Genomic Panel Likely to Be Cost-effective in AML

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Genomic sequencing methods are likely to be more cost-effective than stepwise addition of single mutational testing in patients with intermediate-risk acute myeloid leukemia (AML), found Sonya Cressman, PhD, a health economist at the Canadian Centre for Applied Research in Cancer Control, Vancouver.

“Genomic sequencing costs have decreased in recent years while the potential list of mutations with prognostic value in AML has increased, hence a genome-wide sequencing approach at diagnosis may offer cost savings when integrated into clinical practice,” she said.

Using a decision analytic model, her group found acceptable incremental cost-effectiveness ratios (ICERs) for genomic sequencing over single mutational testing that would improve further if the cost of sequencing is reduced.

Testing for mutations in genes of prognostic importance in AML can inform treatment decisions once first complete remission (CR1) is achieved. The National Comprehensive Cancer Network currently recommends testing for 3 genes in intermediate-risk AML: FLT3-ITD, NPM1, and CEBPA. “Evidence suggests that testing for 6 others will alter CR1 treatment decisions,” said Cressman. These 6 are IDH1, IDH2, TET2, ASXL1, MLL-PTD, and PHF-6.

A decision tree was used to simulate treatment decisions and outcomes during remission induction. These data were fed into 3 postremission Markov models in which 10-year costs and outcomes following CR1 with stem cell transplant versus chemotherapy or induction failure were calculated. The model was based on 10 years of patient data in British Columbia, and costs for each healthcare state (ie, remission, relapse, death) were added.

AML patients who undergo stem cell transplantation in CR1 incur higher up-front costs than those treated with chemotherapy alone, she said, but survive significantly longer and have longer relapse-free survival. Cost savings may be realized from a reduction of salvage transplants if high-risk patients are treated with a transplant in CR1.

The model assumed a price of $5000 for the gene panel, “which is a very conservative estimate. Apparently, it’s more like $1000,” said Cressman.

The cost of a stem cell transplant had a strong impact on cost-effectiveness, whereas the cost of the genomic test and the addition of other mutational tests were minor contributions to the simulated ICERs.

In the model, all genomic testing strategies yielded an ICER <$100,000 (Canadian) per life-year gained, the threshold that normally defines cost-effective. Passive FLT3-ITD, NPM1, and IDH1/2 testing dominated the model. Testing for FLT3-ITD, NPM1, MLL-PTD, ASXL1, TET2, and PHF-6 mutations produced an ICER of $97,880 per life-year gained.

Utilizing the genomic sequencing panel increased the rate of stem cell transplants by 13% and yielded an ICER of $55,316 per life-year gained. “It’s pretty likely that this will be considered a cost-effective way to work up AML in an intermediate-risk group,” she concluded.

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