Ibrutinib Plus R-CHOP Cost-Effective for Young Patients With ABC-DLBCL

Adding ibrutinib (Imbruvica) to the R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate [Oncovin], and prednisone) makes treating young people with activated B-cell–like diffuse large B-cell lymphoma (ABC-DLBCL) significantly more expensive. However, a new analysis suggests the addition is still cost-effective.

Ibrutinib plus R-CHOP is financially justifiable in younger patients due to its lower risk of adverse events, better overall survival rates, and higher quality of life, according to a new study, which was published in Current Oncology.

Ibrutinib | Image Credit: CLShebley

The study authors note that the standard treatment for DLBCL has long been the R-CHOP protocol. However, they said a significant unmet need remains in DLBCL due to the relatively high rates of relapse and refractory disease.

One potential strategy has been to add ibrutinib to the regimen. The Bruton’s tyrosine kinase (BTK) inhibitor plays a role in disrupting the B-cell receptor pathway; this pathway, the authors noted, is “central to the pathogenesis of the ABC subtype of DLBCL.” A 2019 study comparing ibrutinib plus R-CHOP to R-CHOP alone found adding ibrutinib improved outcomes in patients with ABC-DLBCL who were 60 years or younger.

In the new report, the investigators aimed to aid clinical decision-making by investigating how ibrutinib affected cost-effectiveness and patient-centered outcomes. They created a Markov decision-analysis model to compare R-CHOP with and without ibrutinib in a hypothetical patient population with a new diagnosis of ABC-DLBCL who were aged 60 and younger. The model analyzed treatment pathways, adverse events, relapses, and death.

Based on 10,000 simulations over a 30-year period, and with a willingness-to-pay threshold of CAD$100,000 (about US$74,000) per quality-adjusted life year (QALY), the authors found adding ibrutinib was the more cost-effective option.

“The results indicated that I-RCHOP was more cost-effective, with greater quality-adjusted life years (15.48 vs 14.25 years) and an incremental cost-effectiveness ratio [ICER] of CAD$34,111.45/QALY [about US$25,335] compared to R-CHOP only,” they found.

The investigators noted that it is significant that their model found the addition of ibrutinib to be cost-effective considering the drug’s high cost. They said the therapeutic regimen may become even more cost-effective over time. Ibrutinib tends to have a higher price in higher-income countries, the authors said, but they added that cost can be a barrier even in lower-income countries where it sells for a lower price.

“Given the increasing availability of generic medications, we anticipate that I-RCHOP, with its promising treatment profile in this subset of the patient population will become more cost-effective,” they said.

In the meantime, they said research is also underway into other regimens that may ultimately prove more cost-effective. Strategies under investigation include adding the second-generation BTK inhibitor acalabrutinib (Calquence) to R-CHOP and the so-called pola-R-CHP regimen of polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin hydrochloride, and prednisone.

The authors noted several limitations to their study. They said the limited number of studies of ibrutinib plus R-CHOP led them to rely heavily on a single study—the 2019 PHOENIX trial. As that trial was relatively recent, there were limited data available on long-term outcomes.

“To address these data gaps, probability values from other trials encompassing a broader, non–age-limited, nonsubtyped population were incorporated into the model,” they explained.

The authors added that the process of choosing treatment options for high-risk patients is inherently complicated and that the economics of cancer therapies add an extra layer of complexity, creating the need for analyses like theirs.

“Through the incorporation of key variables such as probabilities of adverse events, utilities, and associated costs of advanced treatments, our decision analytic model, while not absolute, offers pertinent and robust results to help inform clinical decision-making processes,” they concluded.

Reference

Rho H, Jeong IJ-H, Prica A. Ibrutinib plus RCHOP versus RCHOP only in young patients with activated B-Cell-like diffuse large b-cell lymphoma (ABC-DLBCL): a cost-effectiveness analysis. Curr Oncol. 2023;30(12):10488-10500. doi:10.3390/curroncol30120764