamma	Expert opinion, CMS^30^,^32
One-off cost at progression	$413	$330	$496	Gamma	Expert opinion, CMS^30^,^32
Other costs
Post-progression treatment costs	$57,574	$46,059	$69,089	Gamma	Data on file
Terminal care costs	$26,275	$21,020	$31,530	Gamma	Betts et al. 2020^33

^aBased on an updated analysis of Bosch et al. 2023²⁵. Low and high values correspond to the 95% bias-corrected and accelerated bootstrap interval.

^bFor rituximab, based on a weighted average of Rituxanⁱ brand (32.34%; NDC: 50242-0051-21) and bio-similars (67.66%) which are further broken down between Ruxienceⁱⁱ (36.74%; NDC: 00069-0238-01), Truximaⁱⁱⁱ (27.51%; NDC: 63459-0103-10), and Riabni^iv (3.41%; NDC: 55513-0224-01). Market shares were based on Genentech internal data (data on file, Genentech, Inc., 2022).

^cCalculated as the sum of leukapheresis, administration, lymphodepleting chemotherapy excluding drug costs, and hospitalization³¹.

^dIn the PSA, unit costs were varied using a gamma distribution and percentages were varied using a beta distribution.

^eAccounted for costs associated with tocilizumab use, ICU admission, and hospitalization (non-ICU) and weighted by the proportion of patients experiencing CRS³¹.

Abbreviations. AE, adverse event; Axi-cel, axicabtagene ciloleucel; CAR, chimeric antigen receptor; Chemo, chemotherapy; CMS, Centers for Medicare and Medicaid Services; CPT, current procedural terminology; CRS, cytokine release syndrome; ea, each; Excl, excluding; HR, hazard ratio; Kg, kilogram; LD, lymphodepleting; Mosun, mosunetuzumab; N/A, not applicable; O-Benda, obinutuzumab + bendamustine; PH, proportion hazard; PI, Package insert; PFS, progression-free survival; OS, overall survival; R-Benda, rituximab + bendamustine; R, rituximab; R-Len, rituxumab + lenalidomide; Taz, tazemetostat; Tisa-cel, tisagenlecleucel; US, United States.

Figure 2. Net monetary benefit associated with mosun (WTP per QALY of $150,000). Abbreviations. Axi-cel, axicabtagene ciloleucel; Mosun, mosunetuzumab; O-Benda, obinutuzumab + bendamustine; QALY, quality-adjusted life year; R-Benda, rituximab + bendamustine; R-Len, rituximab + lenalidomide; RW, real-world cohort; Taz, tazemetostat; Tisa-cel, tisagenlecleucel; vs., versus; WTP, willingness-to-pay.

Table 2. Cost-effectiveness results in base case analysis: costs, life-years, quality-adjusted life-years, and ICERs.

Comparison of mosunetuzumab vs.	Intervention (mosunetuzumab)			Comparator			Incremental			ICER
	Costs	LYs	QALYs	Costs	LYs	QALYs	Costs	LYs	QALYs
Taz	$290,097	13.96	11.06	$394,683	4.25	3.35	−$104,586	9.71	7.72	Mosunetuzumab Dominant
Axi-cel	$293,659	11.06	8.63	$579,112	7.89	6.46	−$285,453	3.17	2.18	Mosunetuzumab Dominant
Tisa-cel	$289,213	9.18	7.18	$552,338	8.21	6.61	−$263,125	0.97	0.57	Mosunetuzumab Dominant
RW	$290,794	10.26	8.09	$210,510	5.45	4.35	$80,284	4.81	3.75	$21,434
O-Benda	$290,925	8.88	6.95	$231,769	6.77	5.57	$59,156	2.10	1.38	$42,731
R-Benda	$289,584	10.70	8.54	$163,774	8.80	6.94	$125,810	1.90	1.60	$78,607
R-Len	$283,028	12.76	10.33	$336,467	14.04	11.09	-$53,439	−1.28	−0.76	$70,557^a

^aMosunetuzumab had lower cost and lower QALYs compared to R-Len in the base case (i.e. R-Len was cost-effective vs. mosunetuzumab at a $150,000 per QALY threshold).

Abbreviations. Axi-cel, axicabtagene ciloleucel; ICER, incremental cost-effectiveness ratio; LYs, life years; O-Benda, obinutuzumab + bendamustine; QALYs, quality-adjusted life years; R-Benda, rituximab + bendamustine; R-Len, rituximab + lenalidomide; RW, real-world cohort; Taz, tazemetostat; Tisa-cel, tisagenlecleucel; vs., versus.

Figure 3. (a) CEAC of mosun vs. R-Len using alternative OS parametric curve (Log-logistic). Abbreviations: Mosun, mosunetuzumab; R-Len, rituximab + lenalidomide; QALY, quality-adjusted life year; WTP, willingness-to-pay. (b) CEAC of mosun vs. R-Len using base case OS parametric curve (exponential). Abbreviations. Mosun, mosunetuzumab; R-Len, rituximab + lenalidomide; QALY, quality-adjusted life year; WTP, willingness-to-pay.

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Data availability statement

The data that support the findings of this study are available in this article. The model is not publicly available due to its intrinsic commercial value and cannot be shared for legal reasons.