Search

Background : Cancer is annually responsible for millions of deaths in Europe and billions of euros in productivity losses; the estimated mortality rate of lymphoma was of 7.07 per 100,000 individuals in Spain in 2018. This study aimed to evaluate the burden that lymphoma mortality represents for the Spanish society. Methods : The human capital approach was used to estimate the costs derived from premature mortality due to lymphoma between 2008 and 2017. Results : The number of deaths attributable to lymphoma increased steadily over the study period; the major number of deaths occurred among males aged 80 to 84 years. During the study period, 97,069 years of productive life were lost, a parameter that decreased noticeably over time due to the reduction in the number of deaths at working age. Productivity losses decreased accordingly. Lymphoma represented the 45.36% of losses due to hematological malignancies, generating €121 million in losses the year 2017. Hodgkin lymphoma was, among hematological malignancies, the malignancy accounting for the highest portion of losses per individual. Conclusions : Lymphoma represents a significant burden that can be reduced with the implementation of improved diagnosis and treatment methods, which must be taken into account in resource allocation and management policies.

Background: Several strategies are available for the initial treatment of advanced-stage Hodgkin lymphoma, but the optimal strategy in terms of cost-effectiveness is unclear. The aim of this study was to compare the quality-adjusted effectiveness and costs of five modern treatment options for transplantation-eligible patients with newly diagnosed advanced-stage Hodgkin lymphoma., Methods: A Markov decision-analytic model was developed using a 20-year time horizon. Five of the most common treatment approaches were selected based on clinical experience and expert opinion: (1) six cycles of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD), including data from the HD2000 trial, Viviani and colleagues, and EORTC trial; (2) six cycles of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP; from the HD15 trial or PET-adapted as in the HD18 trial, two initial cycles of BEACOPP followed by four additional cycles for patients with a positive PET and either two or four additional cycles of BEACOPP for patients with a negative PET); (3) PET-adapted escalation (as in the RATHL trial, two cycles of standard ABVD chemotherapy followed by an additional four cycles of ABVD or AVD in PET-negative patients and four cycles of BEACOPP in PET-positive patients); (4) six cycles of brentuximab vedotin, doxorubicin, vinblastine, dacarbazine (A-AVD) or ABVD as in the Echelon-1 trial; and (5) PET-adapted de-escalation (as in the AHL2011 trial, two cycles of BEACOPP followed by PET2 scan; PET-positive patients received two additional BEACOPP cycles and PET-negative patients received two cycles of ABVD; at PET4, PET-negative patients completed two further cycles of either ABVD or BEACOPP depending on what they received after PET2, and PET-positive patients received salvage therapy). Note that all uses of BEACOPP in these strategies were BEACOPP escalated . The randomised groups of interest from these studies comprised 4255 patients enrolled between April, 2000, and January, 2016. Baseline probability estimates and utilities were derived from the included trials in addition to a systematic review of published studies. A Canadian public health payer's perspective was considered (CAN$1=US$0·74) and adjusted for inflation for 2018. All costs and benefits were discounted by 1·5% per year because life-years now are more valuable than future potential life-years., Findings: Probabilistic analyses (10 000 simulations) showed that, for a willingness-to-pay threshold of CAN$50 000, a PET-adapted de-escalation strategy based on AHL2011 was more cost-effective 87% of the time. This strategy had the highest number of life-years (14·6 years [95% CI 13·7-15·1]) and quality-adjusted life years (13·2 years [95% CI 10·2-14·4]), and the lowest direct costs ($53 129 [95% CI 31 914-94 446]) compared with the other treatment regimens. Sensitivity analyses showed that the model was robust to key variables, including probability of treatment-related mortality, relapse, frequency of secondary malignancy, death from secondary malignancy, and probability of infertility after BEACOPP., Interpretation: Our results suggest that, when considering cost, effectiveness, and short and long-term toxicities, the preferred treatment strategy for patients with newly diagnosed advanced-stage Hodgkin lymphoma is the PET-adapted de-escalation regimen starting with BEACOPP and de-escalating to ABVD as appropriate. Although our findings do not provide an absolute best treatment approach for clinicians to follow for all patients, they can contribute to shared decision making between patients and treating physicians., Funding: None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Classic Hodgkin lymphoma (cHL) stands out as success story in the field of medical oncology, with multiagent chemotherapy with or without radiation leading to durable remission for most patients. Large-scale clinical trials during the past 40 years have sought to minimize toxicities while maintaining strong efficacy, including efforts to reduce the size of radiation fields, minimize alkylator chemotherapy, reduce the number of chemotherapy cycles, and omit radiation in select populations. The last decade has also ushered in novel therapies, including brentuximab vedotin (BV), that have improved clinical outcomes for patients with cHL resistant to standard cytotoxic therapies. More recently, a large randomized trial compared BV plus chemotherapy with chemotherapy alone for first-line treatment of advanced stage cHL. With ∼24 months of available follow-up, the BV containing regimen was found to be associated with a reduction in the risk of progression, death, or incomplete response to first-line treatment (modified progression-free survival). Whether this early signal of improved efficacy is worth the additional acute toxicities and added drug-related expenses associated with incorporating BV into first-line treatment remains controversial. This chapter provides historical background; reviews the cost-effectiveness of available cHL therapies; and summarizes potential ways to balance innovation, affordability, and patient access to novel therapeutics., Competing Interests: Conflict-of-interest disclosure: S.F.H. has received honoraria from Pharmacyclics; consulted for Bayer, Celgene, Genentech, and AbbVie; and received research funding from Celgene, DTRM Biopharma, Debiopharm, and TG Therapuetics., (© 2019 by The American Society of Hematology. All rights reserved.)

Hodgkin lymphoma is a highly curable disease with a peak incidence in young adulthood at times where education, family, and social relations are established. We performed a systematic literature review to assess the impact of Hodgkin lymphoma on the socioeconomic status of adolescent and adult survivors (including educational achievements, occupational aspects, marriage, and parenthood). In total, 39 articles were included. Overall, 26-36% of survivors perceived Hodgkin lymphoma as negatively affecting their socioeconomic status. Studies consistently found educational achievements in line with general population. Employment rates for survivors were comparable to the general population, but lower than before Hodgkin lymphoma diagnosis, with a post-diagnosis increase in disability pension and early retirement. Employed survivors encountered problems related to physical restrictions and recruitment. Marriage and parenthood were not substantially affected. In conclusion, current studies suggest acceptable socioeconomic outcomes following a Hodgkin lymphoma diagnosis but the use of standardized reporting methods hampers comparability across studies.

As part of its Single Technology Appraisal (STA) process, the National Institute for Health and Care Excellence (NICE) invited the manufacturer (Merck Sharp & Dohme; MSD) of pembrolizumab (Keytruda ® ) to submit evidence of its clinical and cost effectiveness for the treatment of patients with relapsed or refractory classical Hodgkin lymphoma (RRcHL) who did not respond to treatment with brentuximab vedotin. Kleijnen Systematic Reviews Ltd, in collaboration with Maastricht University Medical Centre+, was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a detailed review of the evidence for the clinical and cost effectiveness of the technology, based on the company's submission to NICE. According to the NICE scope, pembrolizumab was compared with single or combination chemotherapy. Comparisons were undertaken in two populations: patients who did and did not receive prior autologous stem cell transplant (autoSCT; populations 1 and 2, respectively). Despite it having been recommended by NICE in population 1 at the time the ERG received the company submission, nivolumab was not included as a comparator. No studies directly comparing pembrolizumab and its comparators were identified. One ongoing, single-arm study of the efficacy and safety of pembrolizumab (KEYNOTE-087) and one comparative observational study (Cheah et al., 2016) were used to inform the comparative effectiveness of pembrolizumab and standard of care (SoC), using indirect comparisons in both populations. Almost all analyses showed significant PFS and overall response rate benefits for pembrolizumab versus SoC, but due to being based on indirect comparison, were likely to contain systematic error. The economic evaluation therefore suffered from substantial uncertainty in any estimates of cost effectiveness. Furthermore, there was a lack of evidence on the uptake and timing of allogeneic stem cell transplant, and alternative assumptions had a significant impact on cost effectiveness. Immature survival data from KEYNOTE-087 exacerbated this issue and necessitated the use of alternative data sources for longer-term extrapolation of survival. Some issues identified in the company's analyses were amended by the ERG. The revised ERG deterministic base-case incremental cost-effectiveness ratios based on the company's second Appraisal Consultation Document response for pembrolizumab versus SoC (with a commercial access agreement) for populations 1 and 2 were £54,325 and £62,527 per quality-adjusted life-year gained, respectively. There was substantial uncertainty around these ICERs, especially in population 2. NICE did not recommend pembrolizumab as an option for treating RRcHL in population 1, but recommended pembrolizumab for use within the Cancer Drugs Fund in population 2.

Introduction : Outcomes of patients with classical Hodgkin lymphoma are excellent, and the intent of frontline therapy for even advanced-stage disease has been curative. This review summarizes the role of brentuximab vedotin in the upfront treatment of advanced stage classical Hodgkin lymphoma in the context of reducing therapy-related toxicity without compromising the high cure rate. Areas covered : Strategies to reduce bleomycin-induced lung toxicity include a response-adapted approach investigated in the RATHL study and a replacement of bleomycin with brentuximab vedotin in frontline chemotherapy regimens. In both studies, omission of bleomycin in the non-standard arms decreased the rate of pulmonary toxicity while maintaining high progression-free survival and overall survival rates. Expert opinion : The approval of A+AVD in North America offers a new bleomycin-free regimen for the treatment of advanced-stage HL, but it must be balanced against a risk-adapted approach. Recently presented subset analyses raise a question about which patients benefit most from this therapy.

We performed a survey in Hodgkin lymphoma survivors to learn more about their perspectives on treatment risks and benefits. We sent questions to 1149 survivors from the GHSG's HD13-15 trials with ( N  = 249) or without ( N  =900) documented progression or relapse. The participation rate was 52% ( N  =581). After median follow-up of 106 months, 40% of relapse-free and over 60% of relapsed survivors were still worried about late effects and the possibility of relapse. Chemotherapy, largely independent of its intensity, had been a strain on 74% of relapse-free and 90% of relapsed survivors. Most physical, psychological, and socio-economic sequelae were more frequent among relapsed survivors ( p  < .05) and described as very burdensome. 74% of relapse-free and 61% of relapsed survivors considered primary cure from Hodgkin lymphoma as the most important aspect in the choice of treatment. Accordingly, primary optimal lymphoma control is of utmost importance from the patients' perspective.

Purpose: Improvements in childhood survival rates have been achieved in low- and middle- income countries that have made a commitment to improve access to cancer care. Accurate data on the costs of delivering cancer treatment in these settings will allow ministries of health and donors to accurately assess and plan for expansions of access to care. This study assessed the financial cost of treating two common pediatric cancers, nephroblastoma and Hodgkin lymphoma, at the Butaro Cancer Center of Excellence in rural Rwanda., Methods: A microcosting approach was used to calculate the per-patient cost for Hodgkin lymphoma and nephroblastoma diagnosis and treatment. Costs were analyzed retrospectively from the provider perspective for the 2014 fiscal year. The cost per patient was determined using an idealized patient receiving a full course of treatment, follow-up, and recommended social support in accordance with the national treatment protocol for each cancer., Results: The cost for a full course of treatment, follow-up, and social support was determined to be between $1,490 and $2,093 for a patient with nephroblastoma and between $1,140 and $1,793 for a pediatric patient with Hodgkin lymphoma., Conclusion: Task shifting, reduced labor costs, and locally adapted protocols contributed to significantly lower costs than those seen in middle- or high-income countries.

Socioeconomic status (SES) is a well-known determinant of outcomes in cancer. The purpose of this study was to analyze the impact of the SES on the outcomes of Hodgkin lymphoma (HL) patients from the Brazilian Prospective HL Registry. SES stratification was done using an individual asset/education-based household index. A total of 624 classical HL patients with diagnosis from January/2009 to December/2014, and treated with ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine), were analyzed. The median follow-up was 35.6 months, and 33% were classified as lower SES. The 3-year progression- free survival (PFS) in higher and lower SES were 78 and 64% (p < 0.0001), respectively. The 3-year overall survival (OS) in higher and lower SES were 94 and 82% (p < 0.0001), respectively. Lower SES patients were more likely to be ≥ 60 years (16 vs. 8%, p = 0.003), and to present higher risk International Prognostic score (IPS) (44 vs. 31%, p = 0.004) and advanced disease (71 vs. 58%, p = 0.003). After adjustments for potential confounders, lower SES remained independently associated with poorer survival (HR = 3.12 [1.86-5.22] for OS and HR = 1.66 [1.19-2.32] for PFS). The fatality ratio during treatment was 7.5 and 1.3% for lower and higher SES (p = 0.0001). Infections and treatment toxicity accounted for 81% of these deaths. SES is an independent factor associated with shorter survival in HL in Brazil. Potential underlying mechanisms associated with the impact of SES are delayed diagnosis and poorer education. Educational and socio-economic support interventions must be tested in this vulnerable population., (© 2017 UICC.)

Objectives: Although brentuximab vedotin (BV) has changed the management of patients with relapsed or refractory Hodgkin lymphoma (RRHL), little information is available on routine clinical practice. We identified treatment patterns and costs of care among RRHL patients in the United States (US) treated with BV., Methods: A retrospective observational study of adults initiating BV for RRHL from 2011-2015, with ≥6 months of data prior to and following BV initiation, was conducted. Treatments were classified based on dispensations and chemotherapy administration. Median total and monthly costs were estimated based on all-cause healthcare resource use in 2015 US dollars (USD)., Results: The cohort comprised 289 patients (59% male; mean age at diagnosis, 42 years) with a mean follow-up of 250 weeks. Eleven percent had BV salvage therapy prior to ASCT, and 32% had BV for a relapse post-ASCT. 43% received treatment post-BV, most commonly allogeneic stem cell transplant (SCT) and bendamustine (both 10.2%). Median (IQR) total costs from BV initiation to censoring were 294,790 (142,110-483,360) USD; and were highest among those treated with BV prior to ASCT (up to 421,900 [300,940-778,970] USD). Median monthly costs were almost 20,000 USD per month, and up to 25,000 USD per month among those with BV and ASCT. Medications were the greatest driver of median monthly costs., Conclusions: Median total all-cause costs were almost 300,000 USD, and median monthly costs approximately 20,000 USD, per patient treated. Patients requiring treatment following BV continue to incur high costs, highlighting the economic burden associated with managing patients in the RRHL setting.

Background: Previous studies documented racial/ethnic and socioeconomic disparities in survival after Hodgkin lymphoma among adolescents and young adults (AYA), but did not consider the influence of combined-modality treatment and health insurance., Methods: Data for 9,353 AYA patients ages 15 to 39 years when diagnosed with Hodgkin lymphoma during 1988 to 2011 were obtained from the California Cancer Registry. Using multivariate Cox proportional hazards regression, we examined the impact of sociodemographic characteristics [race/ethnicity, neighborhood socioeconomic status (SES), and health insurance], initial combined-modality treatment, and subsequent cancers on survival., Results: Over the 24-year study period, we observed improvements in Hodgkin lymphoma-specific survival by diagnostic period and differences in survival by race/ethnicity, neighborhood SES, and health insurance for a subset of more recently diagnosed patients (2001-2011). In multivariable analyses, Hodgkin lymphoma-specific survival was worse for Blacks than Whites with early-stage [HR: 1.68; 95% confidence interval (CI): 1.14-2.49] and late-stage disease (HR: 1.68; 95% CI, 1.17-2.41) and for Hispanics than Whites with late-stage disease (HR: 1.58; 95% CI, 1.22-2.04). AYAs diagnosed with early-stage disease experienced worse survival if they also resided in lower SES neighborhoods (HR: 2.06; 95% CI, 1.59-2.68). Furthermore, more recently diagnosed AYAs with public health insurance or who were uninsured experienced worse Hodgkin lymphoma-specific survival (HR: 2.08; 95% CI, 1.52-2.84)., Conclusion: Our findings identify several subgroups of Hodgkin lymphoma patients at higher risk for Hodgkin lymphoma mortality., Impact: Identifying and reducing barriers to recommended treatment and surveillance in these AYAs at much higher risk of mortality is essential to ameliorating these survival disparities., (©2016 American Association for Cancer Research.)

Background: The association between insurance status and outcomes has not been well established for patients with Hodgkin lymphoma (HL). The purpose of this study was to examine the disparities in overall survival (OS) by insurance status in a large cohort of patients with HL., Methods: The National Cancer Data Base (NCDB) was used to evaluate patients with stage I to IV HL from 1998 to 2011. The association between insurance status, covariables, and outcomes was assessed in a multivariate Cox proportional hazards model. Survival was estimated with the Kaplan-Meier method., Results: Among the 76,681 patients within the NCDB, 45,777 patients with stage I to IV HL were eligible for this study (median follow-up, 6.0 years). The median age was 39 years (range, 18-90 years). The insurance status was as follows: 3247 (7.1%) were uninsured, 7962 (17.4%) had Medicaid, 30,334 (66.3%) had private insurance, 3746 (8.2%) had managed care, and 488 (1.1%) had Medicare. Patients with an unfavorable insurance status (Medicaid/uninsured) were at a more advanced stage, had higher comorbidity scores, had B symptoms, and were in a lower income/education quartile (all P < .01). These patients were less likely to receive radiotherapy and start chemotherapy promptly and were less commonly treated at academic/research centers (all P < .01). Patients with unfavorable insurance had a 5-year OS of 54% versus 87% for those favorably insured (P < .01). When adjustments were made for covariates, an unfavorable insurance status was associated with significantly decreased OS (hazard ratio, 1.60; 95% confidence interval, 1.34-1.91; P < .01). The unfavorable insurance status rate increased from 22.8% to 28.8% between 1998 and 2011., Conclusions: This study reveals that HL patients with Medicaid and uninsured patients have outcomes inferior to those of patients with more favorable insurance. Targeting this subset of patients with limited access to care may help to improve outcomes. Cancer 2015;121:3435-43. © 2015 American Cancer Society., (© 2015 American Cancer Society.)

The data on the pharmacoeconomic research of the use of Remaxol in treatment of drug-associated liver injury due to the chemotherapy in cancer patients are presented. The costs-efficiency method was applied to two groups of the patients with drug-associated liver injury treated according to different schemes. The research showed economical benefits of the Remaxol use.

Background: The objective of this study was to compare the outcomes of patients with classical Hodgkin lymphoma (cHL) who achieved complete remission with frontline therapy and then underwent either clinical surveillance or routine surveillance imaging., Methods: In total, 241 patients who were newly diagnosed with cHL between January 2000 and December 2010 at 3 participating tertiary care centers and achieved complete remission after first-line therapy were retrospectively analyzed. Of these, there were 174 patients in the routine surveillance imaging group and 67 patients in the clinical surveillance group, based on the intended mode of surveillance. In the routine surveillance imaging group, the intended plan of surveillance included computed tomography and/or positron emission tomography scans; whereas, in the clinical surveillance group, the intended plan of surveillance was clinical examination and laboratory studies, and scans were obtained only to evaluate concerning signs or symptoms. Baseline patient characteristics, prognostic features, treatment records, and outcomes were collected. The primary objective was to compare overall survival for patients in both groups. For secondary objectives, we compared the success of second-line therapy and estimated the costs of imaging for each group., Results: After 5 years of follow-up, the overall survival rate was 97% (95% confidence interval, 92%-99%) in the routine surveillance imaging group and 96% (95% confidence interval, 87%-99%) in the clinical surveillance group (P = .41). There were few relapses in each group, and all patients who relapsed in both groups achieved complete remission with second-line therapy. The charges associated with routine surveillance imaging were significantly higher than those for the clinical surveillance strategy, with no apparent clinical benefit., Conclusions: Clinical surveillance was not inferior to routine surveillance imaging in patients with cHL who achieved complete remission with frontline therapy. Routine surveillance imaging was associated with significantly increased estimated imaging charges., (© 2014 American Cancer Society.)

Objective: Estimating the cost-effectiveness of 18FDG-PET/CT (positron emission tomography) compared to computer tomography (CT) followed by 18FDG-PET/CT as a confirmatory test for a positive case at the end of treatment in Hodgkin's lymphoma (HL) patients under 18 years-old., Methods: A decision tree was built for comparing 18FDG-PET/CT to CT followed by 18FDG-PET/CT as a confirmatory test for a positive case in detecting residual lesions; outcome was measured in life years gained (LYG). The cost-effectiveness ratio was calculated; the threshold was 3 times the per capita GDP per LYG. Values were expressed in Colombian pesos for 2010 (1 US dollar=$ 1,897.89) and submitted to deterministic and probabilistic sensitivity analysis., Results: Assuming a difference of 13 months in true positives' life expectancy compared to that for false negatives, the cost of an additional LYG with 18FDG-PET/CT compared to CT followed by 18FDG-PET/CT as a confirmatory test for a positive case when evaluating the end of pediatric HL patients' treatment was $ 34,508,590 (COP)., Conclusion: If differential life-expectancy between true positives and false negatives is at least 1.03 years, then using 18FDG-PET/CT for evaluating the end of HL pediatric patients' therapy is a cost-effective strategy for Colombia.

There is no consensus regarding optimal follow-up mode for Hodgkin lymphoma (HL) patients that achieve complete remission following chemotherapy or combined chemo- and radiation therapy. Several studies demonstrated high sensitivity of positron emission tomography/computerized tomography (PET/CT) in detecting disease progression; however, these techniques are currently not recommended for routine follow-up. This retrospective study conducted in two Israeli (N = 291) and one New Zealand academic centres (N = 77), compared a group of HL patients, followed-up with routine imaging every 6 months during the first 2 years after achieving remission, once in the third year, with additional dedicated studies performed due to symptoms or physical findings (Group I) to a group of patients without residual masses who underwent clinically-based surveillance with dedicated imaging upon relapse suspicion (Group II). Five-year overall survival (OS) was 94% and median time to relapse was 8·6 months for both modes. Relapse rates in Groups I and II were 13% and 9%, respectively. During the first 3 years of follow-up, 47·5 and 4·7 studies were performed per detected relapse in Groups I and II, respectively. The current study demonstrated no benefit in either progression-free survival (PFS) or OS in HL patients followed by routine imaging versus clinical follow-up. The cost was 10 times higher for routine imaging., (© 2013 John Wiley & Sons Ltd.)

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

Background: Hodgkin lymphoma (HL) is one of the most common types of cancer among adolescents and young adults (AYAs) in the United States. Unfortunately, a greater percentage of AYAs are presenting with an advanced stage of disease at the time of diagnosis compared with their younger counterparts., Methods: The objective of the current study was to examine the association between possible barriers and characteristics (including gender, race, birthplace, marital status, socioeconomic status [SES], and insurance status) that may increase the risk of advanced stage HL at the time of diagnosis in a large cohort of AYA patients with HL from the California Cancer Registry (7343 incident cases of HL diagnosed from 1988-2006, between ages 15 years-40 years)., Results: AYAs with advanced stage HL were more likely to be male, of Hispanic or black race/ethnicity, foreign born, single, of lower SES, and uninsured or to have only public health insurance (P < .05). Multivariate logistic regression analysis demonstrated that there was a significant increase in the odds of having advanced HL in males (odds ratio [OR], 1.57; 95% confidence interval [95% CI], 1.42-1.74 [P < .0001]), those with the lowest SES (OR, 1.47; 95% CI, 1.23-1.75 [P = .0003]), those without health insurance (OR, 1.76; 95% CI, 1.34-2.31 [P < .0001]), and those with public health insurance (OR, 1.45; 95% CI, 1.23-1.71 [P < .0001])., Conclusions: A strong association was found between male gender, lower SES, and lack of health insurance and advanced stage HL at the time of diagnosis in AYAs (See editorial on pages 000-000, this issue.)., (Copyright © 2012 American Cancer Society.)

Using a questionnaire study, we compared the employment and insurance of Hodgkin lymphoma (HL) survivors versus their siblings. A total of 511 survivors and 224 siblings completed questionnaires. HL survivors were more likely to report job denial, difficulty obtaining insurance due to medical history, and difficulty changing jobs due to fear of losing insurance. On multivariable analysis, male gender, income and scarring of the head and neck were associated with job denial. Male gender and impairment interfering with a job were associated with difficulty obtaining health insurance. Survivors with >4 physician visits in 2 years, <10years from diagnosis, or with permanent hair loss from treatment were more likely to report inability to change jobs due to fear of losing insurance. Compared to their siblings, HL survivors may face greater challenges in obtaining employment and insurance. Late effects from treatment, including permanent cosmetic changes, may contribute to these differences.

Although patients with Hodgkin lymphoma treated with adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy frequently develop neutropenia, febrile neutropenia is uncommon. Three retrospective trials reported that ABVD could be safely administered without dose delays or granulocyte-colony stimulating factor (G-CSF) support. We retrospectively reviewed the charts of 89 patients treated with ABVD and found that the incidence of febrile neutropenia was 0.5% (five of 927 treatments). This prompted a change to our institutional policy so that patients receiving ABVD no longer receive routine G-CSF for uncomplicated neutropenia. We then prospectively assessed the safety of this policy change. Thirty-three patients received a total of 327 ABVD treatments, 185 (57%) of which were administered with a neutrophil count <1.5 × 10(9)/L. Febrile neutropenia occurred in 2/33 patients (6%), complicating 0.6% of chemotherapy treatments (2/327). Eliminating routine G-CSF saved $10 241 per patient. Omission of G-CSF for uncomplicated neutropenic patients receiving ABVD for Hodgkin lymphoma is cost-saving and safe.

Background: The majority of patients with Hodgkin lymphoma (HL) achieve disease remission after primary therapy. To the best of the authors' knowledge, no consensus exists for postremission surveillance imaging., Methods: Retrospectively analyzed were 192 adult patients with classic HL in first remission. Events were defined as recurrent HL or secondary malignancies. Primary outcome was positive predictive value (PPV) of surveillance positron emission tomography/computed tomography (PET/CT) and CT scans in event detection. Secondary outcomes were costs and radiation exposures of surveillance scans., Results: Sixteen events (12 recurrent HL cases and 4 secondary malignancies) were detected during a median follow-up of 31 months. The PPV of surveillance PET/CT was 22.9% compared with 28.6% for CT (P=.73). Factors that were found to significantly improve the PPV of scans in detecting recurrent HL included PET and CT concordance, involvement of a prior disease site, or the occurrence of a radiographic abnormality within 12 months. There were too few events to determine whether event detection by PET/CT versus CT or the presence of symptoms at the time of event detection affected overall outcomes. The cost to detect a single event was approximately $100,000. Radiation exposure to detect a single event was 146.6 millisieverts per patient for each of 9 patients., Conclusions: For patients with HL in first disease remission, surveillance radiography appears to be expensive, with limited clinical impact. Surveillance CT is generally adequate., (Copyright (c) 2010 American Cancer Society.)

Purpose: To assess the cost effectiveness of fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with Hodgkin's lymphoma (HL) with unconfirmed complete remission (CRu) or partial remission (PR) after first-line treatment., Patients and Methods: One hundred thirty patients with HL were prospectively studied. After treatment, all patients with CRu/PR were evaluated with FDG-PET. In addition, PET-negative patients were evaluated with standard follow-up, and PET-positive patients were evaluated with biopsies of the positive lesions. Local unit costs of procedures and tests were evaluated. Cost effectiveness was determined by evaluating projected annual economic impact of strategies without and with FDG-PET on HL management., Results: After treatment, CRu/PR was observed in 50 (40.0%) of the 127 patients; the sensitivity, specificity, and positive and negative predictive values of FDG-PET were 100%, 92.0%, 92.3%, and 100%, respectively (accuracy of 95.9%). Local restaging costs without PET were $350,050 compared with $283,262 with PET, a 19% decrease. The incremental cost-effectiveness ratio is -$3,268 to detect one true case. PET costs represented 1% of total costs of HL treatment. Simulated costs in the 974 patients registered in the 2008 Brazilian public health care database showed that the strategy including restaging PET would have a total program cost of $56,498,314, which is $516,942 less than without restaging PET, resulting in a 1% cost saving., Conclusion: FDG-PET demonstrated 95.9% accuracy in restaging for patients with HL with CRu/PR after first-line therapy. Given the observed probabilities, FDG-PET is highly cost effective and would reduce costs for the public health care program in Brazil.

Survival after Hodgkin lymphoma (HL) is generally favorable, but may vary by patient demographic characteristics. The authors examined HL survival according to race/ethnicity and neighborhood socioeconomic status (SES), determined from residential census-block group at diagnosis. For 12,492 classical HL patients ≥ 15 years diagnosed in California during 1988-2006 and followed through 2007, we determined risk of overall and HL-specific death using Cox proportional hazards regression; analyses were stratified by age and Ann Arbor stage. Irrespective of disease stage, patients with lower neighborhood SES had worse overall and HL-specific survival than patients with higher SES. Patients with the lowest quintile of neighborhood SES had a 64% (patients aged 15-44 years) and 36% (≥ 45 years) increased risk of HL-death compared to patients with the highest quintile of SES; SES results were similar for overall survival. Even after adjustment for neighborhood SES, blacks and Hispanics had increased risks of HL-death 74% and 43% (15-44 years) and 40% and 17% (≥ 45 years), respectively, higher than white patients. The racial/ethnic differences in survival were evident for all stages of disease. These data provide evidence for substantial, and probably remediable, racial/ethnic and neighborhood SES disparities in HL outcomes.

The aim of this study is to assess the effects of Positron Emission Tomography (PET) associated with computed tomography (CT) on resource allocation (costs and savings) of the following treatment in radiotherapy for non small cell lung cancers (NSCLC) and Hodgkin's diseases. A national prospective study was conducted in nine hospitals. Two treatment decisions made on the basis of CT only or on PET associated with, were compared in a before-after design. The direct medical cost of using PET was assessed by micro-costing. The costs of new exams and the costs and savings associated with changes in the chosen treatment were calculated on the basis of reimbursement rates. The economic study was conducted over 2 years and included 209 patients (97 patients with Hodgkin's disease and 112 with NSCLC). The mean cost of using PET, corresponding to an extra cost, was approximately 800 euro (50% for the radionuclide FDG). Radiotherapy treatments were modified for only 10% of patients with Hodgkin's disease with a minor impact on treatment costs versus 40% of patients with lung cancer with a reduction in mean treatment cost of more than 500 euro.

Hodgkin lymphoma (HL) is a common B-cell childhood neoplasm and it has a higher incidence in the 0-14 year age group in developing countries compared to developed countries. Treatment achieves a cure rate of about 80%. In African countries with a small gross domestic product per capita the cost of treating HL in children may be prohibitive. To determine the direct costs of treatment of HL in South Africa and to propose a more cost-effective approach to investigation and treatment for children diagnosed with HL in Africa, tumor registry data for 138 children with HL from two South African hospitals were analysed retrospectively. The cost of treatment for stage 2 disease was calculated, including investigations and chemotherapy. The analysis included the cost of a follow-up period of 2 years. Stage 2 was the most common stage seen, and ABVD protocol was the most common protocol used. The total cost of diagnosing, staging, treating with chemotherapy and following up a child with stage 2 HL for 2 years post-therapy was ZAR 53178.20 = USD 6647.27 = EUR 4431.51. Follow-up expenditure was much higher than initial chemotherapy costs. The major factors driving the cost for the whole group of 138 patients were as follows: stage, radiologic imaging, radiotherapy, second-line chemotherapy, hospitalisation and febrile neutropenia. The total cost of treatment of HL is affordable for first world countries, but it remains expensive for developing countries, especially in Africa where the GDP is often under USD 2000 per head. Early diagnosis, use of less toxic protocols such as ABVD, close monitoring to prevent complications and elimination of unnecessary tests and investigations may reduce the overall cost.

We reviewed the outcome of 24 patients with early and advanced stage Hodgkin lymphoma (HL) treated with ABVD chemotherapy (263 treatment deliveries) without the use of G-CSF over a 3-year period. Patients received full dose ABVD regardless of the absolute neutrophil count (ANC) on the day of treatment if there were no other cytopenias or toxicities. Forty-eight percent of treatment deliveries were given with an ANC <1.0 x 10(9)/L and 18% with an ANC <0.5 x 10(9)/L. Four patients required drug omissions (vinblastine or bleomycin) due to non-hematological side-effects. The rate of neutropenic sepsis was 0.76%. At a median follow up of 17.5 months, one patient had progressive disease requiring intensive treatment and the remainder were in remission post-treatment. Overall survival and event-free survival were 95.8% and 91.7%, respectively. We estimate a saving of 60,000 pounds in pharmaceutical and nursing expenditure related to G-CSF; a saving of 2000 pounds per patient. We conclude that full dose ABVD can be administered to patients with early and advanced stage HL irrespective of isolated neutropenia on the planned treatment day without prophylactic G-CSF or antibiotics and that this practise is safe, efficacious and cost-saving.

Objectives: Positron emission tomography (PET) is an innovative imaging tool. Associated with computed tomography (CT), it allows a better definition for the tumor volume for radiotherapy, compared with CT only. The aim of this study was to assess the effects of PET on resource allocation (costs and savings) and on the choice of the following treatment in radiotherapy., Methods: In 2004 and 2005, 209 patients were enrolled (97 patients with Hodgkin's disease and 112 with non-small cell lung cancer) in a national study conducted in eight hospitals. Two treatment decisions made on the basis of CT only or CT associated with PET, were compared in a prospective study where each subject was his/her own control. The direct medical cost of using PET was assessed by microcosting, using data collected from specific questionnaires. The costs of new tests and the costs and savings associated with changes in the chosen treatment were calculated on the basis of reimbursement rates., Results: The mean cost of using PET was approximately euro 800 per patient (50 percent for the radionuclide 18F-FDG [2-[18F]fluoro-2-deoxy-D-glucose]). Radiotherapy treatments were modified for 10 percent of patients with Hodgkin's disease versus 40 percent of patients with lung cancer. Overall, the use of PET induced both increases and decreases in the mean cost per patient: the net effect was a euro 425 and euro 931 cost increase in lung cancer and Hodgkin's disease, respectively., Conclusions: The use of PET for radiotherapy decision making seems more valuable for lung cancer than for Hodgkin's disease, both in terms of costs and changes in radiotherapy treatment. This result might help policy makers for prioritization.

Objective: Given the potential to limit cost, we conducted a pilot study evaluating delayed, low-dose granulocyte colony-stimulating factor (G-CSF) following chemotherapy for the procurement of peripheral blood progenitor cells (PBPCs) for autologous transplantation and reviewed the relevant literature., Patients and Methods: Twenty-eight patients with various malignancies received cyclophosphamide 4 gm/m(2) and paclitaxel 170 mg/m2 followed by G-CSF 300 microg/d or 480 microg/d starting day +5 until two to four daily large volume leukapheresis yielded > or =5.0 x 10(6) CD34+ cells. We searched MEDLINE, Pubmed, and EMBASE databases from 1990 to the present to identify papers on PBPC procurement using delayed G-CSF (starting day +4 or later) following chemotherapy., Results: G-CSF was administered for a median of 9 days at an average cost of 1260 USD per 70-kg patient. Collection was initiated at a median of 12 days after chemotherapy. A median 2.5 (range 2-4) apheresis were performed yielding an average daily CD34+ collection of 6.9 x 10(6)/kg (range 0.35-56.7). After one apheresis, 82% and 57% of patients collected > or =2.5 x 10(6)/kg and > or =5.0 x 10(6)/kg, respectively. Ultimately, 89% collected > or =5.0 x 10(6)/kg. Febrile neutropenia and catheter-related infection developed in five and two patients, respectively. All patients proceeded to transplantation and engrafted successfully with a median of 14.9 x 10(6)/kg (range 1.05-113) cells infused. Eleven published reports were identified involving 590 patients of whom 498 received G-CSF at a dose range of 250 microg/d to 10 microg/kg/d starting day +4 to 15 for a period of 4 to 9 days for PBPC procurement. Among these reports, 62 to 100% and 33 to 96% of patients collected > or =2 to 2.5 x 10(6) and > or =5.0 x 10(6) CD34+ cells, respectively., Conclusion: The use of delayed, low-dose G-CSF plus chemotherapy for stem cell mobilization was feasible and provides further evidence supporting this potentially cost-effective strategy. A review of the literature supports our findings and emphasizes the need for larger studies to address this issue.

Purpose: To estimate the clinical benefits and cost effectiveness of computed tomography (CT) in the follow-up of patients with complete response (CR) after treatment for Hodgkin's disease (HD)., Patients and Methods: We developed a decision-analytic model to evaluate follow-up strategies for two hypothetical cohorts of 25-year-old patients with stage I-II or stage III-IV HD, treated with doxorubicin, bleomycin, vinblastine, and dacarbazine-based chemotherapy with or without radiation therapy, respectively. We compared three strategies for observing asymptomatic patients after CR: routine annual CT for 10 years, annual CT for 5 years, or follow-up with non-CT modalities only. We used Markov models to calculate life expectancy, quality-adjusted life expectancy, and lifetime costs. Baseline probabilities, transition probabilities, and utilities were derived from published studies. Cost data were derived from the Medicare fee schedule and medical literature. We performed sensitivity analyses by varying baseline estimates., Results: Annual CT follow-up is associated with minimal survival benefit. With adjustments for quality of life, we found a decrement in quality-adjusted life expectancy for early-stage patients followed with CT compared with non-CT modalities. Sensitivity analyses showed annual CT for 5 years becomes more effective than non-CT follow-up if the specificity of CT is 80% or more or if the disutility associated with a false-positive CT result is less than 0.01 quality-adjusted life years (QALYs). For advanced-stage patients, annual CT for 5 years is associated with a very small quality-adjusted survival gain over non-CT follow-up with an incremental cost-effectiveness ratio of 9,042,300 dollars/QALY., Conclusion: Our analysis suggests that routine CT should not be used in the surveillance of asymptomatic patients in CR after treatment for HD.

In 80% of cases Hodgkin's disease is curable following standard chemotherapeutical regimens. Remaining patients require additional chemotherapy, radiotherapy, bone marrow transplantation and even salvage treatment. Patient treatment costs during I, II, and subsequent lines of chemotherapy were evaluated. Patients were divided into three groups. The first group comprised patients who received first-line therapy, and became cured. The second group comprised patients who received first-line therapy, did not achieve cure, were treated by second-line therapy, which proved successful (in four patients including bone marrow transplantation) and were cured afterwards. The third group comprised patients who were not cured, despite one administration of consecutive treatment regimens. They either are surviving with active disease or they have deceased. The total treatment cost was the lowest in 1st group, amounting to the average of 8.356 euro. The highest treatment cost was found in group III amounting the average of 37.159 euro. Treatment costs were influenced by the hospitalization period ((1/3)-(1/2) of the total cost). In the case of disease recurrence following autologous bone marrow transplantation, additional chemotherapy increased costs to 75.484 euro.

Hodgkin's lymphoma occurrence has long been noted to associate with higher socioeconomic status (SES). However, the Hodgkin's lymphoma-SES association has not been examined recently or across important, possibly etiologically distinct, patient subgroups. In approximately 150 million person-years of observation in the multiethnic population of California, we examined the association of Hodgkin's lymphoma incidence with a composite measure of neighborhood-level SES in patient subgroups defined by age, sex, race/ethnicity, and Hodgkin's lymphoma histologic subtype. Using population-based cancer registry data on 3,794 Hodgkin's lymphoma patients diagnosed 1988 to 1992 and 1990 census data, we assigned a previously validated, multidimensional SES index to census block groups of patient residence. We then calculated neighborhood SES-specific incidence rates and estimated rate ratios using Poisson regression. Positive neighborhood SES gradients in Hodgkin's lymphoma incidence were observed only in young adults (ages 15-44 years at diagnosis) with nodular sclerosis Hodgkin's lymphoma and older adult (ages > or =45 years) White and Hispanic males with mixed cellularity Hodgkin's lymphoma. For young adults, associations were marked in Hispanic and Asian women, weaker in Hispanic and White men and White women, and subtle to nonexistent in Blacks and Asian men. Neighborhood SES gradients in Hodgkin's lymphoma incidence varied by age, sex, race/ethnicity, and histologic subtype, underscoring etiologic complexity in Hodgkin's lymphoma. Racial/ethnic gradients were not entirely explained by neighborhood SES. In California, etiologically relevant exposures for young adult Hodgkin's lymphoma, the most common form, could associate more with race/ethnicity or foreign birthplace than neighborhood SES and may be modified by reproductive or other sex-specific factors.

A total of 10-40% of patients with Hodgkin's disease relapse following initial curative therapy. Intensive follow-up is resource intensive and may identify false relapses. We performed a retrospective review of all patients with Hodgkin's disease treated at our centre between 1990 and 1999 to evaluate the utility of the components of follow-up. A total of 107 patients met the inclusion and exclusion criteria. The median age was 33 years and the median duration of follow-up 38 months. The total number of follow-up visits was 1209 and total number of CT scans 283. There were 109 suspected relapses of which 22 proved to be true relapses. Of the latter, 14 were identified clinically, six radiologically and two via lab testing. The routine CT scan detected only two relapses (9%), yet accounted for 29% of the total follow-up costs. Based on data from our centre, the cost per true relapse was $6000 US, 49% incurred by radiological tests. The majority of the cost of follow-up was incurred by routine follow-up (84%) as opposed to the investigation of suspected relapses (16%). We conclude that most true relapses are clinically symptomatic and that the routine CT is an expensive and inefficient mode of routine follow-up.

Purpose: Using a cost-effectiveness analysis, to weigh the costs and benefits of the different staging and treatment options in early-stage Hodgkin's disease., Methods: We constructed a decision-analytic model for a hypothetical cohort of 25-year-old patients with early-stage Hodgkin's disease. Markov models were used to simulate the lifetime costs and prognosis of each staging and treatment strategy. Baseline probabilities and cost estimates were derived from published studies and bills of relevant patient cohorts., Results: Among the six management strategies considered, the incremental cost-effectiveness ratio of laparotomy and tailored treatment compared with mantle and para-aortic-splenic radiation therapy in all clinical stage I-II patients was $24,100/quality-adjusted life year, while that of the strategy of combined modality therapy in all clinical stage I-II patients compared with laparotomy was $61,700/quality-adjusted life year. All the remaining strategies were dominated by one of these three strategies. Sensitivity analysis showed that the cost-effectiveness ratios were driven predominantly by the effectiveness rather than the cost of each strategy. In particular, the analysis was heavily influenced by the utility of the post-laparotomy health state., Conclusions: In considering the various alternative management strategies in early-stage Hodgkin's disease, even very small gains in effectiveness were enough to justify the additional costs of more expensive treatment options.

Patients receiving chemotherapy for Hodgkin's disease can potentially be treated in the out-patient department. In spite of this the proportion of patients receiving the chemotherapy on in-patient departments is 54% per chemotherapy cycle in average in the HD6 trial for advanced Hodgkin's disease of the German Hodgkin Study Group (GHSG). The aim of this retrospective analysis is to identify the set of parameters which influence the decision of in- or out-patient treatment for the patients in the HD6 trial. Parameters tested in the univariate analysis are the patient characteristics, the type of chemotherapy, toxicity and the type of treatment institution. The significant parameters are included in a logistic regression model. From this multivariate analysis the type of treatment institution turned out to be the most important factor in the decision of treatment setting. Restricting the analysis to university clinics, the treatment setting of the first two cycles is more influencial than patient dependent parameters.

As part of an NHS Executive Trent regional initiative we considered the role and cost-effectiveness of high dose chemotherapy in the treatment of relapsed Hodgkin's disease and non-Hodgkin's lymphoma. The key trials and case series show an additional patient benefit of 0.8-1.1 life years over standard chemotherapy. We estimate incremental cost per life year gained of 12 800 pound silver-17 600 pound silver, which reduces further if long-term benefits are considered. High dose chemotherapy in these conditions is both life-saving and cost-effective.

Purpose: To examine the costs and benefits of routine follow-up evaluation in patients treated with radiation therapy for early-stage Hodgkin's disease., Patients and Methods: We retrospectively examined patterns of follow-up evaluation and methods of relapse detection among 709 patients with stage I and II Hodgkin's disease treated with primary radiotherapy between 1969 and 1994. We determined the probability of relapse detection for seven routine follow-up procedures, compared their relative costs, and determined the impact of each procedure on the likelihood of survival following salvage therapy., Results: Relapse has occurred in 157 patients (22%) at a median 1.9 years (range, 0 to 13 years) posttreatment. Relapse was suspected primarily by history (Hx) in 55% of patients, physical examination (PE) in 14%, chest x-ray (CXR) in 23%, and abdominal x-ray (KUB) in 7%. Only one relapse (1%) was identified by a routine laboratory study. The rate of relapse detection was highest for a combination of Hx and PE (78 of 10,000 examinations) followed by CXR (26 of 10,000 examinations). The projected charges (1995 dollars) per relapse detected by routine follow-up Hx and PE were $11,000 compared with $68,000 for CXR and $142,000 for KUB. The 10-year actuarial survival rate following salvage therapy was 65% overall, 65% for patients in whom relapse was detected by Hx or PE, and 69% for patients in whom relapse was detected by radiographs (P = not significant)., Conclusion: The majority of relapses occurred within 5 years of treatment and were identified by Hx and PE. CXR was useful during the first 3 years of follow-up evaluation. KUB, CBC, and laboratory studies accounted for nearly half of all follow-up charges and rarely led to the detection of relapse. Their routine use as a method of relapse detection is questionable. In general, the method of relapse detection did not have a significant impact on the likelihood of successful salvage therapy.

The aim of this study was to estimate costs of treatment for Hodgkin's disease (HD) and the outcome in health in terms of quality-adjusted life-years (QALYs), and compare these to a constructed nontreatment alternative. All 55 patients treated for HD at the oncological unit of the University Hospital of Tromsø between 1985 and 1993 were included. The total treatment costs (medication, hospital stay, hospital hotel stay, radiotherapy, travelling, loss in production, i.e. work) were retrospectively estimated for all patients. In December 1994, the 49 survivors were sent a EuroQol questionnaire recording quality of life: 42 responded. The mean quality of life score was 0.78 on a 0-1 scale, and the mean total cost of treatment was pounds 12512. The total treatment costs were significantly higher in patients with advanced clinical stages of the disease (P = 0.0006), B-symptoms (fever, sweats, weight loss) (P = 0.0027) and relapse (P < 0.0001). The costs of one QALY (with production gains included and using a 10% discount rate) were estimated at pounds 1651. When excluding production gains and using a 5% discount rate, the figures became pounds 1327. This makes HD one of the most cost-effective malignancies to treat.

The objectives of this study were to compare the costs of managing lymphoma patients who underwent mini-BEAM salvage chemotherapy with G-CSF prophylactic support against a group of similar patients without growth factors. Methods used included: 1) A retrospective chart review was conducted to estimate the average length of hospitalization and resource consumption for the management of fever and neutropenia in the two groups of patients and 2) An economic analysis was then performed from a hospital perspective which considered only institutional resource utilization. Costs of antibiotic support and monitoring, lab tests as well as G-CSF were calculated. Results demonstrated that overall, patients who received prophylactic G-CSF after chemotherapy required 2 fewer hospital days compared to controls. The administration of G-CSF resulted in a savings of approximately $1580/patient relative to control. When the initial G-CSF expenditure was included in the analysis, the total net cost/patient was similar between the two groups. In conclusion, the results of the current study support the routine use of G-CSF in patients receiving salvage chemotherapy with mini-BEAM. The initial G-CSF expenditure would be offset by reduced hospitalization.

Patients with advanced lymphogranulomatosis were divided into two subgroups. One, including 9 patients was treated in the hospital, and the second, including 21 patients, was treated at out-patient department. Results of the treatment and its adverse reactions were not significantly different in patients treated on out-patient basis and in hospital. However, unfavourable effect of therapy on patient's psychological status (anxiety) was less expressed in out-patient conditions. Such a way of treatment enables also considerable savings related to the repeated hospitalizations.

Objective: To determine the clinical and economic effects of granulocyte macrophage colony-stimulating factor (GM-CSF) as adjunct therapy in relapsed or refractory Hodgkin disease., Design: A randomized, double-blind, phase III clinical trial., Setting: A tertiary referral center., Patients: Twenty-four patients (twelve of whom were controls) treated with high-dose chemotherapy and autologous bone marrow transplantation., Main Results: The 12 patients treated with GM-CSF, when compared with placebo recipients, had shorter periods of neutropenia (median duration of an absolute neutrophil count of less than 1000 cells/mm3, 16 days compared with 27 days; P = 0.02), shorter periods of platelet-transfusion dependency (median duration, 13.5 days compared with 21 days; P = 0.03), and shorter hospitalizations (median hospital stay, 32 days compared with 40.5 days; P = 0.004). Other clinical outcomes, such as frequency and severity of toxicities, development of pneumonia or infection, in-hospital death, and response rate were similar in the two groups. Actuarial long-term disease-free survival was 64% for patients treated with GM-CSF and 58% for patients who received placebo after 32 months of follow-up (P = 0.15). The group treated with GM-CSF had lower total charges after infusion of autologous marrow than the placebo group (median in-hospital charges, $39,800 compared with $62,500; P = 0.005) because of lower post-infusion charges for room and board, antibiotic therapy, transfusions, laboratory tests, and physical therapy visits., Conclusions: Administration of GM-CSF was associated with acceleration of myeloid and platelet recovery and was cost effective in the treatment of patients with relapsed Hodgkin disease who received intensive chemotherapy.

A clinical algorithm was developed for staging of Hodgkin disease. This represented the treatment logic employed in a specified time period and was used to categorize charges incurred in the staging of 50 consecutive patients who underwent this process at a university hospital. Charges were categorized as: necessary (in concordance with the algorithm), justifiable (a result of care for a separate medical disorder or for consideration of distance), and perceived excess (neither necessary nor justifiable). Thirty per cent of the total charges were identified as perceived excess. Hospitalization accounted for 68 per cent and laboratory charges 22 per cent of the perceived excess charges. Fifty-eight per cent of the patients had a percentage of perceived excess bed charges exceeding 30 per cent of the total. Perceived excess medical hospitalization correlated positively with time from diagnosis to treatment decision. It is recommended that attempts to reduce the expense of Hodgkin lymphoma staging be directed at decreasing hospitalization.

The socioeconomic impact of procedures used in the treatment for Hodgkin's disease was studied on the basis of follow-up data. The first-year costs appeared maximal, viz. approximately 3904.78 rubles per patient. The cost effectiveness of the first-, first two- and first three-year treatment was 8.2, 4.8 and 3.5 higher than the overall costs, respectively. Comparison of costs of treatment and maintenance of the whole of patients with the expected cost effectiveness assuring that at least one-third of rehabilitated patients resume working showed the latter parameter to exceed the overall costs by 1.4 times.