Rituximab Induction Is Cost Effective for Asymptomatic Advanced Follicular Lymphoma

Rituximab induction therapy has the highest probability of cost effectiveness in treating newly diagnosed patients with asymptomatic advanced follicular lymphoma, according to a study published in the British Journal of Haematology.

The researchers estimated the cost-effectiveness of an active treatment strategy with rituximab to watchful waiting. While a previous study analyzed treatment choices in the Canadian health care system, this is the first known UK model that investigates treatment approaches.

Patients included in the study had asymptomatic follicular lymphoma and were deciding between active treatment utilizing rituximab or watchful waiting. If a patient experienced a relapse after active treatment, then he or she would be given another chemotherapy regimen with or without rituximab or an autologous transplantation. A randomized trial of the 3 treatment choices demonstrated no significant difference in survival rates.

Watchful waiting, rituximab induction, and maintenance costs were estimated using dosages and unit costs from the British National Formulary (BNF). Patients who chose watchful waiting—54%—required new treatment within 3 years. Patients treated with rituximab induction had an 11% chance of needing continued treatment after 3 years, while 19% of patients who received induction with rituximab followed by maintenance needed new treatment after 3 years. Annual recurrence rates were converted to 22.8%, 6.7% and 3.9%, respectively.

At follow-up visits, patients underwent physical examinations in which clinicians assessed symptoms and performed tests, such as a full blood count, liver and renal function assessment, and immunoglobin profile. Patients who experienced a recurrence were generally treated with immunochemotherapy. Costs for these tests and procedures were sourced from the National Health Service Reference costs.

Quality of life was measured based on an unpublished Oxford Outcomes study used in the National Institute for Health and Care Excellence (NICE) technology. The researchers assumed that there was no quality of life benefit for patients using watchful waiting compared to rituximab treatment, as it is potentially beneficial to treat the disease than wait for symptoms to arise.

The data show that rituximab induction alone is the most cost-effective approach in treating asymptomatic follicular lymphoma. While treatment outcome was improved when induction of rituximab was paired with rituximab maintenance, the value of the treatment was worth less than the cost. Watchful waiting was deemed the least cost-effective approach in treating advanced follicular lymphoma.

Some study limitations that the authors noted include the uncertainty around treatment in subsequent therapy lines, the unpublished quality of the life study on which researchers formed their model, and the unmeasured cost of possible reduced immunoglobulin levels in a patient when treated with rituximab.

“The results of the base case analysis suggest that rituximab induction alone is the most cost-effective strategy to adopt in patients with asymptomatic follicular lymphoma,” the authors concluded. “This result was shown to be robust in [1]-way and probabilistic sensitivity analyses.”

Reference

Prettyjohns M, Hoskin P, McNamara C, et al. The cost‐effectiveness of immediate treatment or watch and wait with deferred chemotherapy for advanced asymptomatic follicular lymphoma. Br J Haematol. 2018;180(1):52-59. doi: 10.1111/bjh.14990.