A recent publication reports on three systematic reviews that were performed to determine the cost effectiveness, cost, resource utilization, and health-related quality of life (HRQoL) associated with treatments for follicular lymphoma (FL) or  marginal zone lymphoma (MZL). Investigators performed a comprehensive review of MEDLINE, MEDLINE in process, E-pubs ahead of print on Ovid SP, Embase, NHS EED, and the EconLit database from March 2007 to March 2017. 

Studies that involved adults with FL or MZL who received drug therapy, palliative care, or no treatment and that incorporated an economic, cost-related, or HRQoL design were included. Outcomes for these variables were determined for both the United States and United Kingdom markets. Applicable conference proceedings, health technology assessment reports, cost-effectiveness registry data, and information from international drug-related agencies were also included. 

Of the 25 cost-effectiveness studies analyzed, only five were from the U.S. Regimens that were compared included first-line agents with or without maintenance  therapy, i.e., cyclophosphamide/vincristine/prednisone (CVP) with or without rituximab (R); cyclosphophosphamde/doxorubicin/vincristine/prednisone (CHOP), or CVP with or without R; maintenance regimens including R maintenance therapy; and treatment regimens for relapsed or refractory disease that included bendamustine and obinutuzumab with obinutuzumab maintenance or bendamustine alone. 

First-line chemotherapeutic regimens that incorporated R were found to be cost effective for the treatment of FL. In the U.S., regimens incorporating R-CVP compared with CVP monotherapy had projected incremental cost-effectiveness ratios (ICERs) of $28,565/quality-adjusted life-year (QALY) gained and $17,504/life-year (LY) gained. LY gained account for any gains in the length of life equally, regardless of whether or not the treatment improved patients’ HRQoL. The benefits, which were demonstrated as decreases in ICER values, improved annually with $382,642/LY, $193,859/LY, and $102,142/LY at 2, 3, and 4 years after observation (“watch and wait”), respectively, for R-CHOP/R-CVP compared with CHOP/CVP. 

These figures reflected accrual of cumulative survival benefits associated with the use of R while at the same time being associated with negligible costs for post first-line treatment. In FL, R maintenance was also cost effective compared with observation in FL patients with an ICER of $34,842/year unspecified as to whether it was QALY or LY. For treatment of relapsed and/or refractory FL, the ICER for bendamustine and obinutuzumab with obinutuzumab maintenance compared to bendamustine alone was $43,000/QALY.

The lifetime cost and resource utilization (based on U.S. dollars in 2014) associated with FL treatment regimens from the time of diagnosis until death for patients receiving R-CHOP, R + chemotherapy, and R monotherapy were $108,000, $114,800, and $130,300, respectively.

There was some evidence that HRQoL was dependent on stage or progression of the disease, and that chemotherapy was associated with a lower HRQoL compared with no treatment. However, this latter finding did not reach statistical significance. The effects of the “watch and wait” approach varied from being associated with a slightly improved QOL (compared to R monotherapy) to being correlated with more profound fatigue. 

As pharmacists are tasked with providing cost justification for drug budgets, this paper can offer support for oncology pharmacists who are involved in formulary decision making. 

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