CLINICAL NEWS
that this type of surveillance is costly while offering little clinical benefit.
According to the findings in a study by Scott Huntington, MD, from
the University of Pennsylvania, and colleagues, there was negligible benefit
associated with the use of either computed tomography (CT) scans or
positron emission tomography–computed tomography (PET/CT) scans
during the first two years after remission, compared with clinical follow-up
without routine imaging.
In their cost-effectiveness analysis, Dr. Huntington and his team used
a decision-analytic Markov model that allowed them to compare three
different strategies for asymptomatic patients with complete response following primary treatment for DLCBL:
• Follow-up including biannual CT scans for two years (estimated cost
over 2 years = $38)
• Follow-up including biannual PET/CT scans for two years
• Routine clinical follow-up including physical exams, serial history,
and surveillance laboratory evaluations
According to the investigators, two years of routine CT and PET/CT scans
yielded only 0.03 life-years gained and 0.04 life-years gained, respectively,
compared with the routine follow-up group. The survival benefit remained
small when investigators adjusted for quality (0.020 quality-adjusted life
years [QALYs] for the CT group and 0.025 for the PET/CT group). QALY
is a generic measure used to assess the value of a medical intervention,
based on the number of years of life that would be added by the intervention – taking into account the treatment’s impact on both the quality and
quantity of a patient’s life.
This small survival benefit came at a substantial cost: $41,950 for CT
plus clinical follow-up; $42,550 for PET/CT plus clinical follow-up; and
$38,280 for clinical follow-up alone.
The incremental cost-effectiveness ratios were $164,960 per QALY for
CT scans and $168,750 per QALY for PET/CT scans when compared with
routine clinical follow-up.
“Our findings question the role of routine surveillance imaging in this
clinical setting and align with the recent position outlined in the American
Society of Hematology’s Choosing Wisely campaign,” Dr. Huntington told
ASH Clinical News. In their Choosing Wisely campaigns, both ASH and
the American Society of Clinical Oncology have recommended limiting
surveillance imaging in asymptomatic patients who were treated with a
curative intent.
Using health-state transition probabilities from the randomized, controlled CORAL study, they were able to predict patient outcomes.
“Despite the use of conservative model estimates that associate early
imaging-detected relapse with better patient outcomes, our analysis found
routine surveillance imaging to be associated with substantial health-care
costs, but little clinical utility,” Dr. Huntington said.
As a provider, Dr. Huntington himself has changed his recommended
surveillance strategy from routine imaging to non–imaging-based clinical
follow-up. “It has been helpful to discuss the risks and/or benefits of serial
imaging with patients and encourage active engagement in their ongoing
clinical surveillance,” he said.
Commenting on the study’s findings in an accompanying editorial,
Gregory A. Abel, MD, MPH, of the Dana-Farber Cancer Institute, wrote
that the medical community must also consider comparative-effectiveness
data and clinical data when interpreting findings from a cost-effective
analysis. However, he noted that the analysis by Dr. Huntington and his
colleagues does suggest such surveillance is ineffective.
“Importantly, for certain populations at higher risk for relapse (such
as those with double-hit lymphoma), it may still be reasonable,” Dr. Abel
wrote in the editorial. “Moreover, given patient and physician concerns
regarding detecting relapse, it seems unlikely we will eliminate all surveillance imaging until we have something to replace it with. One promising
candidate is peripheral-blood assessment for minimal residual disease.” ●
References
• Huntington SF, Svoboda J, Doshi JA. Cost-effectiveness analysis of routine surveillance imaging of patients with diffuse large
B-cell lymphoma in first remission. J Clin Oncol. 2015 March 30. [Epub ahead of print]
• Abel GA. Does surveillance imaging after treatment for diffuse large B-cell lymphoma really work? J Clin Oncol. 2015 March 30.
[Epub ahead of print]
ASHClinicalNews.org
A New Era for
Waldenström Macroglobulinemia Treatment
In the more than 70 years since Jan G. Waldenström discovered Waldenström
macroglobulinemia, there have been few answers about what causes the malignant B-cell lymphoma or the best way to treat it. But, after the recent discovery of
a single activating somatic mutation present in most patients with the disease and
encouraging survival results with a new medication, the future for patients with
this rare blood cancer looks more promising than ever.
Investigators recently discovered that ibrutinib, the first and only treatment
approved by the U.S. Food and Drug Administration to treat Waldenström macroglobulinemia, produced a two-year overall survival rate of 95.2 percent. In this
prospective study, the drug was also shown to decrease median serum IgM levels,
increase median hemoglobin levels, and reduce bone marrow involvement.
These results compare favorably to response and survival rates seen in previous trials of monotherapies in patients with relapsed or refractory Waldenström
macroglobulinemia, which found response rates of 40 to 80 percent and a median
progression-free survival of 8 to 20 months, the authors noted.
“These findings change the paradigm for an orphan disease that really had
no established therapeutics, and I think they have moved us away from an era of
‘hand-me-down’ therapies,” Steven P. Treon, MD, PhD, the study’s first author
and director of the Bing Center for Waldenström’s Macroglo