OBJECTIVES: Idecabtagene vicleucel (ide-cel), an anti-BCMA chimeric antigen receptor T-cell (CAR-T) therapy (list price $419,500), was approved in 2021 by the US FDA for triple-class refractory multiple myeloma (MM). Another anti-BCMA CAR T-cell therapy, ciltecabtagene autoleucel (cilta-cel), is undergoing FDA review. We evaluated the cost-effectiveness of ide-cel and cilta-cel (assuming price parity with ide-cel).

METHODS: A partitioned survival model evaluated ide-cel and cilta-cel in triple-class relapsed/refractory MM from a US health-payer perspective over a lifetime horizon. Comparators included conventional therapies, belantamab mafodotin-blmf, selinexor-dexamethasone, and salvage autologous stem-cell transplantation. Main outcomes were life-years, lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Future costs and benefits were discounted at 3% per year. We assumed a cost-effectiveness threshold of $150,000/QALY and used probabilistic analyses with 10,000 simulations to evaluate uncertainty.

RESULTS: Ide-cel increased life expectancy by 0.96 years and cost $672,122/QALY gained (95% UI, $498,146-1,008,033) compared with conventional therapy. Cilta-cel increased life expectancy by 2.26 years and cost $295,897/QALY gained (95% UI, $147,591-436,745) compared with conventional therapy. Both CAR T-cell therapies exceeded the cost-effectiveness threshold when compared with the other therapies. Although CAR-T increased life expectancies, because virtually all patients ultimately progress, the high cost of subsequent standard myeloma care ($312,000/year) worsened the overall cost-effectiveness of CAR-T: large price reductions to $32,462 (ide-cel) and $120,850 (cilta-cel) are necessary to meet a $150,000/QALY threshold. If the cost of subsequent care were lowered to conventional cost-effectiveness thresholds, more modest price reductions to $188,802 (ide-cel) and $324,739 (cilta-cel) are needed.

CONCLUSIONS: Ide-cel and cilta-cel are projected to substantively increase life expectancy, but neither is cost-effective at current prices. To meet a $150,000/QALY threshold, the price of ide-cel and cilta-cel need to be reduced by 55% and 23% respectively, and improvements in the cost-effectiveness of subsequent multiple myeloma care are also needed.