Real-world total cost of care for patients undergoing chimeric antigen receptor (CAR) T-cell therapy for relapsed or refractory B-cell lymphoma can exceed $2 million, while about four of 10 patients do not experience a durable response, according to data presented at the American Society of Clinical Oncology’s 2021 virtual annual meeting.

These therapies were approved for this indication in April 2017 (tisagenlecleucel [Kymriah, Novartis]) and October 2017 (axicabtagene ciloleucel [Yescarta, Kite/Gilead]). Since then, there have been little real-world data on CAR T-cell episode total cost of care (TCC) and post-administration clinical events in commercially insured patients, noted the researchers, from Prime Therapeutics and Minnesota Oncology. To shed some light on this area, the team reviewed integrated pharmacy and medical claims for 74 adults who received either axicabtagene ciloleucel or tisagenlecleucel between January 2018 and June 2020 (abstract e19500).

The median TCC for a CAR T-cell episode TCC was $610,999, with a median CAR T-cell drug cost of $411,278—significantly exceeding the $373,000 wholesale acquisition cost for CAR T-cell product to treat B-cell lymphoma, The TCC during the initial CAR T-cell therapy period ranged from $350,000 to more than $2 million, with 12% of episodes exceeding $1 million in total cost, reported Brett Sahli, PharmD, the senior director of value and outcomes at Prime.

Of the 74 members treated with CAR T-cell therapy during the study period, 29 (39%) relapsed. Of these patients, 22 required subsequent chemotherapy, four required a bone marrow transplant and 13 died or were placed on hospice (these categories were not mutually exclusive), with a mean time to event of 228 days.

Dr. Sahli predicted that his team’s findings will prompt discussions on CAR T-cell performance metrics, case rates and future spending, and also guide value-based arrangements for the treatment.

More Relapse Data Needed

The findings regarding relapse are similar to what other institutions are seeing, and mirror updated findings of a clinical update of the pivotal JULIET trial of tisagenlecleucel presented at the 2020 annual meeting of the American Society of Hematology (Blood 2020;136[suppl 1]:48-49). Those results showed a relapse-free probability of 60.4% at 24 and 30 months among 61 patients with an initial response.

“That’s what we are seeing in our patient population as well,” said Sarah Perreault, PharmD, a clinical pharmacy specialist for the cellular therapy program at Yale New Haven Smilow Cancer Hospital, in Connecticut. “We have found similar complete remission rates with [axicabtagene ciloleucel] and [tisagenlecleucel].”

The reported cost of care for these commercially insured patients also mirrors what Yale has seen, Dr. Perreault said. “I know it’s on the pricier side for treatment, but in the end, you’re getting to a 60% cure rate, which is promising for people who have gone through two to four lines of therapy after a relapse. Is that worth over half a million dollars? If you’re curing people you would never cure before, then I would say yes.”

But Dr. Perreault noted that the mean follow-up in the study was 390 days. “That’s a decent time, but the end point for lymphoma is considered to be two years before you can say someone has had a complete remission. So, are they getting a complete remission or just one more year of disease-free life before a high relapse rate? It will take longer-term data to answer that question.”