Cost-Effectiveness of PET Directed Versus Combined Modality Therapy for Early-Stage Favorable Hodgkin's Lymphoma

This cost-effectiveness study utilizes a Markov Model to compare 2 treatment paradigms used in current day practice to treat Early-Stage Hodgkin's Lymphoma: PET directed therapy (chemotherapy with or without further chemotherapy and radiotherapy) versus combined modality therapy (chemotherapy plus radiotherapy). We found that combined modality therapy is the cost-effective strategy in this study, in large part due to the high cost and quality of life impact of salvage high dose chemotherapy and stem cell transplant associated with the higher rates of disease recurrence when radiotherapy is not utilized in the upfront treatment setting. Introduction: The standard of care for early-stage Hodgkin Lymphoma (HL) is combined modality therapy (CMT) consisting of chemotherapy and involved site radiation therapy (ISRT). Recent treatment de-escalation trials have assessed the impact of omitting radiation with the use of positron emission tomography (PET) and have suggested a detriment in progression free survival (PFS) for patients who do not receive radiation therapy (RT) but similar overall survival. The purpose of this study was to compare the cost-effectiveness of PET-directed therapy versus standard of care CMT. Methods: This study used a cost-effectiveness Markov model simulating 5 year outcomes for 1 million patients with early-stage HL treated with either PET-directed therapy consisting of 2 cycles of ABVD chemotherapy +/- ISRT or CMT consisting of 2 cycles of ABVD + ISRT. Patients progressed to no evidence of disease, progression of disease (PD), or death. Patients with PD underwent salvage therapy with high dose chemotherapy and stem cell transplant (HDC-SCT). The primary outcome measured was the incremental cost-effectiveness ratio. Deterministic sensitivity analyses were performed. Results: We found that PET-directed therapy and CMT strategies were associated with costs of $47,362 and $41,167, respectively. The CMT strategy was equally as effective as the PET-directed therapy strategy with QALYs of 3.4. On 1-way sensitivity analyses, the model was most sensitive to CMT and HDC-SCT costs. Two-way sensitivity analyses showed the model was sensitive to the relative costs of these treatments. Conclusion: For patients with early-stage HL, CMT is the cost-effective strategy as compared with PET-directed therapy.