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Scott FI, Hans AK, Gerich ME, Fennimore B, Mamtani R, Vajravelu RK, Lewis JD. Identification of the Most Effective Position for Ustekinumab in Treatment Algorithms for Crohn's Disease. Clin Gastroenterol Hepatol 2021; 19:2082-2092.e10. [PMID: 32801006 DOI: 10.1016/j.cgh.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/04/2020] [Accepted: 08/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ustekinumab is a monoclonal antibody against interleukin 12 and interleukin 23 that has been approved by the Food and Drug Administration for treatment of Crohn's disease (CD). We sought to identify the ideal position for ustekinumab in treatment algorithms for CD. METHODS We constructed a Markov model to identify an optimal treatment sequence for CD that included ustekinumab for 1 year or more. The base case was a 35-year old male with moderate to severe CD who had not previously received biologic or immunomodulator therapy. The standard of care treatment algorithm was defined as initial therapy with infliximab and azathioprine, followed by adalimumab and azathioprine, vedolizumab, and lastly surgical resection. The model assessed positions for ustekinumab before standard of care, ustekinumab after infliximab and azathioprine but before the remaining treatments, after infliximab, azathioprine, and adalimumab but before vedolizumab and surgery, or after the other biologics but before surgery. We derived transition probabilities and quality adjusted life years (QALYs) from relevant trials, observational studies, and time trade-off analyses. Primary analyses consisted of first order Monte Carlo simulation of 100 trials of cohorts of 100,000 individuals. RESULTS Ustekinumab as first-line therapy yielded the greatest QALYs (incremental effectiveness, 0.016-0.020 QALYs), resulting in 10% more patients in remission or response, and 2% fewer surgeries at 1 year, compared with other algorithms. The model was not sensitive to 25% variation in transition probabilities. CONCLUSIONS In a simulation based on a 35-year old male patient with moderate to severe CD, we found that ustekinumab as the first-line biologic therapy yields greater QALYs at the end of 1 year than compared with use later in the CD treatment algorithm.
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Affiliation(s)
- Frank I Scott
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Amneet K Hans
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Mark E Gerich
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Blair Fennimore
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ronac Mamtani
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ravy K Vajravelu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Scott FI, Luo M, Shah Y, Lasch K, Vajravelu RK, Mamtani R, Fennimore B, Gerich ME, Lewis JD. Identification of the Most Cost-effective Position of Vedolizumab Among the Available Biologic Drugs for the Treatment of Ulcerative Colitis. J Crohns Colitis 2020; 14:575-587. [PMID: 31901085 PMCID: PMC7303595 DOI: 10.1093/ecco-jcc/jjz212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS There are limited data on the most cost-effective sequencing of biologics for ulcerative colitis [UC]. METHODS We used Markov modelling to identify the most cost-effective position for vedolizumab among biologics for steroid-dependent UC, with a base-case of a 35-year-old male. We assessed three treatment algorithms, with vedolizumab use: prior to an initial anti-tumour necrosis factor alpha [anti-TNFα] and azathioprine [Algorithm 1]; prior to a second anti-TNF and azathioprine [Algorithm 2]; and prior to colectomy [Algorithm 3]. The initial anti-TNF could be either infliximab or adalimumab. Transition probabilities, costs, and quality-adjusted life-year estimates were derived from published estimates, Medicare, and the Nationwide Inpatient Sample. Primary analyses included 100 trials of 100 000 individuals over 1 year, with a willingness-to-pay threshold of US$100,000. Multiple sensitivity analyses were conducted to assess our findings. RESULTS From a population perspective, when both infliximab and adalimumab are available, vedolizumab was preferred as the first biologic if ≥14% of initial anti-TNF use was adalimumab. If infliximab is the primary biologic, vedolizumab use after infliximab [Algorithm 2] and prior to adalimumab was the most cost-effective strategy. All models were sensitive to biologic pricing. CONCLUSIONS This simulation demonstrated that the most cost-effective strategy in UC depends on the proportion of patients using adalimumab as the initial anti-TNF. If adalimumab was ≥14%, vedolizumab was preferred as the first biologic. When only infliximab was available for first-line therapy, the most cost-effective position of vedolizumab was prior to cycling to adalimumab.
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Affiliation(s)
- Frank I Scott
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO,USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Corresponding author: Frank I. Scott, MD, MSCE, Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA. Tel.: 720-848-2777; fax: 720-848-2778;
| | - Michelle Luo
- University of Pennsylvania School of Arts and Sciences, Philadelphia PA, USA
| | - Yash Shah
- Global Evidence & Out, Takeda Pharmaceuticals, Deerfield, IL, USA
| | - Karen Lasch
- US Medical Department, Takeda Pharmaceuticals, Deerfield, IL, USA
| | - Ravy K Vajravelu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ronac Mamtani
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Blair Fennimore
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO,USA
| | - Mark E Gerich
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO,USA
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,US Medical Department, Takeda Pharmaceuticals, Deerfield, IL, USA
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Scott FI, Shah Y, Lasch K, Luo M, Lewis JD. Assessing the Optimal Position for Vedolizumab in the Treatment of Ulcerative Colitis: A Simulation Model. Inflamm Bowel Dis 2018; 24:286-295. [PMID: 29361100 DOI: 10.1093/ibd/izx045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Vedolizumab, an α4β7 integrin monoclonal antibody inhibiting gut lymphocyte trafficking, is an effective treatment for ulcerative colitis (UC). We evaluated the optimal position of vedolizumab in the UC treatment paradigm. METHODS Using Markov modeling, we assessed multiple algorithms for the treatment of UC. The base case was a 35-year-old male with steroid-dependent moderately to severely active UC without previous immunomodulator or biologic use. The model included 4 different algorithms over 1 year, with vedolizumab use prior to: initiating azathioprine (Algorithm 1), combination therapy with infliximab and azathioprine (Algorithm 2), combination therapy with an alternative anti-tumor necrosis factor (anti-TNF) and azathioprine (Algorithm 3), and colectomy (Algorithm 4). Transition probabilities and quality-adjusted life-year (QALY) estimates were derived from the published literature. Primary analyses included simulating 100 trials of 100,000 individuals, assessing clinical outcomes, and QALYs. Sensitivity analyses employed longer time horizons and ranges for all variables. RESULTS Algorithm 1 (vedolizumab use prior to all other therapies) was the preferred strategy, resulting in 8981 additional individuals in remission, 18 fewer cases of lymphoma, and 1087 fewer serious infections per 100,000 patients compared with last-line use (A4). Algorithm 1 also resulted in 0.0197 to 0.0205 more QALYs compared with other algorithms. This benefit increased with longer time horizons. Algorithm 1 was preferred in all sensitivity analyses. CONCLUSION The model suggests that treatment algorithms positioning vedolizumab prior to other therapies should be considered for individuals with moderately to severely active steroid-dependent UC. Further prospective research is needed to confirm these simulated results.
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Affiliation(s)
- Frank I Scott
- Division of Gastroenterology, Department of Medicine, University of Colorado Denver, Aurora, Colorado.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yash Shah
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Lasch
- US Medical Office, Takeda Pharmaceuticals U.S.A., Inc., Deerfield, Illinois
| | - Michelle Luo
- Health Economics and Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Deerfield, Illinois
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,University of Pennsylvania, Philadelphia, Pennsylvania
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Sabater E, López-Guillermo A, Rueda A, Salar A, Oyagüez I, Collar JM. Cost-Effectiveness Analysis of Bendamustine Plus Rituximab as a First-Line Treatment for Patients with Follicular Lymphoma in Spain. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:465-477. [PMID: 27090915 DOI: 10.1007/s40258-016-0243-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Follicular lymphoma (FL) is the second most common type of lymphoid cancer in Western Europe. OBJECTIVE The aim of this study was to evaluate the cost utility of rituximab-bendamustine treatment compared with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) treatment as a first-line therapy for patients with advanced FL in Spain. METHODS A Markov model was developed to estimate the cost effectiveness of rituximab-bendamustine compared with R-CHOP as first-line treatment for patients with advanced FL in the Spanish National Health System (NHS). Transitions between health states (progression-free, including induction and maintenance; first relapse; second relapse; and death) were allowed for the patient cohort in 4-week-long cycles. Clinical data for the extrapolation of progression-free survival curves were obtained from randomized trials. Mortality rates and utilities were obtained from the literature. Outcomes were measured as quality-adjusted life-years (QALYs). The total costs (€, 2013) included drug costs (ex-factory prices with mandatory deductions), disease management costs and adverse event-associated costs. Costs and outcomes were discounted at a 3 % annual rate. Probabilistic sensitivity analysis was performed using 10,000 Monte Carlo simulations to assess the model robustness. RESULTS Treatment and administration costs during the induction phase were higher for rituximab-bendamustine (€17,671) than for R-CHOP (€11,850). At the end of the 25-year period, the rituximab-bendamustine first-line strategy had a total cost of €68,357 compared with €69,528 for R-CHOP. Health benefits were higher for rituximab-bendamustine treatment (10.31 QALYs) than for R-CHOP treatment (9.82 QALYs). In the probabilistic analysis, rituximab-bendamustine was the dominant strategy over treatment with R-CHOP in 53.4 % of the simulations. CONCLUSION First-line therapy with rituximab-bendamustine in FL patients was the dominant strategy over treatment with R-CHOP; it showed cost savings and higher health benefits for the Spanish NHS.
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MESH Headings
- Antibodies, Monoclonal, Murine-Derived/economics
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/economics
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Alkylating/economics
- Antineoplastic Agents, Alkylating/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bendamustine Hydrochloride/economics
- Bendamustine Hydrochloride/therapeutic use
- Costs and Cost Analysis
- Cyclophosphamide/economics
- Cyclophosphamide/therapeutic use
- Disease-Free Survival
- Doxorubicin/economics
- Doxorubicin/therapeutic use
- Drug Therapy, Combination/economics
- Humans
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/economics
- Lymphoma, Follicular/mortality
- Markov Chains
- Prednisone/economics
- Prednisone/therapeutic use
- Quality-Adjusted Life Years
- Rituximab/economics
- Rituximab/therapeutic use
- Spain/epidemiology
- Vincristine/economics
- Vincristine/therapeutic use
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Affiliation(s)
- Eliazar Sabater
- Pharmacoeconomics and Outcomes Research Iberia, Paseo Joaquín Rodrigo 4- letra I, Pozuelo de Alarcón, 28224, Madrid, Spain.
| | | | - Antonio Rueda
- Oncology Department, Hospital Costa del Sol, Marbella, Spain
| | - Antonio Salar
- Haematology Department, Hospital del Mar, Barcelona, Spain
| | - Itziar Oyagüez
- Pharmacoeconomics and Outcomes Research Iberia, Paseo Joaquín Rodrigo 4- letra I, Pozuelo de Alarcón, 28224, Madrid, Spain
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Scott FI, Vajravelu RK, Bewtra M, Mamtani R, Lee D, Goldberg DS, Lewis JD. The benefit-to-risk balance of combining infliximab with azathioprine varies with age: a markov model. Clin Gastroenterol Hepatol 2015; 13:302-309.e11. [PMID: 25117775 PMCID: PMC4324381 DOI: 10.1016/j.cgh.2014.07.058] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/21/2014] [Accepted: 07/31/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Combination therapy with infliximab and azathioprine has demonstrated benefit over monotherapy for moderate-to-severe Crohn's disease. Clinical trials and models have not accounted for age-specific risks associated with these therapies, including the risk of immunosuppression-related cancer and infection. After accounting for these risks, the strategy yielding the greatest benefit may vary with age. METHODS We assessed age-specific risks and benefits of combination therapy compared with infliximab monotherapy by using Markov modeling. The base case was a 35-year-old male patient with a 1-year time horizon. We assumed the incidence of lymphoma to be 5.28-fold higher with combination therapy. Secondary analyses accounted for life expectancy, therapy beyond 1 year, and age-specific surgical and infection risks. Quality-adjusted life years (QALYs) were calculated for 25- to 75-year old individuals. RESULTS Combination therapy was found to be of greater benefit in the base case (0.7522 QALYs for combination therapy vs 0.7426 QALYs for monotherapy). Accounting for life years lost, monotherapy was the best approach if the hazard ratio for lymphoma with combination therapy was >8.1 patients who were 75 years old. Monotherapy provided greater net benefit to patients 55, 65, or 75 years old if therapy was extended for 9, 7, or 5 years, respectively. For 25-year-old men, monotherapy resulted in fewer deaths but only yielded greater QALYs if the annual incidence of hepatosplenic T-cell lymphoma exceeded 36/100,000 persons. CONCLUSIONS After accounting for age-specific risks of lymphoma, infection, and surgical complications, benefits of combination therapy outweighed the risks as a short-term and intermediate-term strategy for most patients with moderate-to-severe Crohn's disease who were younger than 65 years. For young male patients, combination therapy yields greater QALYs but at cost of an increased risk of death from lymphoma.
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Affiliation(s)
- Frank I Scott
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ravy K Vajravelu
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meenakshi Bewtra
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronac Mamtani
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dale Lee
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David S Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Olin RL, Andreadis C. David Versus Goliath: Decision Analysis Predicts Results of a Large Clinical Trial in Follicular Lymphoma. J Clin Oncol 2013; 31:3608-9. [DOI: 10.1200/jco.2013.50.5099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Federico M, Dondi A. Reply to R.L. Olin et al. J Clin Oncol 2013; 31:3609-10. [DOI: 10.1200/jco.2013.51.7607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Itchaki G, Gafter-Gvili A, Lahav M, Vidal L, Raanani P, Shpilberg O, Paul M. Anthracycline-containing regimens for treatment of follicular lymphoma in adults. Cochrane Database Syst Rev 2013; 2013:CD008909. [PMID: 23832787 PMCID: PMC11290704 DOI: 10.1002/14651858.cd008909.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Anthracycline-containing regimens (ACR) are the most prevalent regimens in the management of patients with advanced follicular lymphoma (FL). However, there is no proof that they are superior to non-anthracycline-containing regimens (non-ACR). OBJECTIVES To compare the efficacy of ACRs to other chemotherapy regimens, in the treatment of FL. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 3), MEDLINE (January 1966 to April 2013), smaller databases, relevant conference proceedings (2004 to 2012) and the National Medical Library (April 2013). SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing ACR with non-ACR for adult patients with FL. We excluded trials in which immunotherapy, radiotherapy alone or stem-cell transplantation were used in one arm alone. Our primary outcome was overall survival (OS). Secondary outcomes included disease control, as measured by progression-free survival (PFS) or remission duration (RD). DATA COLLECTION AND ANALYSIS Two review authors assessed the quality of trials and extracted data. We contacted study authors for additional information. We analyzed trials separately according to resemblance of the chemotherapeutic regimens in study arms, other than the addition of anthracyclines ('same' versus 'different' chemotherapy). Hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals (CI) were estimated and pooled using the fixed-effect model. MAIN RESULTS Eight RCTs, conducted between 1974 and 2011, and involving 2636 patients were included in this meta-analysis. All trials included therapy-naive patients. Rituximab was used in one trial only. Follow-up was between three and five years in most trials (range three to 18 years). All trials were published in peer-reviewed journals.Five trials compared similar chemotherapeutic regimens, except for the anthracycline. In three studies reporting overall survival specifically in FL patients, there was no statistically significant difference between ACR and non-ACR arms (HR 0.99; 95% CI 0.77 to 1.29; I(2) = 0%). ACR significantly improved disease control (HR 0.65; 95% CI 0.52 to 0.81; four trials). Progression or relapse at three years were reduced (RR 0.73; 95% CI 0.63 to 0.85). Anthracyclines did not significantly increase rates of complete response (RR 1.05; 95% CI 0.94 to 1.18) or overall response (RR 1.06; 95% CI 1.00 to 1.12), but heterogeneity was substantial.Overall, ACR were more often associated with cytopenias, but not with serious infections or death related to chemotherapy. Cardiotoxicity, albeit rare, was associated with anthracycline use (RR 4.55; 95% CI 0.92 to 22.49; four trials).Three trials added anthracycline to one arm of two different regimens. None showed benefit to ACR regarding OS, yet there was a trend in favor of anthracyclines for disease control. Results were heterogeneous.We judged the overall quality of these trials as moderate as all are unblinded, some are outdated and are not uniform in outcome definitions. AUTHORS' CONCLUSIONS The use of anthracyclines in patients with FL has no demonstrable benefit on overall survival, although it may have been mitigated by the more intense regimens given in the control arms of three of five trials. ACR improved disease control, as measured by PFS and RD with an increased risk for side effects, notably cardiotoxicity. The current evidence on the added value of ACR in the management of FL is limited. Further studies involving immunotherapy during induction and maintenance may change conclusion.
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Key Words
- adult
- humans
- anthracyclines
- anthracyclines/therapeutic use
- antibiotics, antineoplastic
- antibiotics, antineoplastic/therapeutic use
- antibodies, monoclonal, murine‐derived
- antibodies, monoclonal, murine‐derived/therapeutic use
- antineoplastic combined chemotherapy protocols
- antineoplastic combined chemotherapy protocols/therapeutic use
- induction chemotherapy
- induction chemotherapy/methods
- lymphoma, follicular
- lymphoma, follicular/drug therapy
- lymphoma, follicular/mortality
- lymphoma, follicular/pathology
- maintenance chemotherapy
- maintenance chemotherapy/methods
- randomized controlled trials as topic
- rituximab
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Affiliation(s)
- Gilad Itchaki
- Institute of Hematology, Davidoff Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel. .
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