Frontline rituximab monotherapy induction versus a watch and wait approach for asymptomatic advanced‐stage follicular lymphoma: A cost‐effectiveness analysis

Abstract

BACKGROUND: A watch and wait (WW) strategy is the standard of care for patients with asymptomatic advanced-stage follicular lymphoma. Recent data have demonstrated an improvement in the time to progression with rituximab induction (RI) with or without rituximab maintenance (RM) in comparison with a WW strategy wait in such patients. It remains unclear whether this is a costeffective strategy. METHODS: A Markov decision analysis model was developed to compare the clinical outcomes, costs, and costeffectiveness of RI (4 weekly doses) plus RM (12 doses every 2 months), RI (4 weekly doses), and a WW strategy for patients newly diagnosed with low-burden, asymptomatic advanced-stage follicular lymphoma over a lifetime horizon. Baseline probabilities and utilities were derived from a systematic review of published studies, and they were evaluated on a 6-month cycle. A Canadian public health payer's perspective was adopted, and costs were presented in 2012 Canadian dollars. RESULTS: RI was the cheapest strategy. It was less costly at $59,953 versus $67,489 for the RM arm and $75,895 for the WW arm. It was also associated with a slightly lower quality-adjusted life expectancy at 6.16 quality-adjusted life years (QALYs) versus 6.28 QALYs for the RM strategy but was superior to WW (5.71 QALYs). In sensitivity analyses of key variables, this effectiveness was sensitive to the probability of first and second progression in the RI arm, and this indicated relatively neutral effectiveness between the 2 rituximab arms. CONCLUSIONS: RI without maintenance for asymptomatic advanced-stage follicular lymphoma is the preferred strategy: it minimizes costs per patient over a lifetime horizon. Cancer 2015;121:2637-45.

The cost‐effectiveness of immediate treatment or watch and wait with deferred chemotherapy for advanced asymptomatic follicular lymphoma

“…One of the distinguishing features of this analysis in comparison to previous economic evaluations of watchful waiting and active treatment in other disease areas, was that there was assumed to be no QoL benefit for patients on watchful waiting in comparison to active treatment. This is consistent with the data from the randomised study which showed that QoL with rituximab was at least as good as, and probably better than, watchful waiting (Prica et al, 2015).…”

Cost-Effectiveness Analyses, Costs and Resource Use, and Health-Related Quality of Life in Patients with Follicular or Marginal Zone Lymphoma: Systematic Reviews

“…The cost effectiveness of first-line treatments was evaluated in eight studies (seven for FL, one for FL and MZL) [7][8][9][10][11][12][13], and nine studies reported cost-effectiveness of maintenance treatment [14][15][16][17][18][19][20][21]. Six studies were found to report cost effectiveness of treatments for relapsed/refractory (R/R) FL, while only three studies reported cost-effectiveness evidence for refractory FL.…”

“…R-MCP versus MCP was projected to have an ICER ranging between £4861/QALY gained [9] and £9316/QALY gained (GBP; 2010) [9]. [10], and R monotherapy was dominant over watchand-wait for FL [10]. Additionally, B + R versus R-CHOP was projected to have an ICER of $27,398/QALY gained (CAD; 2012) for FL and $10,012/QALY gained (CAD; 2012) for MZL [10].…”

“…[10], and R monotherapy was dominant over watchand-wait for FL [10]. Additionally, B + R versus R-CHOP was projected to have an ICER of $27,398/QALY gained (CAD; 2012) for FL and $10,012/QALY gained (CAD; 2012) for MZL [10].…”

Rituximab for indolent lymphomas before and after allogeneic hematopoietic stem cell transplantation

“…Overall, results from these randomized trials suggest that an aggressive maintenance rituximab strategy does not significantly impact OS compared with initial observation or first-line rituximab treatment without maintenance, at least within the reported timeframe of follow-up. From a pharmacoeconomics point of view, the implications of these trials on resource use are likely to be substantial [18].…”