Real-World Treatment Patterns, Healthcare Resource Utilization, Costs, and Survival Among Medicare Beneficiaries with Diffuse Large B-Cell Lymphoma (DLBCL)

Background: Given the prevalence of DLBCL and ongoing development of novel therapies, it is important to understand real-world treatment patterns and economic burden in individuals diagnosed with DLBCL. With a median age at diagnosis of 66 years, specific attention to older adults with DLBCL is needed, yet the current literature is limited in this respect. This study aimed to examine treatment patterns, healthcare resource use (HRU), costs, and survival in a national sample of Medicare beneficiaries newly diagnosed with DLBCL.

Methods: This cohort study used Medicare claims data (100%) from 2014 to 2019, the most recently available data at the time of the analysis. The sample included patients with a DLBCL diagnosis between 10/01/2015 to 12/31/2018 (index date = first DLBCL claim date). Additional selection criteria included: continuous Medicare fee-for-service Part A, B, and D coverage in the 12 months pre-index and a minimum of 12 months post-index, no diagnoses for DLBCL and absence of any anticancer treatment in the 12 months pre-index (i.e. incident cases), ≥66 years on index date, and evidence of at least one DLBCL-indicated treatment over follow-up after initial DLBCL diagnosis. Outcomes were reported for the front-line and relapse/refractory settings: (1) treatment patterns (2) Annual all-cause and DLBCL-related HRU (inpatient, outpatient, and physician visits, and hospice care), (3) all-cause and DLBCL-related annual costs, and (4) overall survival (OS).

Results: We identified 11,880 Medicare beneficiaries diagnosed with DLBCL receiving treatment in the frontline setting (mean age 76.5 years, 31.6% age ≥80 years; 50.9% male; 90.0% White). Over a median follow up of 2.1 years, 17.8% went on to receive at least second-line treatment [2L+], 3.9% received at least third-line treatment [3L+], and 0.9% received at least fourth-line treatment [4L+]. Very few patients received a stem cell transplant (3.1%). Median time to treatment initiation from diagnosis was 32.0 days. The majority of frontline patients initiated R-CHOP (61.2%); 8.9% of patients received rituximab monotherapy in the 1L setting. In the relapsed/refractory setting, the most common regimens were bendamustine-based regimens (20.3% [2L+], 20.8% [3L+], 13.6% [4L+]), gemcitabine-based regimens (18.2% [2L+], 20.2% [3L+], 19.1% [4L+]), and CHOP-based regimens (21.1% [2L+], 7.3% [3L+], <10% [4L+]). The median time to next treatment from the end of the previous line of treatment ranged from about 3 weeks to 7 weeks (51.0 days from 1L to 2L, 35.5 days from 2L to 3L, and 20.5 days from 3L to 4L).

HRU was substantial across all lines of therapy in the 12 months after initiating a given line of treatment. Over half of patients (57%) had a hospitalization due to any cause, with the vast majority being DLBCL-related. Hospice use increased in each line of therapy (13% [1L+], 32% [2L+], 44% [3L+], 59% [4L+]). Across all lines of therapy, >70% of all-cause costs are attributable to DLBCL. DLBCL-related total healthcare costs in the 12 months after initiation of treatment were $84,416 (1L+), $80,757 (2L+), $91,493 (3L+), and $74,294 (4L+). Excluding patients who died within 12-months of treatment initiation, DLBCL-related total costs were higher for later lines of treatment ($80,761 [2L+], $118,278 [3L+], $124,134 [4L+]). Less than half of DLBCL-related total costs were attributable to DLBCL-related oral and physician-administered drugs (44% [1L+], 39% [2L+], 37% [3L+], 44% [4L+]).

Median OS from initial DLBCL diagnosis or 1L treatment initiation was not reached. Median OS was 19.9 months, 9.8 months, and 5.5 months from the initiation of 2L, 3L, and 4L treatment, respectively. The 1-year and 3-year OS rate was 81.7% and 65.8% from initial DLBCL diagnosis and 78.9% and 64.3% from 1L treatment initiation, respectively. The 1-year and 3-year OS rate was 58.3% and 39.9% from 2L treatment initiation, and 45.1% and 19.8% from 3L treatment initiation, respectively.

Conclusions: In this real-world study of a national sample of elderly U.S. Medicare beneficiaries diagnosed with DLBCL, we observed high rates of hospitalization and hospice use, poor overall survival in later lines of therapy, and substantial healthcare costs. Our study results when taken together are suggestive of a large current unmet need for more efficacious and well-tolerated therapies for older adults with DLBCL patients in both the front-line and relapse/refractory settings.

Garg:Merck & Co., Inc.: Current Employment. Huntington:Seattle Genetics: Consultancy, Honoraria; Tyme: Consultancy; Genentech: Consultancy; AbbVie: Consultancy; FlatonIron Health: Consultancy; Beigene: Consultancy; AstraZeneca: Consultancy; ADC Therapeutics: Consultancy, Honoraria; Epizyme: Consultancy, Honoraria; Merck: Consultancy; Janssen: Consultancy; Agios: Research Funding; Debiopharm Group: Research Funding; TG Therapeutics: Consultancy, Research Funding; DTRM Biopharm: Research Funding; Pharmacyclics: Honoraria; AstraZeneca: Consultancy; Arvinas, Novartis, Servier, Bayer, SeaGen: Consultancy; Celgene: Research Funding. Puckett:COVIA Health Solutions: Current Employment. Kamal-Bahl:AbbVie, Inc.: Consultancy; Janssen, Inc.: Consultancy; Novartis, Inc.: Consultancy; Merck & Co., Inc.: Consultancy; PhRMA: Consultancy; COVIA Health Solutions: Current Employment. Raut:Merck & Co., Inc.: Current Employment. Ryland:Merck & Co., Inc.: Current Employment. Doshi:Acadia: Consultancy; Allergan: Consultancy; Janssen: Consultancy, Research Funding; Merck & Co., Inc.: Consultancy, Research Funding; Otsuka: Consultancy; Takeda: Consultancy; National Institutes of Health: Research Funding; PAN Foundation: Research Funding; Regeneron: Research Funding; AbbVie, Inc.: Consultancy.