Two studies presented at ASH 2011 reached different conclusions regarding the cost-effectiveness of routine use of the upfront stem-cell mobilizer, plerixafor (Mozobil), before the use of autologous stem-cell transplant.
Reserve Plerixafor for Poor Mobilizers
The addition of chemotherapy to granulocyte colony-stimulating factor (G-CSF) for stem-cell mobilization can increase cell yield and improve mobilization outcomes relative to G-CSF alone. A multicenter study investigated the use of mid-dose VP-16 (etoposide) plus G-CSF in patients with lymphoma and whether plerixafor might be incorporated into this chemo-mobilization backbone in a cost-effective way.
Using a predictive modeling approach, plerixafor could be reserved for patients predicted to be “poor mobilizers,” said William Wood, MD, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill.
“Poor mobilizers” were defined as patients failing to produce 5 × 106 cells in ≤2 days. The researchers identified certain predictors for poor mobilization.
Of 159 patients in this study:
- 90 (57%) were identified as “good mobilizers”
- 43% were “poor mobilizers.”
- Average costs were:
- $14,923 for good mobilizers
- $27,044 for poor mobilizers (P <.05).
The first peripheral blood CD34+ count (obtained between days 9 and 15) accurately predicted good versus poor mobilizers, Dr Wood said.
“Using our data, we estimated that it would not be cost-effective to give plerixafor to all patients, even if 100% of patients subsequently became good mobilizers,” he said.
Instead, by reserving plerixafor for only predicted poor mobilizers at the time of first CD34+ count, the investigators estimated that 64% of these patients would need to become good mobilizers to achieve cost neutrality.
The researchers are still determining the cost-effectiveness of adding plerixafor in patients predicted to be poor mobilizers.
Plerixafor Upfront Is Cost-Neutral
By contrast, the researchers from Mount Sinai Medical Center, NY, concluded that upfront use of plerixafor does not add a substantial cost burden in the setting of transplant for multiple myeloma.
This prospective study included 50 patients with myeloma who underwent transplant, 25 of whom received plerixafor in combination with G-CSF and 25 received G-CSF alone as an upfront mobilization strategy.
Compared with G-CSF alone, plerixafor mobilizations yielded higher numbers of CD34+ cells/kg, higher numbers of CD34+ cells infused, required fewer G-CSF doses for stem-cell collection and for neutrophil recovery, and less apheresis. The plerixafor group had a longer time to neutrophil engraftment; however, this did not translate to longer days of hospitalization posttransplant, said Luis Isola, MD.
The plerixafor group required fewer G-CSF doses for mobilization and for neutrophil recovery, and fewer apheresis sessions. Therefore, this group had a lower cost of G-CSF per patient for stem-cell collection (mean, $2212 vs $2765) and stem-cell recovery (mean, $1677 vs $2653), as well as a lower cost of apheresis per patient (mean, $889 vs $1476).
The mean number of plerixafor doses per patient was 1.8, with a $9081 cost per patient.
“Based on our interim data for overall cost analysis, the plerixafor group had similar cost for blood products per patient, overall cost of medications, overall cost of hospitalization, and cost of hospitalization and apheresis combined per patient,” Dr Isola said.
“These data suggest that using plerixafor for upfront autologous stem-cell mobilization in patients with multiple myeloma significantly improves success rate of mobilization, decreases the number of apheresis sessions, and does not have a substantial pharmacoeconomic impact.” n