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    • Dutch researchers assessed the optimal sequence of treatment for patients with non-transplant eligible (NTE) multiple myeloma (MM) from patient, physician, and society vantage points. They assessed 30 treatment sequences, with up to the lines of therapy versus bortezomib-melphalan-prednisone (VMP)–lenalidomide-dexamethasone (LenDex)–pomalidomide-dexamethasone (PomDex).
    • The investigators found that sequencing starting with daratumumab-VMP or bortezomib-melphalan-prednisone-thalidomide-maintenance bortezomib-thalidomide (VMPT-VT) had the longest OS (7.5 years). This OS is 3.5 additional life-years versus VMP-LenDex-PomDex. Costs ranged between $786 024 and $1 085 794. According to the authors, “The sequence VMPT-VT-carfilzomib-lenalidomide-dexamethasone–panobinostat-bortezomib-dexamethasone had the most favorable cost-effectiveness ratio ($98 585 per life-year gained and $132 707 per QALY gained vs VMP-LenDex-PomDex).”
    • The results suggested that sequences with similar effects vary in health care costs. For instance, although outcomes involving sequences VMP-LenDex-PomDex and LenDex-CarDex-PomDex were comparable, the latter option cost twice as much ($568 884 vs $285 619), on account of higher costs of LenDex versus VMP as first-line treatment.
    • One limitation of the current study is that researchers had to make certain assumptions to compare treatments that are not directly comparable. To overcome this issue, the researchers used relative efficacy between treatment regimens “because the relative difference preserves randomization within the trials.”
    • Another limitation involved actual acquisition prices which may be less in other countries due to discounts. “If the negotiated price reduction has a similar ratio for the drugs, the order of the results will not substantially differ. An advantage of our model is that negotiated discounted prices and prices from other countries can be easily incorporated,” the authors noted.