Abstract

Objectives: Both ASCT and R-Maint have been shown to be effective therapies for treating rituximab naïve patients with relapsed/refractory follicular lymphoma. The aim of this research was to assess the cost effectiveness of ASCT compared to R-Maint in this patient population (following a response to chemotherapy induction) from a UK perspective.

Methods: A literature review of randomised control trials (RCTs) and case series studies suitable for comparing the efficacy of the two treatments in relapsed / refractory follicular lymphoma patients was performed. Given the heterogeneity of relevant study outcomes and designs a naïve indirect comparison was performed. Equivalent efficacy between the two therapies was assumed based upon the indirect comparison; hence a cost minimization approach was utilized. The starting time point of the analysis was following 3 cycles of CHOP therapy. In the EORTC 20981 trial both RCHOP and CHOP induction therapies were used; to reduce heterogeneity between the trial populations being compared, only results from patients who received CHOP induction in this trial were considered. Drug, administration, adverse event, and monitoring costs were evaluated from the start of treatment to the point of relapse after which time-point cost equivalence was assumed between the two therapies. Resource use and unit costs were sourced from published NHS reference costs, the EORTC 20981 study, and clinical expert opinion. Uncertainty around the assumption of equal efficacy was explored using threshold analysis based on an assumed incremental cost effectiveness ratio (ICER) threshold of £30,000 and an average utility score of 0.71 for patients with follicular lymphoma (derived from the literature).

Results: One RCT and 6 case series for ASCT and one RCT for R-Maint were identified. The estimated cost of R-Maint and ASCT was £12,275 and £25,563 respectively, resulting in an estimated incremental cost of ASCT over R-Maint of £13,288 per patient. ASCT would have to offer an additional 7.5 months of overall survival to be considered cost effective compared to R-Maint.

Conclusions: There is a high degree of certainty that ASCT produces higher costs compared to R-Maint, however it is uncertain whether ASCT offers an increase in either progression-free or overall survival over R-Maint in rituximab naïve patients. Consequently R-Maint may be considered a cost-saving treatment option for such patients in the treatment of relapsed/refractory follicular lymphoma patients compared to ASCT.

Author notes

Disclosure:Employment: Gavin Lewis and I (Douglas Millar) are employees of Roche Products Ltd manufacture of rituximab, one of the comparitors considered in this abstract. Research Funding: Dr Marcus has received research funding from Amgen and Gilead. Honoraria Information: Dr Marcus has received honoraria from Roche and Genentech. Membership Information: Dr Marcus has had membership of an Ad board for Genentech and Roche.