title: Comparing the cost-effectiveness of rituximab maintenance and radioimmunotherapy consolidation versus observation following first-line therapy in patients with follicular lymphoma.
abstract: BACKGROUND
  Phase 3 randomized trials have shown that maintenance rituximab (MR) therapy or radioimmunotherapy (RIT) consolidation following frontline therapy can improve progression-free survival for patients with follicular lymphoma (FL), but the cost-effectiveness of these approaches with respect to observation has not been examined using a common modeling framework.
  
  
  OBJECTIVE
  To evaluate and compare the economic impact of MR and RIT consolidation versus observation, respectively, following the first-line induction therapy for patients with advanced-stage FL.
  
  
  METHODS
  We developed Markov models to estimate patients' lifetime costs, quality-adjusted life-years (QALYs), and life-years (LYs) after MR, RIT, and observation following frontline FL treatment from the US payer's perspective. Progression risks, adverse event probabilities, costs, and utilities were estimated from clinical data of Primary RItuximab and MAintenance (PRIMA) trial, Eastern Cooperative Oncology Group (ECOG) trial (for MR), and First-line Indolent Trial (for RIT) and the published literature. We evaluated the incremental cost-effectiveness ratio for direct comparisons between MR/RIT and observation. Model robustness was addressed by one-way and probabilistic sensitivity analyses.
  
  
  RESULTS
  Compared with observation, MR provided an additional 1.089 QALYs (1.099 LYs) and 1.399 QALYs (1.391 LYs) on the basis of the PRIMA trial and the ECOG trial, respectively, and RIT provided an additional 1.026 QALYs (1.034 LYs). The incremental cost per QALY gained was $40,335 (PRIMA) or $37,412 (ECOG) for MR and $40,851 for RIT. MR and RIT had comparable incremental QALYs before first progression, whereas RIT had higher incremental costs of adverse events due to higher incidences of cytopenias.
  
  
  CONCLUSIONS
  MR and RIT following frontline FL therapy demonstrated favorable and similar cost-effectiveness profiles. The model results should be interpreted within the specific clinical settings of each trial. Selection of MR, RIT, or observation should be based on patient characteristics and expected trade-offs for these alternatives.
authors.affiliation: H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
authors.forename: Qiushi
authors.initials: Q
authors.lastname: Chen
authors.affiliation: H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
authors.forename: Turgay
authors.initials: T
authors.lastname: Ayer
authors.affiliation: Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Loretta J
authors.initials: LJ
authors.lastname: Nastoupil
authors.affiliation: Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, GA, USA.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Rose
authors.affiliation: Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA. Electronic address: crflowe@emory.edu.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Flowers
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D058846:Antibodies, Monoclonal, Murine-Derived / Q000191:economics* / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000191:economics* / Q000627:therapeutic use; D003131:Combined Modality Therapy / Q000191:economics; D003362:Cost-Benefit Analysis / Q000379:methods; D005260:Female; D006801:Humans; D008224:Lymphoma, Follicular / Q000188:drug therapy / Q000191:economics* / Q000532:radiotherapy; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D019370:Observation / Q000379:methods; D016499:Radioimmunotherapy / Q000191:economics*; D000069283:Rituximab; D055815:Young Adult
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D000970:Antineoplastic Agents; D000069283:Rituximab
keywords: cost-effectiveness; follicular lymphoma; lymphoma; maintenance; non-Hodgkin lymphoma; radioimmunotherapy; rituximab