Primary Risk Drivers
Below is a snapshot of domains that materially influence the MARA Rating.
Clinical effectiveness
The clinical evidence for axicabtagene ciloleucel is derived from the ZUMA-5 study, which is a single-arm, open-label, phase 2 study. While it suggests that the therapy may increase the time before disease progression and overall survival, the evidence is limited by the lack of direct comparative data against standard care and the immaturity of survival data. The committee noted that the long-term treatment effect remains uncertain, leading to a rating of B++ for comparable efficacy to existing options.
Cost effectiveness
The cost-effectiveness estimates for axicabtagene ciloleucel were found to be above the acceptable range for Healthcare resources, with ICERs exceeding £40,000 per QALY gained. The committee highlighted significant uncertainties in the economic model, particularly regarding immature overall survival data and the lack of direct comparative efficacy data. This results in a rating of B for poor value.
Quality of life
No health-related quality-of-life data was collected in the ZUMA-5 and SCHOLAR-5 studies. The committee noted that the utility values used in the economic model were derived from studies that may not accurately reflect the quality of life for patients after multiple treatments. This lack of direct evidence and reliance on potentially inappropriate utility values leads to a rating of B.
Supporting Domains
Safety and Adverse Effects
The safety profile of axicabtagene ciloleucel is generally acceptable, with manageable adverse events reported in the ZUMA-5 study. While there are some concerns regarding the potential for serious adverse events, the overall tolerability is considered good, leading to a rating of A.
Comparator Selection
The company used a blended comparator approach based on the SCHOLAR-5 study, which included various treatments for relapsed or refractory follicular lymphoma. While this approach is acceptable, the lack of established standard treatment after 3 or more systemic treatments raises concerns about the appropriateness of the comparators used, resulting in a rating of B++.
Patient Population and Subgroups
The ZUMA-5 study included a relevant population with relapsed or refractory follicular lymphoma, and the committee concluded that the trial population is broadly generalizable to the Healthcare clinical practice. This leads to a rating of A for moderate representativeness.
Care Pathway Integration
The integration of axicabtagene ciloleucel into existing healthcare pathways is manageable, with minor adjustments needed for its administration. The committee noted that the therapy fits within the current treatment framework for relapsed or refractory follicular lymphoma, leading to a rating of A+.
Resource Use and Cost Implications
The economic model indicates a high resource burden associated with axicabtagene ciloleucel, raising concerns about its affordability. The committee noted that the costs associated with the therapy are significant, leading to a rating of B++.
Evidence Quality and Robustness
The evidence base is primarily derived from a single-arm study (ZUMA-5) with limited comparative data. The committee noted gaps in evidence quality and potential biases, leading to a rating of B++.
Uncertainty, Sensitivity, and Broader Impacts
There are significant uncertainties surrounding the long-term effectiveness and cost-effectiveness of axicabtagene ciloleucel, particularly due to the immaturity of survival data and the lack of direct comparative evidence. This leads to a rating of B+.
