Total cost comparison in relapsed/refractory multiple myeloma

Figures & data

Table 1.  Adverse event rates, event costs and AE management costs.

Grade 3/4 AEs	AE incidence		AE unit cost
	LEN/DEX23	BORT24	Cost per event (2011 USD)	Cost source
Neutropenia	33.4%	14%	$149 (inflated from 2010)	Goulart and Ramsey35
Febrile neutropenia	2.3%	NR	$11,857 (inflated from 2010)	Goulart and Ramsey35
Thrombocytopenia	12.2%	30%	$149 (inflated from 2010)	Goulart and Ramsey35
Anemia	9.9%	10%	$869 (inflated from 2010)	Goulart and Ramsey35
PN	NR	8.00%	$1017 (inflated from 2001)	Calhoun et al.36
DVT/PE^a	2.05%	NR	$28,343 (inflated from 2002)	Elting et al.37
Diarrhea	3.1%	7%	$2733 (inflated from 2003)	Dranitsaris et al.38
Vomiting	1.7%	3%	$1069 (inflated from 2006)	Tina Shih et al.39
Herpes zoster^b	NR	0.3%	$1108 (inflated from 2008)	White et al.40
Pneumonia	8.5%	NR	$13,320 (inflated from 2006)	Eber et al.41
Total AE management costs during median study period	$2243	$460
Treatment weeks (per protocol or to progression)	52	27
Total AE management costs per day	$6.16	$2.44

^aAdjusted to reflect 75% reduction from prophylaxis.

^bAll grades; adjusted to reflect 85% reduction from prophylaxis.

AE, adverse event; BORT, bortezomib; DEX, dexamethasone; DVT/PE, deep vein thrombosis/pulmonary embolism; LEN, lenalidomide; NR, not reported; PN, peripheral neuropathy; TTP, time to progression; USD, United States dollar17,29,35–46.

Table 2.  Medical costs and drug costs.

	LEN/DEX	BORT
Number of office visits	16	35
Rate (CPT 99212: office/outpatient visits)	$41.45	$41.45
Evaluation and management cost per patient	$663.20	$1450.75
Number of administrations	0	35
Rate (CPT 96409: chemo IV push single drug)	$112.80	$112.80
Administration cost per patient	$0.00	$3948.00
Percentage of patients hydrated	0%	25%
Rate (CPT 96360: hydration IV infusion init)	$57.08	$57.08
Hydration cost per patient	$0.00	$499.45
Number of CBCs	17	52
Rate (CPT 85025: complete CBC w/auto diff WBC)	$43.00	$43.00
Lab tests cost per patient	$731.00	$2236.00
Herpes zoster (for Velcade patients)^a	NA	$21.78
DVT/PE (for Revlimid patients)^b	$1713.05	NA
Prophylaxis costs per patient	$1713.05	$21.78
Total medical cost per patient	$3064.25	$8155.98
Treatment period (weeks)	52	27
Daily medical cost per patient	$8.42	$43.15
Drug cost per treatment day	$359.67	$1450.75
Treatment days/cycle days	21/28	4/21 then 4/35
Daily drug cost until progression	$270	$274

^aAssumes patients receive prophylaxis with generic acyclovir 400 mg/day. Cost based on WAC cost of $0.17 per 400 mg tablet × 7 days per week for treatment with BORT44,45.

^bCosts based on an enoxaparin AWP of $32.47 per 40 mg syringe and aspirin at $0.01 per tablet45.

The herpes zoster prophylaxis costs may be conservative and may not reflect more extensive regimens provided to certain patients17,26,36,45,46.

DVT/PE, deep vein thrombosis/pulmonary embolism; LEN, lenalidomide; DEX, dexamethasone; CBC, complete blood cell count.

Figure 1.  Cumulative total cost difference (BORT minus LEN/DEX) (USD). Excess costs principally due to higher medical and AE management costs for BORT (BORT, bortezomib; DEX, dexamethasone; LEN, lenalidomide).

Table 3.  Total costs of treatment over a 12-month period^a.

Average cost per day and cumulative costs	LEN/DEX	BORT	Difference (favoring LEN/DEX)
Average drug cost per day	$270	$274	$4
Average medical and AE management cost per day	$15	$57	$43
Average total cost per day	$285	$332	$47
Cumulative annual total cost	$103,871	$121,007	$17,136
Average cost without progression (cost until disease progression, divided by cumulative days until progression)
Average total cost per month without progression	$8949	$10,105	$1155

^aAssumes no patient cost-sharing.

AE, adverse event; BORT, bortezomib; DEX, dexamethasone; LEN, lenalidomide.

Table 4.  Sensitivity analyses tested: impact vs base-case cost; cost difference of sensitivity case.

Sensitivity scenario vs base case of $17,136 lower cost of LEN/DEX	Annual impact vs base case (favoring LEN/DEX)*	Annual net total cost difference (favoring LEN/DEX)*
Post-progression scenario: Patients initially treated with BORT switch to LEN/DEX after relapse	$6587	($10,549)
Patient cost-sharing: 20% for office-administered therapy (BORT) and 28% for pharmacy-dispensed therapy (LEN/DEX)32	($7574)	($24,709)
Physician reimbursement rate: Change in administration reimbursement rate for BORT to ASP + 10%	($3777)	($20,913)
Administration of subcutaneous BORT at $72.71 per administration	$2710	($14,426)
AE management: Addition of grade 2 PN for BORT (18% incidence)11	($354)	($17,490)
AE management: 28% reduction in PN through use of SC route of administration for BORT31	$44	($17,092)
Vial wastage: 10% of BORT administrations are billed as administered rather than full-vial quantities	$3689	($13,447)
Adjusted TTP to align comparator arms: Multiply actual TTP by ratio of TTP in comparator arms	$2902	($14,234)

*Numbers in parentheses indicate impact or savings in favor of LEN/DEX; numbers without parentheses indicate impact or savings in favor of BORT.

AE, adverse event; ASP, average sales price; BORT, bortezomib; DEX, dexamethasone; LEN, lenalidomide; PN, peripheral neuropathy; SC, subcutaneous.

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