Economic evaluation of therapeutic sequences in the treatment of patients with chronic lymphocytic leukemia and coexisting conditions: Una Valutazione Economica Delle Sequenze Terapeutiche nel Trattamento di Prima Linea Della Leucemia Linfatica Cronica in Pazienti Unfit non Pretrattati

Introduction Chronic lymphocytic leukemia (CLL) is a chronic lymphoproliferative syndrome and it is the most common hematological malignancy in Western countries. It has a tendency to develop subsequent relapses, so affected patients are likely to undergo more than one line of treatment. Methods Rather than evaluating the cost-effectiveness of individual therapeutic agents, it becomes therefore recommendable for decision-makers to identify an optimal sequencing of such agents. A four-year cost-consequence analysis was conducted, comparing three alternative strategies for the first-line treatment of patients with previously untreated CLL and coexisting conditions: i) obinutuzumab with chlorambucil (Obi-Clb), ii) rituximab with chlorambucil (Rtx-Clb), and iii) ofatumumab with chlorambucil (Ofa-Clb). Only drug costs were considered in the analysis. Results In two trials, median time to next treatment (TTNT) was longer in Obi-Clb (51.1 months) as compared to Rtx-Clb (38.2 months) or to Ofa-Clb (39.8 months). Therefore, during a 48-month time horizon, patients treated with Obi-Clb would maintain on average the first line treatment; on the contrary, patients treated with Rtx-Clb or with Ofa-Clb would receive on average a second line treatment consisting in the majority of cases of ibrutinib monotherapy, or rituximab with idelalisib or rituximab with bendamustine. The sequence using Obi-Clb regimen in first line showed the lower mean cost of treatment: €22,958 over the 48-month time horizon. Sensitivity analyses on a couple of scenarios provided similar conclusions in terms of overall costs. Conclusion Obi-Clb as first-line treatment appears a recommendable strategy in terms of drug costs in the treatment of patients with previously untreated CLL and coexisting conditions.