Cost-Effectiveness of Rituximab Maintenance Treatment Versus Autologous Stem Cell Transplantation (ASCT) in Patients with Relapsed Follicular Lymphoma (FL).

PURPOSE: High dose chemotherapy followed by ASCT is commonly used in responding patients with FL as consolidation treatment in first relapse. Recently, rituximab maintenance treatment has shown to improve both progression free (PFS) and overall survival (OS) in the same patient population. The objective of this analysis was to estimate the incremental cost-effectiveness of rituximab maintenance compared to ASCT in patients with FL in first relapse.

METHODS: Efficacy data for rituximab maintenance treatment was derived from the EORTC 20981 trial (van Oers et al, ASH 2005). FL patients (n=334) were randomized to observation or rituximab maintenance treatment in first relapse. Rituximab maintenance treatment consisted of eight infusions during two years. The reported PFS for R-CHOP induction followed by maintenance arm was 51.9 mo, in comparison to 23.1 mo for observation arm. Efficacy data on ASCT and immunochemotherapy were derived from local experience during 1994–2005. Twelve patients with relapsed FL received ASCT, and had median PFS of 34.1 mo. In comparison, fifty patients who received immunochemotherapy without neither ASCT nor rituximab maintenance had a PFS of 21.8 mo, which is comparable to the outcome of R-CHOP treated patients in the observation arm of the EORTC 20981 study. To estimate the incremental resources involved we included therapy associated costs, and visit costs during the first two years. Rituximab maintenance costs included eight infusion visits, in addition to drug costs. Costs for ASCT were based on real data of individual patients, collected from hospital’s accounting systems. These costs are also used as prices charged by Helsinki University Hospital (HUCH) in Finland. The costs included only direct medical costs for hospital services and were calculated in 2004 prices.

RESULTS: The cost of rituximab maintenance treatment was estimated to be approximately EUR 19.700. The actual cost of ASCT was approximately EUR 38.600. In terms of health benefits, rituximab maintenance seems to provide longer PFS after first relapse, with incremental difference of 17.8 mo, based on these early results reported. In the base case, therapy associated costs were lower in the rituximab maintenance treatment group. After sensitivity analysis without follow-up visit costs, this difference remained. Thus, rituximab maintenance treatment was the dominant choice in treating FL patients at first relapse, when compared to ASCT.

CONCLUSIONS: This analysis cloncludes that new treatment approaches may lead to improved PFS combined with cost savings in those FL patients where ASCT previously has been the preferred treatment option. The potential impact of these findings on the whole FL patient population will be discussed.