Wang, X.J., Tang, T., Farid, M., Quek, R., Tao, M., Lim, S.T., . . . Chan, A. (2016). Routine primary prophylaxis for febrile neutropenia with biosimilar granulocyte colony-stimulating factor (Nivestim) or pegfilgrastim is cost effective in non-Hodgkin lymphoma patients undergoing Curative-Intent R-CHOP chemotherapy. PLOS One, 11, e0148901. 

To compare the cost-effectiveness of various strategies of myeloid growth factor prophylaxis for reducing the risk of febrile neutropenia (FN) in patients with non-Hodgkin lymphoma in Singapore who are undergoing R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy with curative intent

Seven prophylaxis strategies were evaluated: (a) primary prophylaxis (PP) with biosimilar filgrastim throughout all cycles of chemotherapy, (b) PP with biosimilar filgrastim during the first two cycles of chemotherapy, (c) secondary prophylaxis (SP) with biosimilar filgrastim, (d) PP with pegfilgrastim throughout all cycles of chemotherapy, (e) PP with pegfilgrastim during the first two cycles of chemotherapy, (f) SP with pegfilgrastim, and (g) no prophylaxis (NP). Cost-effectiveness was expressed as the cost per episode of FN avoided over six cycles of chemotherapy.

• N = N/A   
• AGE = N/A
• MALES: N/A, FEMALES: N/A
• CURRENT TREATMENT: Chemotherapy, immunotherapy
• KEY DISEASE CHARACTERISTICS: Patients with non-Hodgkin lymphoma (NHL) treated with R-CHOP

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Singapore

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care

• Case-controlled study using published data set to estimate the rate of FN
• A mathematical model was used to compare anticipated costs.

A Markov model was constructed with TreeAge Pro 2013 to compare seven prophylaxis strategies for FN. Primary prophylaxis was defined as the routine administration of a granulocyte–colony-stimulating factor (G-CSF) with each cycle of chemotherapy, regardless of whether the patient had previously experienced an episode of FN. Secondary prophylaxis was defined as the initiation of a G-CSF in subsequent cycles of chemotherapy after the patient experienced a FN episode. The model target population was a hypothetical cohort of patients with NHL (mean age = 55 years) undergoing R-CHOP as a curative treatment. The time horizon of this model was 18 weeks, which was the period of six chemotherapy cycles. The Markov model was used with a cycle length of one week (seven days). Data from observational studies were used to determine the anticipated rate of FN.

The costs associated with the strategies were $3,813 (strategy 2), $4,056 (strategy 5), $4,545 (strategy 1), and $5,331 (strategy 4), respectively. The incremental cost-effectiveness ratios were $13,532 for strategy 5 versus strategy 2, $22,565 for strategy 1 versus strategy 5, and $30,452 for strategy 4 versus strategy 1, respectively, per episode of FN avoided. Strategy 2 was the most cost-effective.

The routine use of prophylactic G-CSF in the first two cycles of R-CHOP for NHL was more cost-effective than the routine use of G-CSF for all cycles of chemotherapy, with minimal clinical significance on efficacy. Routine use of prophylactic G-CSF during the first two cycles of R-CHOP for NHL or during all cycles of R-CHOP was more cost-effective than no prophylaxis.

• Risk of bias (no random assignment)
• This study used a mathematical model with data sets to predict the costs associated with G-SCF use.
• The study did not enroll patients to evaluate outcomes.
• The authors assumed that using a biosimilar filgrastim for seven days would have the same outcomes as pegfilgrastim.

Using G-CSF is a cost-effective way to prevent FN in patients undergoing R-CHOP chemotherapy. Cost-effectiveness is further improved when a G-CSF is used during the first two cycles, but this may produce different clinical benefits, requiring further study.