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Cost-Effectiveness Analysis of Rituximab Maintenance Treatment

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Cost-Effectiveness Analysis of Rituximab Maintenance Treatment ARTIGO ORIGINAL Cost-effectiveness Analysis of Rituximab Maintenance Treatment in Patients With Follicular Lymphoma who Respond to First Line Induction Therapy in Portugal Análise de Custo-efetividade de Rituximab no Tratamento de Manutenção de Doentes com Linfoma Folicular, Com Resposta à Terapêutica de Indução em Primeira Linha, em Portugal Susana Carvalho1; Marília Gomes2; Herlander Marques3; Catarina Pereira4; Darío Rubio-Rodríguez5; Carlos Rubio-Terrés5; Carlos Sottomayor6 1. Serviço de Hematologia, Instituto Português de Oncologia de Lisboa, Francisco Gentil, E.P.E., Lisboa, Portugal 2. Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal 3. Serviço de Oncologia Médica, Hospital de Braga, Braga, Portugal 4. Market Access, Roche Farmacêutica Química, Lda., Amadora, Portugal 5. HEALTH VALUE, Madrid, Espanha 6. Serviço de Oncologia, Hospital Pedro Hispano, Matosinhos, Portugal Correspondência: Catarina Pereira, [email protected]. Recebido: 6/8/2015; Aceite: 23/12/2015. 17 Abstract Introduction: To perform a cost-effectiveness analysis of follicular lymphoma maintenance treatment after first-line induction with rituximab compared to observation in Portugal. Methods: A Markov follicular lymphoma model was developed with four health states: progression free survival on first and second lines, progression and death. The transition probabilities between health states were obtained from the PRIMA and EORTC20981 clinical trials and the health states utilities from the literature. The analysis considered the Portuguese National Health Service perspective and includes only direct costs. Resource consumption was estimated by a Portuguese clinical expert panel. The unit costs (€ in 2014) were estimated using Portuguese official databases. Deterministic and probabilistic analyses were performed. Results: In the base case, for a time horizon of 10 years, the cost per life year gained and per quality-adjusted life-year were € 10,634 and € 10,664, respectively. The sensitivity analyses confirmed the stability of the base case for time horizons of 20 and 30 years, varying between € 7,430 and € 7,155. Maintenance with rituximab is cost-effective for a time horizon of 5.5 years (cost per quality-adjusted life-year gained of € 23,616). Conclusion: According to the present model rituximab maintenance treatment of follicular lymphoma patients that respond to first line induction therapy in comparison with observation is cost-effective in Portugal. Keywords: Cost-Benefit Analysis; Follicular Lymphoma; Portugal; Rituximab. Resumo Introdução: Realizar uma análise de custo-efetividade de rituximab no tratamento de manutenção do linfoma folicular após indução em primeira linha, em comparação com observação, em Portugal. Métodos: Desenvolveu-se um modelo de Markov para o linfoma folicular com quatro estados de saúde: sobrevivência livre de progressão, após primeira e segundas linhas, progressão e morte. As probabilidades de transição entre estados de saúde foram obtidas a partir dos ensaios clínicos PRIMA e EORTC20981 e Rev Port Farmacoter | 2016;8:17-26 ARTIGO ORIGINAL as respetivas utilidades a partir da literatura. A perspetiva da análise foi a do Serviço Nacional de Saúde português e incluiu apenas os custos diretos. O consumo de recursos foi estimado por um painel de peritos constituído por clínicos portugueses. Os custos unitários (€ em 2014) foram estimados usando bases de dados oficiais portuguesas. Realizaram-se análises determinísticas e probabilísticas. Resultados: No cenário base, para um horizonte temporal de dez anos, os custos por ano de vida ganho e por ano de vida ajustado pela qualidade foram de € 10 634 e € 10 664, respetivamente. As análises de sensibilidade confirmaram os resultados do cenário-base para horizontes temporais de 20 e 30 anos, variando entre € 7430 e € 7155. O tratamento de manutenção com rituximab é custo-efetivo para um horizonte temporal de 5,5 anos (custo por ano de vida ajustado pela qualidade ganho de € 23 616). Conclusão: De acordo com o atual modelo, o tratamento de manutenção com rituximab em doentes com linfoma folicular que responderam à terapêutica de indução em primeira linha, em comparação com a observação, é custo-efetivo em Portugal. Palavras-chave: Análise Custo-Benefício; Linfoma Folicular; Portugal; Rituximab. Introduction been demonstrated that the best therapy for FL Non-Hodgkin’s follicular lymphoma (FL) is a cancer patients with treatment criteria is the association of associated with the B-cells of the germinal center of the rituximab (first rodent/human chimeric monoclonal lymph node. It is the second most common lymphoma antibody directed against antigen CD20 for sub-type that is known for its indolent course, with non-Hodgkin’s lymphoma) with chemotherapy.6 18 long median survivals up to 14 years.1,2 More recently, the results of the PRIMA (Primary Despite the high response rate to the initial treatment, the RItuximab and MAintenance) clinical trial indicates majority of patients relapse afterwards. Approximately that maintenance treatment with rituximab in FL 80% of patients are diagnosed with advanced disease patients that respond to first line induction regimens (stages III or IV)3 and considered incurable with (R-CHOP, R-CVP or R-FCM) increases the conventional treatments. For these patients the progression free survival with a hazard ratio of 0.55 objective is to accomplish “optimal palliative care” with (95% CI; 0.44-0.68; p <0.0001) in comparison with the aim of prolonging survival and achieve long periods observation.7 Thus, maintenance with rituximab has free of disease symptoms, reduce both the chemotherapy become a formal therapeutic indication. However, toxicity and the psychological burden of active pharmacoeconomic studies that exactly assess the life-threatening illness.4 economic impact and the real clinical benefit of this Taking into account that a) some people may not require new therapeutic approach are still limited. treatment for 20 years or more and b) the natural course In this context, the purpose of this study is to of the disease with spontaneous remissions between perform a cost-effectiveness analysis of rituximab 15 and 20% of cases in some asymptomatic patients a maintenance first line treatment in patients with FL conservative (or “watch and wait”) approach is taken.1-4 receiving rituximab plus chemotherapy compared to In symptomatic patients and in an attempt to alter the observation in Portugal. course of the disease, a different treatment approach in lymphoma therapy consists on a maintenance Methods treatment after patients achieve an adequate response Pharmacoeconomic Model in induction. This maintenance treatment must be seen The study consisted of a pharmacoeconomic model as part of an integrated approach in the management of that allows simulations to be made of complex these patients. healthcare processes associated with medicinal Over the last few years the introduction of a new products. This model was prepared, following a treatment option – immunotherapy with monoclonal previously established protocol, using estimations antibodies – has led to an increase in treatment obtained from the available data on the efficacy, specificity, reduced toxicity and also synergistic toxicity and costs associated with the alternatives effects with conventional chemotherapy due to their being compared.8 An adaptation of an international distinct mechanism of action.5 Thus, it has currently Markov model was developed for the Portuguese Rev Port Farmacoter | 2016;8:17-26 Rev Port Farmacoter | 2016;8:17-26 ARTIGO ORIGINAL Health System9,10 with a structure that is shown in Fig. 1 and described later in more detail. The transition Table 1 – Principal premises and assumptions made in the pharmacoeconomic analysis performed using a Markov probabilities between the model health states were model obtained from the PRIMA and EORTC20981 clinical 7,11 trials, costs and resources use consumption from Item Reference Portuguese sources and the health states utilities from the literature. 1. Health states of the model: PFS-1L, PFS-2L, progression, 9 death (Fig. 1) 7 2. Patients with follicular lymphoma who respond to first line induction therapy with R+CT regimen G 3. Mean age (56.0 years) body weight (71.15 kg) and height 7,25,26 (162.75 cm) of the cohort A D Progression 4. Maintenance regimen with rituximab: 375 mg/m2 every 8 7 E weeks during 2 years compared to observation B 7,11 H 5. Transition probabilities considered in the model: see Table 2 PFS-1L PFS-2L 6. Transition cycle duration: monthly, with mean cycle correction 9 F 7. Time horizon analysis: until death or 30 years (it is 14 C estimated that only 5% of the cohort would survive to that Death period)[10-30 years]* 8. Weibull model for the extrapolation of the permanency 15 PFS -1L : progress ion-free survival in patients who respond to induction therapy in first-l ine (R-C H OP , R -CVP o R-FCM), followed by r i t u xim a b in PFS or the transition to progression or death, in the maintenance or observation. I PFS -2L : progress ion-free s urvi val in patients who relapse after PFS-1 L time horizon (calculated from the transition probabilities) and respond to a second-line i nduction, foll owed by ritux im ab [gamma, exponential, log-logistic, log-normal and Gompertz maintenance. A-C: Transition probabilities obtained from the PRIMA study. distributions]* D-I: Transition probabilities obtained from the EORTC 20981 study. 9. Mortality by all causes in Portugal
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