Navigating the economic value of treatment sequencing in large B-cell lymphoma: Insights into optimizing value and patient outcomes of CAR T-cell and other available therapies in Brazil

BackgroundThe advent of chimeric antigen receptor t-cell therapy (CAR T) has ushered in a new treatment paradigm in relapsed or refractory (R/R) diffuse large b-cell lymphoma (DLBCL) in which patients have the potential to be cured of their disease. However, as a result of non-clinical barriers and eligibility misinterpretations, patients may not receive CAR T therapy and are instead misallocated to treatment pathways which may result in suboptimal costs and outcomes. We sought to quantify the financial impact of these misallocations across the treatment sequences of therapies available to patients with R/R DLBCL in Brazil.MethodsWe developed a patient-level discrete event simulation model to compare treatment options within the sequence of available therapies for DLBCL in Brazil. A cost offset analysis was performed to analyze the financial impact of possible DLBCL treatment sequences with axicabtagene ciloleucel (axi-cel), epcoritamab, and standard-of-care (SoC) therapies. Sensitivity analyses were conducted to examine costs and outcomes for axi-cel compared to tisagenlecleucel (tisa-cel), another available CAR T therapy in Brazil.ResultsWe found that using axi-cel before epcoritamab in the 3L setting was cost-saving compared to using epcoritamab before axi-cel. Compared to both epcoritamab and SoC therapies, cost offsets were observed across all treatment lines due to the prolonged survival of treating with axi-cel compared to other options, and savings were greater when axi-cel was administered earlier in the treatment sequence. Sensitivity analyses demonstrated that treating with axi-cel in 3L was less expensive than treating with tisa-cel.ConclusionAdministering CAR T therapies like axi-cel before epcoritamab or SoC in R/R DLBCL can lead to substantial cost offsets as fewer patients ultimately progress to subsequent treatment lines. Optimal R/R DLBCL outcomes and costs can be achieved in Brazil through maximizing the potential for cure by treating eligible patients with axi-cel ahead of other available therapies.