Patterns of Care and Resource Use Among Elderly Relapsed/Refractory Follicular Lymphoma Patients: US Medicare Claims Analysis

Background: Follicular lymphoma (FL) is the second most common type of non-Hodgkin lymphoma (NHL) and most common indolent NHL. Rituximab-based chemotherapy is highly effective and considered the mainstay first-line (1L) treatment for FL, though many patients relapse and continue through successive lines of therapy. These relapsed/refractory (R/R) patients experience worse outcomes and represent an unmet need for more effective treatment approaches. This study examined treatment patterns, health care resource utilization (HCRU), and costs among R/R FL patients initiating third line (3L) therapy between 2011 and 2020.

Methods: This retrospective, observational study used Center for Medicare and Medicaid fee-for-service Medicare data. The sample included treated patients with FL (identified via 1 inpatient or 2 outpatient claims) aged ≥66 years who initiated 1, 2, and 3L therapy between January 1, 2011, and December 31, 2020. Patients were required to have continuous coverage in the 12 months pre-FL diagnosis and 3 months post-diagnosis and were followed until discontinuation of enrollment or death. Line of therapy (LoT) was calculated until the end of treatment, death, or transformation to diffuse large B-cell lymphoma. Outcomes included patient characteristics, treatment patterns, health care costs and HCRU.

Results: This analysis identified 8737 1L, 1847 2L, and 410 3L treated FL patients. Median age at the start of each LoT was 75 years at 1L, 77 at 2L, and 79 at 3L. Of R/R FL patients initiating 3L, the most common baseline Charlson comorbidities included diabetes without chronic complications (23%), chronic pulmonary disease (22%) and renal disease (20%), 32% were defined as having progression of disease within 2 years of 1L (POD24), and 30% were defined as double refractory to both an anti-CD20 agent and an alkylating agent. Treatment utilization rates were similar across LoTs; the most used regimens were rituximab/obinutuzumab (R/O) (used 35% of the time in 1L, 33% in 2L, and 31% in 3L) and bendamustine + R/O (39% in 1L, 33% in 2L, and 21% in 3L). Mean duration of 1L treatment was longer for patients who only initiated 1L (10.1 months) vs. those with R/R FL who went on to initiate 2L and 3L (7.5 and 7.4 months, respectively). As R/R FL patients who initiated 3L moved through LoTs, increases were observed in the number of patients with at least 1 inpatient admission (17% in 1L and 31% in 3L) and with at least 1 emergency room visit (27% in 1L and 41% in 3L). Mean total all-cause costs per-member per-month (PMPM) also increased with each subsequent LoT ($15,917 in 1L, $17,767 in 2L, and $18,266 in 3L). In addition, mean total all-cause costs of R/R FL patients defined as POD24 and double refractory were higher in 3L; $20,172 PMPM and $21,724 PMPM, respectively).

Conclusions: In this elderly R/R FL population, similar therapies were used across multiple LoTs. With each subsequent LoT, treatment duration shortened and notably, costs and HCRU increased. Additionally, patients defined as POD24 and double-refractory experienced higher costs. This research highlights a substantial unmet need in R/R FL for novel therapeutic options that can provide better outcomes and reduce HCRU.