The Burden Of Illness and Prevalence In Diffuse Large B-Cell (DLBCL) and Follicular (FL) Lymphomas
Authors: Dulac III Edward J , Joy Karen A , Ndindjock Roger , Coyle Katharine B , Wade Rolin L 
Published: October 2019

Abstract

Introduction
In non-Hodgkin lymphoma (NHL), particularly diffuse large B-cell (DLBCL) and follicular (FL) lymphomas, the prevalence, burden of disease, including that of relapse/recurrence, and quality of life (QoL) play a role in how novel treatment strategies are evaluated. We conducted a literature review to identify whether the current understanding of the prevalence, burden of illness (BOI) including QoL in these two predominant NHL histologies is sufficient to support novel treatment and resource allocation decisions.

Methods
Using EMBASE, PubMed, Cochrane, conference abstracts, treatment guidelines, and government, business and industry literature such as data from the WHO, we identified estimates for prevalence and BOI, defined as disease-related costs and QoL, for DLBCL and FL, from 2005 to 2013 in the US and EU5 (France, Germany, Italy, Spain, UK). In addition to appropriate MeSH (Medical Subject Headings) terms, search terms included, but were not limited to, burden of illness, quality of life, QoL, HRQoL, cost, direct cost, resource use, resource utilization, economic, incidence, prevalence, epidemiology, and mortality.

Findings
BOI-related information within DLBCL and FL are very limited and antiquated

DLBCL
Only one health economic study was identified – a US study using data from 1999-2000 in patients with aggressive NHL, including DLBCL (Kutikova et al. Leuk Lymphoma. 2006). Among the patients receiving initial treatment, which did not include the current standard of care R-CHOP, 68% of patients experienced treatment failure. The incremental cost of treatment failure was $14,174 per month, driven by higher initial treatment costs ($13,866 vs $4,754) and the need for secondary and/or palliative care ($5,062). However, these data may not accurately depict relapse rates and costs associated with more current standards of care. For QoL, one study was identified in DLBCL, a US based study in the elderly. The NCI sponsored Surveillance, Epidemiology, and End Results-Medical Health Outcomes Survey database was used to evaluate QoL in elderly DLBCL patients using the Short Form (SF-36) Health Survey. Patients surveyed 0–1 year after the diagnosis of DLBCL had poor QoL scores (physical component [PCS] median=33.6, mental component [MCS] median=40.8, poor self-rated health: 51.6%) (Kelly et al. Blood. 2012).

FL
Only one health economic study was identified – a US study using data from 2006-2009 which estimated the cost of disease progression. Results showed that mean overall per patient per month (PPPM) costs over the 6-month follow-up were significantly higher for patients with progressive disease (PD) vs non-PD ($3527 vs. $860; difference=$ 2667; p<0.001) (Beveridge et al. Leuk Lymphoma. 2011). One QoL study was identified, a UK study that reported statistically significant differences by disease state using multiple QoL instruments. The total scores derived from the Functional Assessment of Cancer Therapy – Lymphoma (FACT-Lym) questionnaire showed that relapsed patients have lower QoL scores (109.7) than newly diagnosed patients (136.4), those achieving partial (128.81) or complete response (133.28), or when disease free (135.26) (p = 0.001) (Pettengell et al. Ann of Oncol. 2008).
Regarding prevalence data, in the EU5, prevalence of DLBCL ranges from 30 – 58% of NHL cases and in the US estimates range from 25 – 35%. Prevalence of FL is lower, ranging from 11 – 19% in the EU5 and 20 – 25% in the US. Regarding the prevalence of relapse/recurrent disease, one-third of DLBCL patients are either relapsed or refractory after standard therapy (Friedberg. Clin Cancer Res. 2011; Abramson et al. Blood. 2005).

Conclusions
Currently available data related to BOI and prevalence are limited and dated making it difficult to accurately assess the impact of DLBCL and FL on patients and healthcare systems. In the absence of renewed information it may be challenging to quantify the incremental impact that novel regimens may have on clinical outcomes, BOI, and QoL. While NHL mortality has steadily decreased over the past few decades as treatment options have improved, updated and accurate epidemiologic and BOI data are needed to better characterize the impact that novel treatments in development may have on the overall clinical, BOI and patient-reported outcomes in DBLCL and FL.

Disclosures:
Dulac: Celgene Corporation: Employment. Joy: IMS Health: Employment. Ndindjock: IMS Health: Employment. Coyle: IMS Health: Employment. Wade: IMS Health: Employment, Research Funding.