Primary Risk Drivers
Below is a snapshot of domains that materially influence the MARA Rating.
Clinical effectiveness
The evidence indicates a moderate benefit of ixazomib combination over lenalidomide and dexamethasone, with a statistically significant improvement in progression-free survival (22 months vs. 13 months, p=0.0033). However, the overall survival data was not statistically significant (hazard ratio 0.85, p=0.232), indicating some limitations in the evidence.
Cost effectiveness
The cost-effectiveness estimates for ixazomib combination are likely to be below £30,000 per QALY gained, which is considered acceptable by NICE. The committee acknowledged the level of uncertainty but recognized the robust nature of the data presented.
Quality of life
Patient experts reported that ixazomib combination allowed for a long period of progression-free survival and improved quality of life with minimal side effects. The utility values used in the economic model were deemed acceptable and aligned with literature, indicating moderate improvements in HRQoL.
Supporting Domains
Safety and Adverse Effects
The ixazomib combination was reported to have a very good safety profile with mostly mild or moderate adverse events. Patient experts noted minimal side effects, which supports a strong tolerability profile compared to existing therapies.
Comparator Selection
The committee confirmed that lenalidomide plus dexamethasone is the most relevant comparator for ixazomib combination, as it is the standard treatment after 2 or 3 lines of therapy. This selection aligns with clinical practice and the treatment pathway.
Patient Population and Subgroups
The trial population included individuals who had received 2 or 3 previous lines of therapy, which is representative of the intended patient population. However, there were some concerns regarding generalizability due to differences in the SACT dataset.
Care Pathway Integration
Ixazomib combination can be integrated into existing treatment pathways with minor adjustments. The oral administration of ixazomib is particularly beneficial for patients, reducing the need for hospital visits.
Resource Use and Cost Implications
The budget impact of ixazomib combination is manageable and aligns with planning. The committee noted that the treatment provides significant benefits that justify the costs, despite some concerns about resource burden.
Evidence Quality and Robustness
The evidence base is primarily derived from the TMM1 phase 3 trial, which is robust but has some limitations, particularly regarding overall survival data. The committee found the evidence acceptable for decision-making despite these concerns.
Uncertainty, Sensitivity, and Broader Impacts
While there are uncertainties regarding the overall survival estimates and the impact of subsequent treatments, the committee acknowledged the high unmet need for effective treatments in this patient population, which mitigates some concerns.
