Societal implications of medical insurance coverage for imatinib as first-line treatment of chronic myeloid leukemia in China: a cost-effectiveness analysis

<p><b>Objectives:</b> Imatinib (Glivec) and nilotinib (Tasigna) have been covered by critical disease insurance in Jiangsu province of China since 2013, which changed local treatment patterns and outcomes of patients with chronic myeloid leukemia (CML). This study evaluated the long-term cost-effectiveness of insurance coverage with imatinib as the first-line treatment for patients with CML in China from a societal perspective.</p> <p><b>Methods:</b> A decision-analytic model based on previously published and real-world evidence was applied to simulate and evaluate the lifetime clinical and economic outcomes associated with CML treatments before and after imatinib was covered by medical insurance. Incremental cost-effectiveness ratio (ICER) was calculated with both costs and quality-adjusted life years (QALYs) discounted at 3% annually. Different assumptions of treatment benefits and costs were taken to address uncertainties and were tested with sensitivity analyses.</p> <p><b>Results:</b> In base case analysis, both cost and effectiveness of CML treatments increased after imatinib was covered by the medical insurance; on average, the incremental QALY and cost were 5.5 and ¥277,030 per patient in lifetime, respectively. The ICER of insurance coverage with imatinib was ¥50,641, which is less than the GDP per capita of China. Monte Carlo simulation resulted in the estimate of 100% probability that the insurance coverage of imatinib is cost-effective. Total cost was substantially saved at 5 years after patients initiated imatinib treatment with insurance coverage compared to no insurance coverage, the saved cost at 5 years was ¥99,565, which included the cost savings from both direct (e.g. cost of bone marrow or stem cell transplant) and indirect costs (e.g. productivity loss of patients and care-givers).</p> <p><b>Conclusions:</b> The insurance coverage of imatinib is very cost-effective in China, according to the local cost and clinical data in Jiangsu province. More importantly, the insurance coverage of imatinib and nilotinib have changed the treatment patterns of CML patients, thus dramatically increasing life expectancy and quality-of-life (QoL) saving on productivity losses for both CML patients and their caregivers.</p

EZH2 Mutations Are Related to Low Blast Percentage in Bone Marrow and -7/del(7q) in De Novo Acute Myeloid Leukemia

<div><p>The purpose of the present work was to determine the incidence and clinical implications of somatic EZH2 mutations in 714 patients with de novo acute myelogenous leukemia by sequencing the entire coding region. EZH2 mutations were identified in 13/714 (1.8%) of AML patients were found to be more common in males (<i>P</i> = 0.033). The presence of EZH2 mutations was significantly associated with lower blast percentage (21–30%) in bone marrow (<i>P</i><0.0001) and -7/del(7q) (<i>P</i> = 0.025). There were no differences in the incidence of mutation in 13 genes, ASXL1, CBL, c-KIT, DNMT3A, FLT3, IDH1, IDH2, MLL, NPM1, NRAS, RUNX1, TET2, and WT1, between patients with and without EZH2 mutations. No difference in complete remission, event-free survival, or overall survival was observed between patients with and without EZH2 mutation (<i>P</i>>0.05). Overall, these results showed EZH2 mutation in de novo acute myeloid leukemia as a recurrent genetic abnormality to be associated with lower blast percentage in BM and -7/del(7q).</p></div

Kaplan-Meier survival curves according to EZH2 mutation status.

<p>(A) EFS in de novo AML patients according to EZH2 mutations. The green line represents patients with mutated EZH2 (n = 12); and magenta line, patients with unmutated EZH2 (n = 277; <i>P</i> = 0.2283); (B) OS in de novo AML patients according to EZH2 mutations. The green line represents patients with mutated EZH2 (n = 12); and the magenta line represents patients with unmutated EZH2 (n = 277; P = 0.5001).</p

Comparison of clinical and laboratory features between AML patients with and without EZH2 mutation.

ψ<p>Risk status: Better-risk: inv(16)/t(16;16), t(8;21),t(15;17); Intermediate-risk: normal, +8, t(9;11), other undefined risk; Poor-risk: complex, −5, 5q−, −7, 7q−, 11q23(non t(9;11)), inv(3), t(3;3), t(6;9), t(9;22).</p><p>(A) Structure of the EZH2 protein and location of EZH2 mutations. (B) DNA sequencing chromatograms of AML genomic DNA samples showing 14 mutations in 13 AML patients.</p

Genomic array data.

<p>A: The respective breakpoints and FISH clones at ACTR2 and inside RAF1 of der(2)t(2;3)(p14;p25) in KARPAS-1106P as revealed by genomic arrays expands the FISH data. B: Color coded plots of FARAGE (purple), KARPAS-1106P (pink), MEDB-1 (blue), U-2940 (green)—show genomic copy number (solid) and LOH (barred) at 12 loci (1p12, 2p15, 2p16, 6q23, 7p22, 7q31, 8q24, 9p21, 9p24, 16p13, 15q23, 19q13, together with OMIM genes below. Copy number polymorphic regions (<a href="http://dgv.tcag.ca/dgv/app/home" target="_blank">http://dgv.tcag.ca/dgv/app/home</a>) are shown between, listing gains (blue), losses (red), and copy number neutral alterations, such as inversions (gray).</p

Spectral Karyotyping (SKY): FARAGE (A), KARPAS-1106P (B), MEDB-1 (C) and U-2940 (D).

<p>Inverse DAPI G-banding shown left of corresponding pseudocolored SKY. Arrows show deletions (white), duplications (red), and translocations (ochre). After trypsin G-banding (not shown) analyses were extended to prepare consensus karyotypes. Individual metaphases sometimes departed from consensus karyotypes, e.g. note loss of Y-chromosome in MEDB-1. Note absence of key cytogenetic rearrangements and relative lack of rearrangement when compared to cHL cell lines. Thus the salient cytogenetic features of PMBL are essentially negative with respect to neighboring entities, cHL and PMBL.</p

Fluorescence in situ hybridization (FISH) Analysis.

<p>A-D: Shows the cytogenetic configuration of focal deletions affecting 16p13 including the SOCS1 locus (arrows) in three PMBL cell lines: monoallelic in FARAGE, biallelic in KARPAS1106P and U-2940 effected by t(16;16) rearrangement, but absent in MEDB-1. E/F: Shows deletions affecting the PTPN1 locus in KARPAS-1106P (E) and MEDB-1 (F). Twin partial chromosome 20 long-arm deletions in KARPAS-1106P effect PTPN1 monosomy, while in MEDB-1 where the gene is mutated this locus escapes deletion despite proximity to a translocation breakpoint therein. G-I: Shows analysis of der(3)t(2;3)(p14;p25) in KARPAS-1106P. The respective breakpoints at 2p14 and 3p25 were placed close to ACTR2 (within clone RP11-441L10) and RAF1 (within RP11-148M13). Coordinates and labelling scheme are shown below. Coordinates (MBp) are from HG19. FISH was performed using tilepath BAC clones.</p

Gene expression at genomically rearranged loci.

<p>A: Microarray expression data for genes implicated at CNV (mainly deletions). Note, for example gene silencing accompanying focal biallelic deletions at multiple loci: including, CD58 at 1p12 in KARPAS-1106P; MSH6 and FBXO11 at 2p26 in FARAGE; TNFAIP3, AIMP2 at 6q23 in U2940; EIF2AK1 at 7p22 in U-2940; CDKN2A at 9p21 in KARPAS-1106P and U-2940; CD274 at 9p24 in U-2940; SOCS1 at 16p13 in KARPAS-1106P and U-2940; and KIAA0355 at 19q13 in U-2940. B: Shows qPCR expression of select target genes at recurrent PMBL amplicons (2p15, 9p24) and a deletion (16p13) set against TBP reference in cell lines FARAGE, KARPAS-1106P, MEDB-1, and U-2940 (PMBL) shown blue, alongside reference SU-DHL-8 (DLBCL) shown red. Diamonds indicate undetectable expression. Quantitative data were verified by twofold or more biological replication.</p