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Positioning Model to Evaluate CARVYKTI in Second Line vs Later Lines | Rafael Fonseca, MD | IMS 2024
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• October 8, 2024
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At the International Myeloma Society meeting in Rio, we were able to present a poster that looks at the modally and the predicted outcomes for the different times at which a patient could use a CAR-T. Now, in the ideal world, we would have a prospective, randomized phase three trials that could address these questions, but as you will see by the numbers I give you, it would take us another 10 years to know the answer to that. With the recent approval of the use of CAR-T earlier in relapse by the FDA, a very common question is, should I use a CAR-T for that first relapse or should I save it for a subsequent one? Now, the way we created this model, we used a Flat Iron database, which is a claims database from insurance companies, and we tried to build a model around the following principles. First, we wanted to know the duration of what's called time to next treatment, so the duration of disease control for patients in that first relapse. Then we had two comparisons. One is gratitude for patients who are in that first relapse and then getting the CAR-T cell product, and then patients on the Flat Iron database also were on what we call standard of care, and how long do they last in that treatment. Then in between, we put what we call the attrition rate, and that is now extensively documented and well published, which reflects the fact that not all patients will go on to the subsequent of therapy for multiple reasons, but unfortunately sometimes that is because of disease progression or disease associated death. We did a sensitivity analysis where we played with different percentages for attrition. Lastly, we looked at overall survival from the time of initiation of therapy in that second relapse, so that's when you start your second relapse therapy all the time that we can measure that overall survival, and that was again for patients who are getting CAR-T or who are getting standard of care. What we were able to find is that if you put the CAR-T for the first relapse and standard of care for the second relapse, you have a median predicted overall survival with a model, not real world, but with a model of 8.8 years. If you do the opposite, if you start with standard of care and then you say, I want to use the CAR-T for my second relapse, then it's 5.5 years. So it's 3.3 years difference between the two approaches. Now for people who know and who are strict about how this evidence works, yes, we acknowledge the only way to address this in a definitive way is with those prospective trials, but until we get there, this is one of the ways by which we can go ahead and make decisions. So for me, I have to admit that I'm not 100% committed, but more and more I'm thinking that I'm going to be using things like CAR-T cells for that very first relapse.

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