Rituximab More Cost-Effective Than Watch and Wait for Follicular Lymphoma

For patients with low-burden, asymptomatic advanced-stage follicular lymphoma, a treatment strategy of rituximab induction without rituximab maintenance was the most cost-effective approach, according to the results of a Canadian cost-effectiveness analysis published in Cancer.

“A rituximab-containing monotherapy induction strategy for asymptomatic advanced-stage follicular lymphoma is the dominant strategy over a watch and wait approach and maximizes both life expectancy and quality-adjusted life expectancy while being cost-saving,” wrote Anca Prica, MD, of the division of hematology at Princess Margaret Cancer Centre in Toronto, and colleagues. “Rituximab induction monotherapy, consisting of 4 weekly doses, is the most cost-effective strategy overall, with neutral effectiveness in comparison with rituximab induction followed by maintenance, but it leads to significant cost minimization over a lifetime horizon.”

Patients with advanced follicular lymphoma often are advised to adopt a watch and wait approach to their disease, as multiple randomized clinical trials have shown that there is no detriment in terms of survival to delaying chemotherapy compared with initiating upfront treatment.

However, according to Prica and colleagues, these early clinical studies compared the watch and wait strategy with cytotoxic regimens. More recent data have shown improvements in time to progression with the anti-CD20 antibody rituximab induction with or without rituximab maintenance compared with watch and wait. Therefore, in this analysis, the researchers wanted to compare the use of rituximab with the watch and wait approach in terms of cost effectiveness.

Prica and colleagues used a Markov decision analysis model to compare clinical outcomes, costs, and cost effectiveness of treatment with rituximab induction plus rituximab maintenance, rituximab induction alone, or a watch and wait strategy with patients with newly diagnosed advanced-stage follicular lymphoma. The results were calculated in Canadian dollars.

Results showed that rituximab induction alone was the cheapest strategy with a cost of $59,953 compared with $67,489 for the rituximab maintenance arm and $75,895 for the watch and wait arm. In addition, rituximab induction had a lower quality-adjusted life years (QALYs) expectancy compared with rituximab maintenance (6.16 QALYs vs 6.28 QALYs), but had a slightly higher expectancy than the watch and wait approach (6.16 QALYs vs 5.71 QALYs).

“The rituximab induction strategy is $15,942 less expensive than watch and wait with an expected benefit of 0.45 QALYs and is $7,536 cheaper than rituximab maintenance, with rituximab maintenance being more effective by 0.12 QALYs or 1.44 months,” the researchers wrote. “Thus, watch and wait is dominated by both rituximab induction and rituximab maintenance.”

According to the researchers, this cost effectiveness was sensitive to the probability of a patient having first and second progression in the rituximab induction arm, which indicated a relatively neutral effectiveness between the two treatment arms.

“With a willingness-to-pay threshold of $50,000, rituximab maintenance became cost-effective if the [first progression] probability was more than 0.036,” the researchers wrote. “Similarly, the model was sensitive to the probability of progressive disease 2 after bendamustine and rituximab in the rituximab induction arm, with the rituximab induction strategy becoming dominant if the probability was less than 0.024, and rituximab maintenance became cost-effective if the probability was more than 0.045.”