Primary Risk Drivers
Below is a snapshot of domains that materially influence the MARA Rating.
Clinical effectiveness
The evidence indicates that venetoclax plus low dose cytarabine significantly increases overall survival compared to low dose cytarabine alone in patients with untreated acute myeloid leukaemia who are unsuitable for intensive chemotherapy. The committee concluded that this combination meets NICE’s criteria for a life-extending treatment at the end of life, demonstrating a clear clinical advantage.
Cost effectiveness
The cost-effectiveness analysis shows that the incremental cost-effectiveness ratio (ICER) for venetoclax plus low dose cytarabine is £10,948 per QALY gained, which is well below the £50,000 threshold typically considered acceptable by NICE. This indicates a strong economic value for the treatment.
Quality of life
While the document does not provide extensive data on HRQoL, it suggests that patients value increased survival and the possibility of long-term remission. The oral administration of venetoclax allows for home treatment, which may enhance quality of life by reducing hospital visits. However, specific validated HRQoL measures are not detailed.
Supporting Domains
Safety and Adverse Effects
The safety profile of venetoclax is acceptable, with manageable adverse events reported. The committee noted that the adverse event data sourced from a separate study was unlikely to significantly impact the cost-effectiveness results, indicating a good tolerability overall.
Comparator Selection
The treatment was compared against low dose cytarabine, which is the standard of care for patients who cannot undergo intensive chemotherapy. The committee recognized the necessity of using subgroup data to compare venetoclax plus low dose cytarabine with the relevant comparator, which supports the appropriateness of the selected comparator.
Patient Population and Subgroups
The trial population is considered broadly generalizable to the intended patient population in England, particularly those with over 30% bone marrow blasts. However, there are some limitations regarding the subgroup analysis for patients with 20% to 30% blasts, which were not included in the submission.
Care Pathway Integration
The treatment can be integrated into existing healthcare pathways with minor adjustments, as it allows for home administration and reduces the need for hospital visits. This aligns well with current clinical practices for managing acute myeloid leukaemia.
Resource Use and Cost Implications
The budget impact is manageable, with the treatment being cost-effective and the potential for significant savings due to reduced hospitalizations. The commercial arrangement also provides a discount, further supporting its economic viability.
Evidence Quality and Robustness
The evidence is based on a randomized controlled trial (VIALE-C) with a sample size of 211, which provides a solid foundation for the findings. However, there are some methodological concerns regarding the subgroup analyses that introduce a degree of uncertainty.
Uncertainty, Sensitivity, and Broader Impacts
While there are some uncertainties related to the subgroup analyses and the assumptions made in the economic model, the overall context supports the treatment’s use, particularly given the significant unmet need in this patient population.
