For now, chimeric antigen receptor (CAR) T-cell (CAR-T) therapies are largely administered in the inpatient setting at large academic centers, but efforts are under way to move this procedure to the outpatient setting—not only at academic centers but also at capable community oncology practices.
And a recent economic analysis in JAMA Network Open indicates that such a move to the outpatient setting — specifically the community oncology outpatient setting — could shave off some of the costs associated with this high-dollar procedure.1
Using an assumptions-based model, the researchers estimated the total cost of care for a single CAR-T procedure to be $454,611 for the academic inpatient setting and $421,624 for the nonacademic specialty oncology network outpatient setting — a cost difference of $32,987 favoring the community outpatient setting.1
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“It’s no secret that if you do outpatient therapy for almost anything, not just CAR-T, that you will get a lower cost,” said Mounzer Agha, MD, director of the Mario Lemieux Center for Blood Cancers at UPMC Hillman Cancer Center, and the clinical director of hematopoietic stem cell transplantation of UPMC, Pittsburgh, Pennsylvania, during an interview with Cancer Therapy Advisor.
The majority of the total cost of care was the CAR-T product itself — $373,000 — which did not vary by site of care and was equal to the list price of axicabtagene ciloleucel (axi-cel, Yescarta®). The only other CAR-T product currently approved for use in the US is tisagenlecleucel (tisa-cel, Kymriah®), priced at $475,000, and both products are indicated for relapsed or refractory large B-cell lymphoma, among a few other indications.
According to the analysis, switching the site of care would not affect the cost of the CAR-T product itself — that cost was the same between sites of care. Instead, the cost-savings would come from a $29,834 difference in hospitalization and office visit costs and a $3154 difference in procedure costs, both favoring the community outpatient setting.1
Lead study author Gary Lyman, MD, MPH, a senior lead for health care quality and policy within the Hutchinson Institute for Cancer Outcomes Research, Seattle, Washington, told Cancer Therapy Advisor that this study should be viewed as an “interesting, but not earth-shattering” study. “The idea is here’s one way — in addition to eventually cutting down on the cost of the technology — that the cost of using this technology might be reduced over time,” he said.
The analysis was sponsored by Juno Therapeutics, which has several CAR-T therapies in its pipeline, including lisocabtagene maraleucel (JCAR017) for large B-cell lymphoma. (Dr Lyman received no financial compensation from Juno for helping conduct the analysis or write the journal article.)
Regarding the findings, Dr Lyman cautioned that the patient would first have to be deemed a candidate for being treated as an inpatient or outpatient. “That’s not going to be everybody — there are going to be patients with advanced lymphoma who are either too sick, too elderly, [or have] too many other comorbid conditions where you wouldn’t consider doing outpatient.”
The analysis also showed that a CAR-T product with a higher incidence of adverse events (97.5%) had a larger range of total costs compared with a product with a lower incidence of events (50%). The study authors asserted this finding indicates a CAR-T therapy with a “better” safety profile may be “more economical.”1
A better safety profile, however, does not necessarily mean new CAR-T products need to come to market. The safety profile of existing CAR T-cell products could be tweaked by adding other medications.
For instance, the single-arm, multicenter ZUMA-19 trial is evaluating whether prophylactic treatment with lenzilumab, an anti-human granulocyte macrophage-colony stimulating factor (GM-CSF) monoclonal antibody, could reduce the toxicity of axi-cel in patients with relapsed or refractory diffuse large B-cell lymphoma (ClinicalTrials.gov Identifier: NCT04314843).
Paolo Strati, MD, assistant professor of lymphoma and myeloma, at MD Anderson Cancer Center, Houston, Texas, told this publication the research being done to mitigate toxicity could both avoid treatment-related mortality and reduce costs for health care by allowing outpatient administration.
The analysis has several limitations, given that the model was created using data from the literature and publicly available databases and relied on several assumptions.
Although the analysis suggests outpatient administration could lead to cost savings, whether it is safe and confers the same efficacy is a different question. “I think it’s very premature to try to say that outpatient therapy for CAR T is feasible and doable and costs less money,” said Dr Agha.
