Total cost of care for multiple myeloma can be significantly affected by selection of dosing regimen.
Ryan Haumschild, PharmD, MS, MBA: I want to shift the conversation now to more economic considerations. Mr Ali, when we start to think about fixed dosing vs variable dosing in the anti-C38 regimens, how do you think that affects the total cost of care? Are there any patients who may benefit from the use of 1 agent over another in your experience?
Amir Ali, PharmD, BCOP: Real-world dosing can certainly differ from PI [principal investigator] recommended dosing. There are a lot of pharmacoeconomic studies that go around and discuss the differences between these dosing regimens and how they’re used, and the pharmacoeconomic impacts between the 2. There are some studies that look at daratumumab vs isatuximab, and there are benefits with using real-world dosing with isatuximab.
Regarding chair time, there are a couple of important pieces to keep in mind. One, do you monitor? Do you not monitor after a subcutaneous infusion? That’s in consideration. Another is a patient-specific consideration: subcutaneous vs IV [intravenous]. The subcutaneous volume for the subcutaneous daratumumab is 15 mL. That’s a lot of volume to be injecting subcutaneously. Some patients may find that uncomfortable. I anticipate that other formulations will come around with other CD38 products. I can’t make assumptions, but most likely we’ll see that.
Along with cost considerations, we focus on patient-specific factors, efficacy between products, and the data. We look at, for example, patients with poor renal function and how the data look and reflect that. We look at high-risk cytogenetics in refractory patients, and then compare products when making a decision.
Ryan Haumschild, PharmD, MS, MBA: I appreciate you talking through those considerations of chair time and dosing, because this is a high-cost disease state. Figuring out the total cost of care and what the offsets might look like is important. Not as valuable as some of the outcomes, but it’s definitely something that should be considered. In addition to some of those economic impacts, I always think about the quality-of-life and patient-reported outcomes. It’s something else that we’re always trying to consider as we evaluate regimens for patients.
Mr Hossain, describe the quality of life for a patient with relapsed/refractory multiple myeloma. How does this quality-of-life change after these multiple relapses? How do you help patients understand the big picture of treatment vs the fear of an adverse reaction that could impact their quality of life?
Shahrier Hossain, PharmD, BCOP: Absolutely. This is a great question. We always need to keep in mind that this is an incurable disease. There’s a study from Germany that looked at 40 centers and the quality-of-life outcomes across several lines of therapy. These were academic medical centers and clinics. The study showed that patients had a score of 61 to 62 points on the Global Health Score, and this was in the first line of therapy. This decreased 15 points by the time they went to the fourth or later lines of therapy. In the overall patient population, the general population, their average scores were about 67, so even if you look at the first-line therapy, these patients are a little sicker, a little worse off. They have a worsening quality of life.
This is corroborated by other studies that looked at plasma cell diseases overall, not just multiple myeloma. On a personal experience, that the thing that I always like to think about is that these patients end up coming to the clinic for a lot more than treatment. They often need blood, platelets, growth factors, infusions, and electrolyte corrections. In terms of understanding the big picture of treatment vs adverse effects, it’s reassuring the patient, “You’re in a scary situation because your disease has come back, but we’re here for you. We’re here to walk you through those adverse effects. You need to know what those adverse effects are.” I’m a big proponent of pharmacist-led education of patients and getting them to understand, “This is what the clinical trial says. They report everything on earth, but here’s what you practically need to know to be safe.”
Ultimately, when it comes to the big picture of where treatment is going, patients are the ones who drive that to an extent. They have those discussions with the team: “Am I really going to take that jump to CAR [chimeric antigen receptor] T-cells, CRS [cytokine release syndrome], or anything of that nature? Will I even make it to the point where I need to collect my cells for 6 months and have them manufactured?” Those end-of-life discussions are very important to have to make sure we know what the patient needs and wants.
Ryan Haumschild, PharmD, MS, MBA: I appreciate you going through quality of life because we want patients to live a fulfilled life, especially if we’re adding multiple lines of therapy and having them live longer. We want to make sure they’re able to do their activities of daily living and still have some functional improvement.
Transcript edited for clarity.