ASH: Financial Toxicity and Follicular Lymphoma

I'm back to looking at ASH abstracts after a short break to be thankful. (And thanks to all of you who commented. I've always said I would still keep up the blog even if no one else read it -- I like to write, and it gives me an excuse to keep up on what's happening with Follicular Lymphoma. But it's still pretty great to hear from other FL patients that I'm helping them.)  

As you probably know, ASH is the American Society for Hematology, and their big conference takes place every year at the beginning of December. The abstracts or summaries of the presentations get put online about a month before that, and I like to go through them and write about things that I find interesting. Not always the most important, but the ones I find interesting.

The ASH presentation that caught my eye today is called "Impact of Treatment Sequencing on Outcomes and Costs in Relapsed Follicular or Other Low Grade B-Cell Non-Hodgkin Lymphoma – Results of an Evidence-Based Budget Impact Model."It deals with an important issue for cancer patients, though they don't use the actual phrase -- financial toxicity. Just as cancer treatment has physical toxicity and side effects, it can have financial side effects, too. Too many of us already know this.

The researchers wanted to know, basically the best FL treatment sequence for the buck -- what is the most effective sequence of treatments relative to cost? What's the longest a patent can go between treatments for the least money?

To do this, they looked at data from research that has already taken place in the past. They compared treatments that are recommended by the National Comprehensive Cancer Network by looking at the number of treatment cycles that each treatment requires, the number of days a treatment was received, the duration of response (how long it keeps working), rate of side effects and associated costs (like medicine to treat nausea, for example), and total treatment costs, including drugs, medical treatment, and laboratory testing. All of that information helped them figure out how much each treatment would cost for a typical patient (one that had the typical amount of treatment for the typical amount of time for the typical cost).

They looked at all of this information for a few different scenarios. Follicular Lymphoma is considered incurable, which means patients often need multiple treatments. So, using the NCCN guidelines, they looked at typical first-line treatments (the first treatment a patient receives), consolidation treatment (sometimes given right after first-line as a way of cleaning up any left-over cancer cells), and second-line treatment (given after the first-line stops working). 

The specific first-line treatments they looked at were Bendamustine + rituximab (BR); Bendamustine + Obinutuzumab (OB); CHOP rituximab (R-CHOP); CHOP + Obinutuzumab (O-CHOP); CVP+ rituximab (R-CVP); CVP + Obinutuzumab (O-CVP); and Lenalidomide + rituximab (R-squared). [No straight Rituxan? Hmmm.]

The Consolidation treatments they looked at were Rituximab maintenance (RM); Obinutuzumab maintenance (O); and RadioImmunoTherapy (Zevalin).

The Second-Line treatments were RIT; Lenalidomide only; and Lenalidomide + Obinutuzumab (LO).

You get all that? 

They looked at the cost for each of those treatments, then added up the cost for the possible sequences. Maybe a patient first has RCHOP, consolidates with R-maintenance, then eventually needs Lenalidomide a few years later. Now create sequences with all of the possible combinations. 

I'm not going to go through every combination, but I encourage you to look at the abstract and see the tables with the information. It's pretty easy to read. 

What the researchers highlight:

The treatment sequence of first-line BR followed by Consolidation with (Zevalin) had the longest predicted duration of response (2586 days, or a little over 7 years). The cost would be $212,485. Next best was BR followed by R-maintenance, costing $233, 388 for a duration of response of 2478 days (a little under 7 years). The predicted duration of response for treatment sequences that started with O-CHOP, O-CVP and R-CHOP and then followed by Zevalin were about 1000 days (roughly 3 years) less than BR + Zevalin. 

The longest duration of response came from BR followed by Lenalidomide + Obinutuzumab, at 2778 days (about 7.7 years), but at a cost of $796,695.

Again, look at the link for more. It's pretty interesting.

[And, as I look at this again and think about you, dear readers for whom I am thankful, I know many of you live outside the U.S. and those numbers don't mean much. So here's a small gift: a link to a site that lets you convert currency.]

What I also find interesting is that a couple of treatments involving Lenalidomide had astronomical costs -- BR with second-line Lenalidomide, and R-CVP followed by Lenalidomide, each cost over $4 million for a typical patient. Lenalidomide has to be taken every day, as a pill. That adds up (especially if the price goes up.) Zevalin keeps costs down because it is given in just two doses.

My thoughts on all of this (as always, I remind you that I am not a doctor, so don't take anything I say as medical advice. Talk to your own doctor about that):

There are, as always, some warnings about research like this. It looks at published data on median or "typical" patients, so the results are going to be different for every patient. Some will get a longer response from first-line treatment, others will not respond to consolidation, etc.

But I think those "typical" responses are how insurance companies (in the U.S., or national healthcare agencies in other countries) decide on which treatments to recommend. And, in the unfortunate situation that a patient has to pay all or most of the cost of treatment, this kind of sequence analysis matters -- how many days of being free from cancer will I get for the money I pay? Better to lay less for a shorter response? Pay more for a longer response? Find some way of balancing the two? This research helps to answer those questions.

The really big take-away for me, though, is in comparing the costs of treatment to something like CAR-T. When different versions of CAR-T have been approved, there was a lot of discussion about their cost. Since each treatment is created specifically for an individual patient, the cost is pretty high -- up to $500,000. 

But if you are a patient who gets a long duration of response -- maybe even a cure -- for a half million dollars, that seems pretty good compared to, say, BR followed by Lenalidomide + Obinutuzumab, which would cost almost $300,000 more. 

And as far as financial toxicity goes, I really appreciate that the researchers considered not just the cost of the treatment itself, but of all the other things that go with it, including laboratory fees, medications to deal with side effects, doctor visits, etc. Those things matter. It would be a lot harder to calculate, but it would have been even better if they had included things like lost wages from missing work on days when fatigue was just too much.

But honestly, I'm happy with what the researchers do include here. It's an important topic, and one that doesn't get talked about nearly enough. I'm guilty of it, too -- I get excited about new treatments without thinking about how much they'll cost, and if they will be affordable.

I hope more research like this comes out, and gets a lot of attention. At least in the U.S., financial toxicity is a major issue for too many cancer patients, and awareness of the issue just might lead to something being done about it.