Cost-Effectiveness of Lisocabtagene Maraleucel vs Axicabtagene Ciloleucel and Tisagenlecleucel for Third-Line or Later Treatment for R/R DLBCL

In a recent study, Christopher Parker, MSc, Bristol Myers Squibb, Uxbridge, UK, and colleagues compared the cost-effectiveness of chimeric antigen receptor T-cell (CAR-T) therapies lisocabtagene maraleucel (liso-cel) vs axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa) as third-line or later treatment for patients with relapsed or refractory large B-cell lymphoma (R/R LBCL) in the US (Adv Ther. 2023 Mar 22;40:2355-2374. doi:10.1007/s12325-023-02444-x.)

The cost-effectiveness estimation of liso-cel vs axi-cel and tisa-cel was performed through a partitioned survival model that followed the International Society for Pharmacoeconomics and Outcomes Research good modeling practice guidelines. They pulled patient data from the TRANSCEND NHL 001 (TRANSCEND) trial for patients with R/R LBCL who had at least two prior therapies, including anthracycline and rituximab. The starting age for patients in the model was 60 years old, and 36% were female. The average outcomes and costs for each cohort and their respective CAR-T therapies were used to calculate the total outcomes and costs of the treatment arms. Only direct medical costs were taken into account as part of the analysis.

Progression-free survival and overall survival among the patients were extrapolated through mixture cure models. Patient-level data for liso-cel was retrieved from TRANSCEND; reconstructed patient-level data for axi-cel data was retrieved from the ZUMA-1 study; tisa-cel data was pulled from the JULIET study; and SCHOLAR-1 was used for the salvage chemotherapy data. Grade 3 or higher adverse events (AE) (including all-grade cytokine release syndrome, neurological events, and hypogammaglobulinemia) associated with liso-cel, axi-cel, and tisa-cel were included in the main model; however, the main model did not include additional treatment or pretreatment regimens.

The study found that more patients in the liso-cel cohort remained alive at 5 years of treatment compared to the axi-cel cohort (43% vs 39%, respectively). In addition, the total costs were higher for those who received the axi-cel treatment ($515,085) vs those who received the liso-cel treatment ($440,106). The authors note that this difference in costs was due to more patients in the axi-cel group receiving CAR-T infusion—with high drug acquisition costs—and the costs of AE management, which were significantly higher for axi-cel at $51,643 compared to liso-cel at $16,180. The liso-cel treatment also had a lower incremental cost of −$74,980 and was marginally more effective (0.002 incremental quality-adjusted life-years [QALYs]) than the axi-cel treatment.

The researchers also found that fewer patients in the tisa-cel treatment cohort were still alive at 5 years of treatment compared to those in the liso-cel cohort (25% vs 43%, respectively). Thus, the patients who received liso-cel treatment had more life-years than those who received the tisa-cel treatment (6.18 vs 3.75, respectively). The liso-cel cohort also had higher QALYs at 5.09 compared to the tisa-cel cohort, which was 3.07. Of note, since fewer patients in the tisa-cel cohort were receiving CAR-T infusion, tisa-cel treatment was associated with total costs that were lower than liso-cel treatment ($372,180 vs $440,106). Although the tisa-cel treatment had lower costs, liso-cel had “superior survival” with greater QALYs (2.02) compared to tisa-cel, which resulted in an incremental cost of $33,618 per QALY gained.

The authors acknowledge that the study had several limitations. For example, there were trial design differences that could not be adjusted for, including disease histology of patients during enrollment, their CAR-T infusion setting, and time to CAR-T infusion. These differences may have led to bias cost-effectiveness in the data. In addition, the study used clinical trials to collect data, which may not be an accurate reflection of real-world practice.

Ultimately, liso-cel was found to be more cost-effective than axi-cel and tisa-cel. Although axi-cel and liso-cel had similar QALYs, treatment cost was less for liso-cel, in part because this group of patients had lower rates of AEs of special interest for CAR-T therapies. When compared to tisa-cel, liso-cel led to more QALYs but at a greater cost due to the higher drug acquisition costs.

“Overall, our findings provide the comparative cost-effectiveness of CAR-T cell therapies and highlight some of the key drivers of the cost-effectiveness (eg, acquisition costs, AE rates, and survival benefits), which can inform clinical and payer decision-makers,” said Dr Parker and colleagues.