Direct costs associated with multiple myeloma treatment are expenses related to drugs, hospitalizations, physician visits, lab work, imaging studies, and other supportive care.

The cost of most drugs used in multiple myeloma is approximately 100,000 dollars per year and combination regimens with a Proteosome inhibitor, immunomodulatory agent, and an anti CD-38 targeted monoclonal antibody costs 300,000—600,000 US dollars per year [9]. This cost is expected to rise with disease progression and exposure to multiple classes of drugs. Yang et al. in a retrospective cohort study of 1,521 patients with multiple myeloma of which 66.8% were double class exposed (DCE) and 33.2% were Triple class exposed (TCE) identified that the overall mean total all-cause health care costs were $20,338 PPPM (85% MM-related) of which drug cost accounted to $11,435 PPPM. The drug cost in DCE vs TCE was $9,854 vs $16,117 PPPM and drug cost was the overall cost driver in both populations [3]. In an analysis by Hollmann et al. evaluating the cost burden of relapsed or refractory MM patients treated with triplet regimens over 1 year suggested that the average monthly cost per patient per triplet regimen ranged from $13,784 to $30,657. The study also reported that drug acquisition and treatment duration accounted for the cost of treatment [4]. A study based on 600 multiple myeloma patients receiving treatment in Singapore found that daratumumab based regimens were more expensive than bortezomib based regimens due to unit cost difference but after comparing treatment costs for post progression treatment regimens, patients incurred higher costs following first line bortezomib based regimen than daratumumab [10]. Use of the most effective regimen early in the disease course and use of maintenance therapy after first line treatment to delay progression although may incur higher drug costs but have been found to lower overall costs during the disease course [11,12,13]. Prior studies have also reported that transitioning treatment in multiple myeloma patients to home-based setting for drug infusions is cost-effective and helps patients spend more time with family [14, 15]. In Table 1 we summarize the drug costs of different lines of therapy for patients with Multiple Myeloma.

Yang et al. reported overall MM-related emergency department visits, outpatient physician office visits, other outpatient visits, visit for outpatient prescriptions, and hospitalizations PPPM were 0.05, 3.22, 4.19, 0.89, and 0.10 respectively with median length of hospital stay being 1.02 days PPPM [3]. The study also reported that the proportion of patients with at least 1 MM-related ED, outpatient, and inpatient visit during the study period were 22%, 55%, and 99% respectively and that healthcare resource utilization was higher in TCE than DCE population even though TCE population had shorter follow-up period. Gupta et al. queried a commercial insurance database between 2016 to 2021 to identify 1492 patients with multiple myeloma on therapy. They had reported that although mean monthly outpatient and inpatient visits (5.0–5.6 OP visits; 0.21–0.32 IP visits) remained stable across advancing Lines of therapy(LOT), the mean all cause monthly costs (not including medication cost) were 16%—35% lower in LOT 1 ($23.6 K) compared to LOT 4($31.8 K) [16]. This may suggest that choosing the most effective regimen for the first LOT may be a cost-effective strategy and reduce the overall treatment cost by lowering inpatient and outpatient visits.

There is limited data on the indirect costs incurred by multiple myeloma patients. Most studies focus on drug costs, inpatient, and outpatient costs when reporting cost burden in multiple myeloma patients. Indirect costs like loss of income, supportive care service costs, disability claims, absenteeism, presenteeism, caregiver absenteeism, loss from early retirement and premature death etc. are often ignored underestimating the economic burden on multiple myeloma patients and the society. While direct medical costs may be easier to obtain from billing and administrative databases, estimating indirect costs involves longitudinal assessment of work-related limitations and productivity losses using standardized questionnaires and tools along with patient reported outcomes. The heterogeneity in economic burden based on patient, disease, treatment, and socioeconomic factors further complicates assessment of indirect costs.

Drug administration time needs to be considered while assessing the economic burden of treatments in multiple myeloma. Traditional chemotherapy regimens often demand significant time commitment from patients, caregivers, and healthcare workers taking up to 65 min for each administration session which is around 24—36 h per year (Table 2). Newer therapies like T-cell engagers would consume around 5 min per session for their administration and around 3 h per year, resulting in a substantial reduction in healthcare resource utilization and potential cost savings (Table 2).

Robinson et al. in an analysis based on ‘a” multicenter randomized control study of 263 relapsed refractory multiple myeloma (RRMM) patients reported that only 10.8% of patients aged ≤ 65 years were working and 37% of those working reported absenteeism of ≥ 1 day over last 4 weeks. The study also noted that 48% of the patients not working attributed it to their RRMM [17]. Merola et al. analyzed around 300 newly diagnosed multiple myeloma patients on oral vs injectable chemotherapy regimens and reported that patients on oral regimens had fewer days of absenteeism (83 vs 110 days) and lower costs incurred from productivity loss ($14,429 vs $18,315) over 1 year period [18]. Another European based cross-sectional study of 115 newly diagnosed multiple myeloma (NDMM) patients undergoing ASCT suggested of 76.5% of the total cohort that were productive before ASCT, only 39.1% were able to maintain productive life post ASCT and average per patient productivity loss over 20-year horizon to be around 290,601 euros [19]. In an analysis on multiple myeloma patients from Portugal, Miguel et al. suggested that indirect costs account to 18% of total cost burden with early retirement being the major driver of this cost and caregiver’s work absence being the least affecting factor [20].

Hence therapies which can 1. Minimize indirect costs to patients 2. Which will continue leading a productive life as desired by patients should also be taken account of in cost analysis.