Comparing the Cost-Effectiveness of Rituximab Maintenance and Radioimmunotherapy Consolidation versus Observation Following First-Line Therapy in Patients with Follicular Lymphoma

Abstract

OBJECTIVES Phase 3 randomized trials have shown that rituximab maintenance (MR) therapy or radio-immunotherapy (RIT) consolidation following frontline therapy can improve progression-free survival for patients with follicular lymphoma (FL), but the cost-effectiveness of these approaches with respect to observation has not been examined using a common modeling framework. METHODS We developed Markov models to estimate patients’ lifetime costs, quality-adjusted life years (QALYs), and life years (LYs) after MR, RIT, and observation following frontline FL treatment from the US payer’s perspective. Progression risks, adverse event probabilities, costs, and utilities were estimated from clinical data of PRIMA, ECOG trial (for MR) and FIT trial (for RIT), and the published literature. We evaluated the incremental cost-effectiveness ratio for direct comparisons between MR/RIT and observation. Model robustness was addressed by one-way and probabilistic sensitivity analyses. RESULTS Compared with observation, MR provided additional 1.089 QALYs (1.099 LYs) and 1.399 QALYs (1.391 LYs) based on PRIMA and ECOG trials respectively, and RIT provided additional 1.026 QALYs (1.034 LYs). The incremental cost per QALY-gained was $40,335 (PRIMA) or $37,412 (ECOG) for MR, and $40,851 for RIT. MR and RIT had comparable incremental QALYs before first progression, while RIT had higher incremental costs of adverse events due to higher incidences of cytopenias. CONCLUSIONS MR and RIT following frontline FL therapy demonstrated favorable and similar cost-effectiveness profiles. The model results should be interpreted within the specific clinical settings of each trial. Selection of MR, RIT, or observation should be based on patient characteristics and expected tradeoffs for these alternatives.

Systemic Front Line Therapy of Follicular Lymphoma: When, to Whom and How

“…A randomized phase II trial, comparing RIT consolidation with RM, showed a higher PFS with RM than with RIT consolidation, without any difference in OS 136. Moreover, both strategies (RM and RIT consolidation) showed comparable incremental quality-adjusted life-years before the first progression, but a higher incidence of haematogical toxicity was observed in the RIT arm 137. Therefore consolidation with RIT after standard R-based induction therapy is not routinely performed.…”

Follicular Lymphoma: First-Line Treatment Without Chemotherapy for Follicular Lymphoma

“…They estimated the total cost difference to be $69,000 per patient when incorporating costs of the drug, as well as costs for the infusion center, nursing support, and pharmacy preparation [44••]. Rituximab maintenance has been looked at by several groups after chemoimmunotherapy induction and has been felt to be cost effective in terms of quality-adjusted life years (QALY) [53,54]. & A focus of the RESORT trial was illness-related anxiety.…”

Next-Generation Prognostic Assessment for Diffuse Large B-Cell Lymphoma

“…However, an investigator can sample the values of the factors based on the summary of patient characteristics in the published paper, feed the values of the variables that have been previously calibrated and calibrate the effect (i.e., relative risks and hazard ratios, among others) of new factors by comparing the simulated OS and the survival curve presented in the published paper. Modeling studies have used this approach to simulate and compare outcomes for cancer treatments [122,127–128]. For example, a second-level DLBCL prognostic model might expand on the basic model by incorporating new factors from published studies of:

The standard of care treatment: R-CHOP in Phase III clinical trials [3,56–60,62–64];

Biological subtypes of DLBCL [16,18,22,25– 26,28,129–133];

Novel treatments such as emerging studies for lenalidomide + R-CHOP, ibrutinib + R-CHOP, obinutuzumab + CHOP, bortezomib + R-CHOP, carfilzomib + R-CHOP [71–75,134];

Treatment-specific biological effects such as outcomes for non-GCB DLBCL in the Phase II study of lenalidomide + R-CHOP [73].

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