Applied Health Economics and Health Policy

, Volume 14, Issue 4, pp 465–477 | Cite as

Cost-Effectiveness Analysis of Bendamustine Plus Rituximab as a First-Line Treatment for Patients with Follicular Lymphoma in Spain

  • Eliazar Sabater
  • Armando López-Guillermo
  • Antonio Rueda
  • Antonio Salar
  • Itziar Oyagüez
  • Juan Manuel Collar
Original Research Article



Follicular lymphoma (FL) is the second most common type of lymphoid cancer in Western Europe.


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.


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.


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.


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.


Follicular Lymphoma Bendamustine Bayesian Information Criterion Progression State Spanish National Health System 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors would like to acknowledge the reviewers from Applied Health Economics and Health Policy for their helpful comments provided during the review process.

Compliance with Ethical Standards


This work was performed thanks to financial support from Mundipharma Pharmaceuticals, S.L. (Spain).

Conflict of interest

ES and IO are employed by PORIB, a consultant company specializing in health economic evaluations. JMC is employed by Mundipharma Pharmaceuticals. AR has received honoraria from Mundipharma Pharmaceuticals, for advocacy tasks related to the present work as well as investigational funds and lecture honoraria from Roche Pharma. AS and ALG have received honoraria from Mundipharma Pharmaceuticals for advocacy tasks related to the present work.


ES, IO and JMC conceived the model. ES and IO developed the model and drafted the manuscript. AR, AS and ALG validated the model structure, provided the data related to clinical practice and reviewed and approved the final version of manuscript.

Supplementary material

40258_2016_243_MOESM1_ESM.docx (33 kb)
Supplementary material 1 (DOCX 33 kb)


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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Eliazar Sabater
    • 1
  • Armando López-Guillermo
    • 2
  • Antonio Rueda
    • 3
  • Antonio Salar
    • 4
  • Itziar Oyagüez
    • 1
  • Juan Manuel Collar
    • 5
  1. 1.Pharmacoeconomics and Outcomes Research IberiaMadridSpain
  2. 2.Haematology DepartmentHospital ClinicBarcelonaSpain
  3. 3.Oncology DepartmentHospital Costa del SolMarbellaSpain
  4. 4.Haematology DepartmentHospital del MarBarcelonaSpain
  5. 5.Medical DepartmentMundipharma PharmaceuticalsMadridSpain

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