Multiple myeloma is a rare, incurable hematologic malignancy. It has a tendency to develop subsequent relapses, so affected patients are likely to undergo more than one line of treatment. Rather than evaluating the cost-effectiveness of individual therapeutic agents, it becomes therefore recommendable for decision-makers—from both a clinical and an economic perspective—identifying an optimal sequencing of such agents.
Lenalidomide and bortezomib are the most used drugs in Italy for the treatment of relapsed/refractory multiple myeloma (rrMM). In the present work a cost-analysis was conducted, comparing two alternative strategies: bortezomib as a second-line therapy followed by lenalidomide+dexamethasone (len/dex) after progression (sequence A) vs len/dex followed by bortezomib (sequence B). Only drug costs were considered in the analysis.
Based on outcomes from phase III trials, total time to progression (TTP) was longer in sequence B (17.1+4.9=22 months) as compared to sequence A (7+10.6=17.6 months). Average costs per progression-free month in the respective sequences were quite comparable: €4,109 vs €4,061.
Sensitivity analysis on a couple of scenarios (assuming patient pooling when using bortezomib and assuming the association of bortezomib with pegylated liposomal doxorubicin) provided similar conclusions as regards costs.
Though sequences A and B look equivalent in terms of cost per progression-free month, it should be considered that with a longer total TTP (as in sequence B) costs for a fourth-line treatment, together with other medical costs (diagnostics, hospitalisations) following progression, are postponed; moreover, a longer TTP means a better quality of life for the concerned patient.
Despite the simplifications adopted in this study, len/dex as second-line treatment appears a recommendable strategy in the treatment of rrMM.