Costs of Imatinib, Costs of Transplants and Gross National Income Per Capita Impact on Transplant Rates for Chronic Myeloid Leukemia in European Countries.

Hematopoietic stem cell transplants (HSCT) are among the most expensive medical procedures. As a consequence, transplants are preferentially done in more wealthy countries. This significant dependency between transplant rates (number of transplants per 10 million inhabitants) and gross national income (GNI) per capita has been well described. We noticed a different pattern in HSCT for chronic myeloid leukemia (CML) in recent years. We did investigate the evolution of transplant rates for leukemias in Europe in respect to the economy of the participating 38 countries. Using World Bank definitions, countries were grouped according to their GNI per capita into low (A), middle (B), and high income (C) countries and trends of transplant rates for CML and acute myeloid leukemia (AML) were computed with regression analyses from 1991 to 2004. Transplant rates increased for AML in significant dependency with GNI per capita from 0.1 (A), 0.3 (B) and 12 (C) in 1991 to 2.8 (A), 22 (B) and 47 (C) in 2004. Transplant rates were distinct by World Bank category and the increase presented in all three groups with a near linear clear predictability as illustrated by the R² ’s of 93.55, 94.34 or 98.76 (Groups A, B, C). A different pattern was observed for CML. Initially transplant rates did increase from 0.1 (A), 0.7 (B) and 13 (C) in 1991 to 0.28 (A), 15 (B) and 28 (C) in 1999, distinct by World Bank category and with a similar linear prediction pattern as for AML (R² 96.39, 95.75, 95.35 for groups A, B, C). Transplant rates then declined for CML in high income countries (C), they remained at the same level in middle income countries to the extent that comparable transplant rates (15, 15) were observed for middle and high income countries in recent years. We compared costs. Costs for one year treatment with Imatinib (400 mg daily dose) in the different participating European countries ranged between 28 000 and 44 000 Euros with a median of 30 411 Euros (mean 32 417 Euros). Costs for an allogeneic HSCT from an HLA identical sibling ranged from 26 515 Euros to 180 000 Euros with a median of 63 450 Euros (mean 72 173 Euros). Cost comparisons indicate that cost for an allogeneic HSCT correspond to 0·9 to 5·9 (median of 2·0, mean 2·3) years of drug treatment. Data suggest that Imatinib has replaced HSCT preferentially in countries with high income. HSCT remains a cost effective procedure in countries with middle income. Cost considerations appear to impact on the choice between a once in a lifetime procedure or continuous drug treatment. Integration of cost analyses into the decision algorythms will become of increasing importance.