Primary Risk Drivers
Below is a snapshot of domains that materially influence the MARA Rating.
Clinical effectiveness
The evidence from the CASSIOPEIA trial demonstrates that daratumumab in combination with bortezomib, thalidomide, and dexamethasone significantly improves overall survival and progression-free survival compared to the standard treatment. The trial results indicate a hazard ratio of 0.50 for progression-free survival and 0.52 for overall survival, which shows a clear clinical advantage.
Cost effectiveness
The cost-effectiveness estimates for daratumumab in combination are within the range considered acceptable by NICE, specifically between £20,000 to £30,000 per QALY gained. This indicates that the therapy provides a defensible economic value relative to its benefits.
Quality of life
While the committee acknowledged that daratumumab in combination is well tolerated and may improve patient outcomes, there is no strong evidence presented that demonstrates significant improvements in health-related quality of life compared to standard care. The committee concluded that there were no additional gains in HRQoL over those already included in the QALY calculations.
Supporting Domains
Safety and Adverse Effects
The adverse event profile of daratumumab in combination is considered acceptable, with manageable adverse effects and a low rate of severe events. The committee noted that the incidence of severe adverse events was low, and the treatment was generally well tolerated.
Comparator Selection
The primary comparator, bortezomib plus thalidomide and dexamethasone, is appropriate as it reflects current Healthcare practice for untreated multiple myeloma when a stem cell transplant is suitable. The committee recognized that this comparator has comparable efficacy and costs.
Patient Population and Subgroups
The trial population in the CASSIOPEIA study is largely representative of the intended patient population, specifically adults with untreated multiple myeloma eligible for autologous stem cell transplant. However, there are some limitations regarding age restrictions in the trial.
Care Pathway Integration
The integration of daratumumab into existing treatment pathways is feasible, with the committee concluding that consolidation treatment could be incorporated into Healthcare practice with few challenges. This indicates a good fit with current clinical practices.
Resource Use and Cost Implications
The budget impact of daratumumab in combination is manageable and aligns with Healthcare planning. The committee noted that the economic model reflects the costs associated with the treatment and its integration into practice.
Evidence Quality and Robustness
The evidence base is supported by a robust Phase 3 trial (CASSIOPEIA) with a large sample size and low risk of bias. However, there are some uncertainties regarding the long-term survival extrapolations.
Uncertainty, Sensitivity, and Broader Impacts
There are notable uncertainties regarding the long-term treatment effects and the implications of minimal residual disease status on survival outcomes. The committee recognized these uncertainties but deemed the overall conclusions stable enough for decision-making.
