Therapeutic options in the treatment of multiple myeloma - Pharmacoeconomic and quality-of-life considerations

A review of current treatment options in multiple myeloma is presented, inc luding data on health-related quality of life and pharmacoeconomics. For in duction chemotherapy, no combination of cytostatic drugs has been shown to be consistently superior to the simple cyclic oral treatment with melphalan and prednisone that has been available for 30 years. The total resource co nsumption and direct costs per patient treated with melphalan and prednison e is approximately $US 10 000 (1995 values). As median survival is prolonge d from less than a year in untreated patients to 30 to 36 months, this trea tment must be considered cost effective. Interferon-a has a modest effect o n progression-free and overall survival when added to chemotherapy regimens . However, the high cost and toxicity of this drug results in an unfavourab le cost-utility ratio, estimated to be between $US50 000 to $US 100 000 per quality-adjusted life-year gained. Clinical trials suggest that high dose chemotherapy followed by autologous stem cell support administered to patients who have achieved disease stabil isation or objective response to conventional induction chemotherapy, prolo ngs median survival by about 1.5 years. Preliminary cost-utility analyses s uggest a cost per life-year gained of $US30 000 to $US40 000. Further poten tial improvements of this therapeutic modality are under way. Several bisphosphonates have been tested for the ability to prevent the ske letal complications of multiple myeloma. Monthly infusions of pamidronate h ave been shown in 1 randomised trial to significantly reduce the rate of sk eletal complications. Unfortunately, the rapid and widespread acceptance of this therapy seems to preclude further prospective, placebo-controlled tri als with cost-utility evaluation.