Analysis of the Potential Cost Utility of the Addition of Rituximab to Standard Chemotherapy in Adults with Aggressive B Cell Non-Hodgkin Lymphoma in Uganda

Abstract

Background: Rituximab is a monoclonal antibody that confers a survival benefit in adults with aggressive B cell Non-Hodgkin Lymphoma (B-NHL), and has been shown to be cost-effective in in high-income settings. Rituximab is not widely available in Uganda and other low-income countries due to cost. This is an evaluation of the potential cost-utility of the addition of rituximab (R-CHOP) to standard first-line chemotherapy (CHOP) for adults with aggressive B-NHL. Methods: A Markov model was developed to evaluate R-CHOP vs CHOP in adults with aggressive B-NHL treated at the Uganda Cancer Institute (UCI) over a lifetime horizon, from the perspective of the Uganda Ministry of Health. Main outcomes were disability-adjusted life-years (DALYs) averted and the incremental cost effectiveness ratio (ICER). A 3% discount rate was applied. Sensitivity analyses were performed to evaluate uncertainty. Results: The addition of rituximab to CHOP increased life-years (LYs) by 0.32 years (1.96 years with R-CHOP vs 1.62 years with CHOP) and decreased DALYs by 0.05 (0.32 with R-CHOP vs 0.26 with CHOP). The incremental cost of adding rituximab to CHOP was $3,153 per patient. The ICER comparing R-CHOP vs. CHOP was $9,313 per LY gained and $60,719 per DALY averted. Conclusions: Compared to a cost-effectiveness threshold of 3 times GDP per capita ($1,812 for Uganda in 2019 USD), rituximab is not cost-effective in this setting. As rituximab has been shown to improve to outcomes in adults with aggressive B-NHL, the Ugandan Ministry of Health may wish to further evaluate pricing options.