Economic evaluation of combination therapy including two or more expensive oncologic agents:

Background: Currently in the Netherlands, the combination of lenalidomide (Revlimid®) and bortezomib (Velcade®) is not reimbursed by the government. Several articles tend to prove that lenalidomide is more potent than thalidomide hence doctors would like to use it for newly diagnosed patients with multiple myeloma. Objective: To estimate the cost-effectiveness of VRD Velcade®;Revlimid®;Dexamethasone®) vs. VTD (Velcade®;Thalidomid®;Dexamethasone®) for newly diagnosed patients with multiple myeloma. Methods: A cost utility analysis was run based on a markov model with thirty cycles of 6 months taking the perspective of the Dutch government. The data for VRD and VTD come from two different clinical trial conducted by Paul G Richardson and Michele Cavo. Each patient enters the model and receives either VRD or VTD in first line. The patient has three possibilities: he can stay in the progression free state, progress or die. If the patient progressed, he then received the second line VD (Velcade®-Dexamethasone®) and once again if he progressed the patient received the third line MP (Mephalan®-Prednisone®). Costs of treatment, hospitalisation and adverse events were extracted from Dutch patient level data and other cost-effectiveness study. Results: The combination using thalidomide (VTD) is the more cost-effective treatment with 38725.56 €/LYs and 50296.70 €/QALYs, it gives an ICERs of -28894.91 €/LYs or -31919.99 €/QALYs. VTD gives more QALYs to the patient but is also less costly according to the results. In a scenario with a 5% higher effectiveness for VRD compare to VTD, it still has a more favourable ratio. The cost over the fifteen years of trial increased by 380 177.79€ compare to the base case scenario. The PSA indicate that the transition probabilities are the factors with the higher uncertainty, hence it has a major impact on the cost-effectiveness. Conclusion: The results suggest that the addition of lenalidomide instead of thalidomide to bortezomib and dexamethasone is not cost-effective. Even with a higher effectiveness lenalidomide seems to be too expensive to have a favourable ratio. Lenalidomide is therefore more adapted for second line of therapy for specific risk groups if data shows a significant benefit.