Abstract
Introduction Acute promyelocytic leukemia (APL) is distinguished by the presence of a translocation between chromosomes 15 and 17 [t(15;17)]. All-transretinoic acid (ATRA) plus arsenic trioxide (ATO) is considered as the first line treatment of APL, and can induce a complete remission (CR) in greater than 90% of patients, with a 2-year overall survival (OS) of 99% (Lo-Coco et al, N Eng J Med, 2013). Due to the high treatment costs of this regimen, the International Consortium on Acute Promyelocytic Leukemia (IC-APL) developed a protocol to diminish the economic burden associated with the treatment of APL (Ribeiro & Rego, Hematol Am Soc Hematol Educ Progr, 2006). We performed a cost-effectiveness analysis (CEA) and a cost-utility analysis (CUA) of the IC-APL protocol in Mexico, and compared it with the costs of the first line treatment of this disease in other countries.
Methods We compared the patients in our institute, which were treated with the IC-APL protocol, with patients treated at other institutions with the first line treatment. For the CEA, the CR was compared with the cost of each protocol, and then compared by using the incremental cost-effectiveness ratio (ICER); for the CUA the quality-adjusted life years (QALY) were obtained and compared with the cost of each protocol, and then compared by using the incremental cost-utility ratio (ICUR).
Results CR was achieved in 18 patients (90%) treated with the IC-APL protocol as a first line option; only 1 patient (5%) died in induction; of the patients that achieved CR, 1 relapsed (5.5%). The mean estimated OS was89 months (CI 95%; 86.619 - 101.515), with 89% of patients alive at 39 months; the mean estimated disease free survival (DFS) was 91 months (CI 95%; 83.711 - 99.818), with 94% of patients free of disease at 24 months. The median treatment cost of the IC-APL protocol was $ 21 369 USD. The median length of treatment was 29 months (range, 27 - 39 months), with a median of life without treatment of 41 months (0 - 68 months). The average number of years of life was 7.84 years, with the average QALY of 6.1 (table 1). The total cost of ATRA + ATO in Italy was $ 60 354 USD, in Canada $ 124 108 USD (QALY of 14.68) and in the USA $ 136 170 USD (QALY of 14.33). The CEA yielded $227, $603, $1241 and $1351 USD per % of CR in Mexico, Italy, Canada and the USA, respectively. When comparing the ICER between the IC-APL and the ATRA+ATO protocols, we found a difference of $6 497, $19 133 and $17 123 USD in Italy, the USA and Canada, respectively (table 2) In relation to the CUA, each QALY gained in Mexico costs $3 500 USD, in Canada $11 979 USD, and in the USA $13 955 USD. When comparing the ICUR between the IC-APL and the ATRA+ATO protocols, we founda difference of $13 955 and of $19 133 and of $11 979 USD in the USA and Canada, respectively (table 3).
Conclusion Similar clinical endpoints were achieved with the IC-APL protocol when compared with first line treatment, with better outcomes in the cost-effectiveness and cost-utility analyses.
No relevant conflicts of interest to declare.
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