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Original Investigation
January 23, 2020

Cost-effectiveness of Tisagenlecleucel vs Standard Care in High-risk Relapsed Pediatric Acute Lymphoblastic Leukemia in Canada

Author Affiliations
  • 1Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 3Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 4Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
  • 5Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
JAMA Oncol. Published online January 23, 2020. doi:10.1001/jamaoncol.2019.5909
Key Points

Question  What is the value of the novel immunotherapy, tisagenlecleucel, compared with current standard care for eligible pediatric patients with relapsed acute lymphoblastic leukemia in Canada?

Findings  In this study of 3 pooled clinical trials of 192 patients and cancer registry of 118 patients, accounting for the lifetime quality-adjusted life-years and total cost of tisagenlecleucel compared with current standard care resulted in an incremental cost per quality-adjusted life-year gain of tisagenlecleucel ranging from CaD $71 000 (US $53 933) to CaD $281 000 (US $213 453), based on assumed cure rates of 40% to 10%.

Meaning  Given the current list price of tisagenlecleucel and its currently known effectiveness, tisagenlecleucel had an incremental cost per quality-adjusted life-year gain in the upper ranges of typical willingness-to-pay thresholds; determining if this product is cost-effective is highly dependent on the assumed cure rate.

Abstract

Importance  Tisagenlecleucel, a chimeric antigen receptor T-cell therapy for relapsed or refractory pediatric acute lymphoblastic leukemia, has been approved for use in multiple jurisdictions. The public list price is US $475 000, or more than CaD $600 000. Assessing the cost-effectiveness of tisagenlecleucel is necessary to inform policy makers on the economic value of this treatment.

Objective  To assess the value for money of tisagenlecleucel compared with current standard care for tisagenlecleucel-eligible pediatric patients with acute lymphoblastic leukemia under unknown long-term effectiveness.

Design, Setting, and Participants  A cost-utility analysis of tisagenlecleucel compared with current standard care using a Canadian population-based registry of pediatric patients with acute lymphoblastic leukemia was performed. Results from 3 pooled single-arm tisagenlecleucel clinical trials and a provincial pediatric cancer registry were combined to create treatment and control arms, respectively. The population-based control arm consisted of patients meeting clinical trial inclusion and exclusion criteria, starting at second relapse. Multistate and individual-level simulation modeling were combined to predict patient lifetime health trajectories by treatment strategy. Tisagenlecleucel efficacy was modeled across long-term cure rates, from 10% to 40%, to account for limited information on its long-term effectiveness. Uncertainty was tested with 1-way and probabilistic sensitivity analysis. Data were collected in September 2017, and analysis began in December 2017.

Exposures  Tisagenlecleucel compared with current standard care for tisagenlecleucel-eligible patients.

Main Outcomes and Measures  Relative health care costs, survival gains, and quality-adjusted life-years (QALYs) between tisagenlecleucel and current standard care.

Results  The treatment and control arms were modeled on 192 and 118 patients, respectively. The mean (SD) age of control individuals was 10 (4.25) years, and the mean (SD) age of the pooled clinical trial sample was 11 (6) years. The control individuals had 78 boys (66%), and the pooled clinical trial sample had 102 boys (53%). Treatment with tisagenlecleucel was associated with an additional 2.14 to 9.85 life years or 1.68 to 6.61 QALYs, compared with current care. The average additional cost of tisagenlecleucel was CaD $470 013 (US $357 031). Accounting for the total discounted cost over the patient lifetime resulted in an incremental cost of CaD $71 000 (US $53 933) to CaD $281 000 (US $213 453) per QALY gain.

Conclusions and Relevance  To our knowledge, this study offers the first cost-effectiveness analysis of tisagenlecleucel compared with current standard care for pediatric patients with acute lymphoblastic leukemia using a constructed population-based control arm. At a willingness-to-pay threshold of $150 000/QALY, tisagenlecleucel had a 32% likelihood of being cost-effective. Tisagenlecleucel cost-effectiveness would fall below $50 000/QALY with a long-term cure rate of over 0.40 or a price discount of 49% at its currently known effectiveness.

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