Cost-Effectiveness of Shortening Treatment Duration Based on Interim PET Outcome in Patients With Diffuse Large B-cell Lymphoma

Guideline recommendations for diffuse large-B-cell lymphoma treatment are shifting from long to short treatment duration. Using a Markov model, we evaluated the cost-effectiveness of this shortening in treatment duration, separately in I-PET positive and I-PET negative patients. We showed that this shift is justified for I-PET negative patients, but not for I-PET positive patients as shortening treatment duration in these patients has harmful consequences. Background: Guideline recommendations for diffuse large-B-cell lymphoma (DLBCL) treatment are shifting from long to short treatment duration, although it is still unclear whether shortening treatment duration does not cause any harm. As interim PET (I-PET) has high negative predictive value for progression, we evaluated the cost-effectiveness of shortening treatment duration dependent on I-PET result. Materials and Methods: We developed a Markov cohort model using the PET Re-Analysis (PETRA) database to evaluate a long treatment duration (LTD) strategy, ie 8x R-CHOP or 6x R-CHOP plus 2 R, and a short treatment duration (STD) strategy, ie 6x R-CHOP. Strategies were evaluated separately in I-PET2 positive and I-PET2 negative patients. Outcomes included total costs and quality-adjusted life years (QALYs) per patient (pp) from a societal perspective. Net monetary benefit (NMB) per strategy was calculated using a willingness-to-pay threshold of euro 50,000/QALY. Robustness of model predictions was assessed in sensitivity analyses. Results: In I-PET2 positive patients, shortening treatment duration led to 50.4 additional deaths per 1000 patients. The STD strategy was less effective (-0.161 [95%CI:-0.343;0.028] QALYs pp) and less costly (- euro 2768 [95%CI: euro 8420; euro 1105] pp). Shortening treatment duration was not cost-effective (incremental NMB euro 5281). In I-PET2 negative patients, shortening treatment duration led to 5.0 additional deaths per 1000 patients and a minor difference in effective ness (-0.007 [95%CI:-0.136;0.140] QALY pp). The STD strategy was less costly (- euro 5807 [95%CI:- euro 10,724;- euro 2685] pp) and led to an incremental NMB of euro 5449, indicating that it is cost-effective to shorten treatment duration. Robustness of these findings was underpinned by deterministic and probabilistic sensitivity analyses. Conclusion: Treatment duration should not be shortened in I-PET2 positive patients whereas it is cost-effective to shorten treatment duration in I-PET2 negative patients.

Automated summary

Guideline recommendations for diffuse large-B-cell lymphoma (DLBCL) treatment are shifting towards shorter treatment duration, but it is unclear whether shortening treatment duration causes harm. Using a Markov model, this study evaluated the cost-effectiveness of shortening treatment duration based on I-PET results, showing that it is justified to shorten treatment duration for I-PET negative patients but not for I-PET positive patients as it has harmful consequences.