ALBERT

Description: With increasingly effective therapy for patients with aggressive histology non-Hodgkin’s Lymphoma and Hodgkin’s Lymphoma, more patients are attaining complete remission and are eligible for follow-up monitoring. Such monitoring offers the potential for early detection of relapse and surveillance for late effects of treatment, but is resource-intensive and may lead to unnecessary investigation of false relapses and cumulative radiation exposure. A number of Practice Guidelines (PG) provide recommendations on follow-up of patients with lymphoma, but provide conflicting recommendations particularly relating to the use of imaging. The PG of the American College of Radiology (ACR) and the National Comprehensive Cancer Network (NCCN) recommend routine use of imaging in follow-up, while those of the Canadian Association of Radiologists (CAR) and Cancer Care Ontario (CCO) recommend limiting imaging to patients suspected of relapse and those at higher risk of recurrence. We conducted a survey of practicing hematologists across Canada to document follow-up practice of patients outside of clinical trials. A 12-question survey was mailed to 244 Hematologists identified from the database of the Royal College of Physicians and Surgeons of Canada. The Dillman method was used to administer the questionnaire with a second mailing sent at 4 weeks to non-respondents. The target response rate was 50%. 127 responded (52%) after the second mailing. 93% indicated that they routinely follow-up patients in remission following curative treatment. 41% reported following patients indefinitely, 39% followed patients for up to 5 years, and 22% tailored the duration to the risk of relapse (generally 2–5 years). The median visit interval in years 1–2 was 3 months, years 3–5 6 months, and beyond 5 years 12 months. 41% used imaging (generally CT scans) routinely in all patients, while 31% used scans only in patients in partial remission and 21% in patients felt to be high risk at presentation. The majority of respondents performed CBC and LDH blood testing routinely in all patients and performed serum TSH levels in patients following mediastinal radiation. Serum electrolytes, liver function testing and blood films were ordered routinely only by a minority of respondents. 27% of practitioners reported utilizing printed educational material for patients and/or primary care practitioners regarding follow-up. 25% indicated an intent to change their follow-up practice in the near future, generally citing a plan to limit the duration of follow-up and to decrease reliance on CT scanning. Conclusion: This national survey indicates that the majority of Canadian hematologists routinely follow patients with lymphoma after curative treatment. The use of imaging in follow-up is variable, but is more consistent with the recommendations of the CAR and CCO than the ACR and NCCN.

Description: Introduction: Health utilities (HU) elicited directly from patients have immediate application in facilitating medical decision-making and cost-effectiveness determinations. Collection of HU using generic health status scales enable comparisons across diseases, but may not be sensitive to variations in health states within a particular disease. The EuroQOL EQ5D is a generic scale that has never been used to generate utilities in a broad spectrum of follicular/indolent lymphoma patients and has not been validated in this context. Methods: A consecutive, cross-sectional cohort of patients attending an outpatient malignant hematology clinic at a major cancer centre (Toronto, Canada) represented the eligible study population. Patients with a diagnosis of FL or other indolent NHL who consented to the study were asked to complete demographic and disease specific questionnaires in addition to the EuroQOL EQ-5D and Functional Assessment of Cancer Therapy (FACT)-Lymphoma quality of life assessment tools. Results: Eighty-four patients completed the survey study (〉95% response rate). Mean age was 58.7 (+/− 13.8 SD) and 55% were male. Diagnoses included FL (55%), CLL (25%), and other indolent NHL (20%). The majority of patients presented in advanced stage (stage III–IV; 65%) and had received some therapy to date, although 29% were still being observed at the time of survey administration. The mean utility score for the population was 0.84 (+/− 0.24; range 0–1). We evaluated the construct that patients receiving active treatment and those who were not in remission would have lower utility scores. Indeed, utilities were higher in patients being observed (0.91 +/− 0.16) compared to those in first remission (0.84 +/− 0.25), subsequent remissions (0.81 +/− 0.20), or those who were receiving active chemotherapy (0.75 +/− 0.27; p=0.049). Patients who were being followed in ongoing remission also trended to higher health status values (mean 0.88 +/− 0.21) compared to those who were not in remission (0.80 +/− 0.22; p=0.15). Utilities elicited from the EQ5D showed a moderate correlation with a criterion measure of quality of life, the FACT-Lymphoma scale (Spearman correlation coefficient 0.54, p

Description: Background Azacitidine (AZA) is a nucleoside metabolic inhibitor indicated for the treatment of patients with myelodysplastic syndromes (MDS). In Canada, it is supplied as a lyophilized powder in 100-mg vials priced at 628 Canadian dollars (C$). The product monograph indicates that the reconstituted drug may be held under refrigerated conditions (2-8°C) for up to a maximum of 8 hours. At a recommended dosing of 75 mg/m2 x 7 days and average body surface areas (BSA) ranging between 1.7-1.9 m2, most patients require more than a single vial reconstituted each day resulting in a drug wastage that might range from 58-72 mg/patient/day. Without strategies to mitigate this wastage, up to 40-50% of the daily dosage for patients of average BSA is thus discarded. At our center, AZA acquisition costs are reimbursed by the provincial funding agency according to mg dispensed and administered (dollars/mg) and not for total vials used; the potential cost of drug wastage is substantial. Walker et al. (Can J Hosp Pharm 2012) recently demonstrated that AZA reconstituted in cold (4°C) sterile water, and stored at -20°C for up to 4 days retained more than 90% of its initial concentration. The Odette Cancer Centre has used this reconstitution and storage strategy since November 2011. In addition, ‘batching’ of AZA patients on the same days and at the same times is attempted wherever possible. We audited AZA prescription use and drug wastage over 1 year after adopting this strategy to determine if the anticipated drug wastage was actually minimized. Methods From December 2011 until November 2012 all patients with MDS treated with at least 1 cycle of AZA were identified via the Cancer Centre pharmacy database. Analysis of the prescribed and wasted doses of AZA was performed. We retrospectively retrieved the mean number of doses administered per patient and per cycle. The mean BSA was determined for all patients, and the mean dose per injection as well as the mean number of cycles per patient was calculated. The total amount of actual drug wastage (based on the pharmacy records) was compared to the projected amount of drug wastage without implementing the new strategy. Results Thirty-one patients (mean BSA of 1.86 m2) received 1167 injections of AZA over 170 cycles of treatment (mean of 5.48 cycles per patient). The mean dose prescribed was 141.7 mg per injection (95% confidence interval 139.43-143.98). Over 12 months a total of 165,370 mg was dispensed at a cost of C$1,038,523.60. The projected amount of AZA that would have been dispensed without adopting the new strategy would have been 233,400 mg, representing potential drug wastage of 68,030 mg at a cost of C$427,228.40. With the mitigating strategies implemented, the actual amount of wasted drug was 2,400 mg at a cost of C$15,072. Expiry on shelf accounted for 52% of the drug wastage (1,240 mg). Drug expiry outside the freezer due to human error, patients failing to arrive on the day of treatment, freezer technical issues, or other causes accounted for 48% of the drug wastage. The average waste per patient per cycle of treatment due to drug expiry on shelf was only 7.3 mg at a cost of C$45.70. If a solitary patient (without patient batching) of average BSA 1.86 m2had been treated without our policy of cold (4°C) water reconstitution and freezing, the drug wastage (cost) would have been 425.6 mg (C$2,672.70)/7 day cycle. In contrast, cold (4°C) sterile water reconstitution with overnight freezing of vials and syringes would result in a drug wastage of 25.6 mg/7 day cycle (C$160.70), a 94% cost savings due to wastage. Conclusions Shelf-life extension with cold (4°C) sterile water reconstitution and freezing of vials and syringes is a simple policy that reduces the waste of AZA by 72-98%. This, in addition to other drug waste minimization strategies like patient batching can lead to significant reductions in drug expenditure and substantial cost-saving. Disclosures: Charbonneau: Hospira: Honoraria; BD Medical: Honoraria; Sanofi: Honoraria; Hoffman LaRoche: Honoraria. Buckstein:Celgene: Honoraria, Research Funding.

Description: Background: Approximately 20–40% of pts with NDMM present with RI, which is associated with a negative impact on survival (Rajkumar, 2005). In the pivotal phase 3 FIRST trial (median follow-up 37 months [mos]), continuous Rd improved progression-free survival (PFS) vs. melphalan-prednisone-thalidomide (MPT) in elderly NDMM pts by 28% (25.5 vs. 20.7 mos; HR = 0.72; P 〈 0.01) (Facon, Blood 2013). Although 121 pts receiving continuous Rd are still on Tx, the interim overall survival (OS) analysis showed a 22% reduction in the risk of death in favor of continuous Rd vs. MPT (HR = 0.78; P = 0.02). The present analysis was conducted to determine the impact of RI on PFS, OS, and time to 2nd antimyeloma Tx (AMT) as clinical study outcomes. Methods: Pts were randomized to 3 Tx arms: continuous Rd until progression (n = 535); Rd for 18 cycles (72 weeks) (Rd18; n = 541); or MPT for 12 cycles (72 weeks) (n = 547). Enrolled NDMM pts were categorized according to their renal function: 24% had normal renal function (creatinine clearance [CrCl] ≥ 80 mL/min), 44% presented with mild RI (≥ 50 and 〈 80 mL/min), 23% had moderate RI (≥ 30 and 〈 50 mL/min), and 9% had severe RI (〈 30 mL/min). Pts requiring dialysis were excluded. Lenalidomide starting dose was 25 mg QD for pts with normal renal function or mild RI, 10 mg QD for moderate RI, and 15 mg QOD for severe RI. Melphalan dose was reduced by 50% in pts with moderate or severe RI. The primary endpoint was PFS (continuous Rd vs. MPT); secondary endpoints were OS, overall response rate, time to response, duration of response, time to Tx failure, time to 2nd AMT, health-related quality of life, safety, and improvement in renal function from baseline. Improvement in RI was defined as shifts from baseline to most extreme post-baseline value of the calculated CrCl as a measure of renal function during the active Tx (N = 1484). Results: A PFS benefit favored continuous Rd vs. MPT irrespective of the degree of renal function (Table 1): there was a benefit in pts with normal renal function (HR = 0.72 (0.51–1.02); P = 0.06), and better in pts with mild RI (HR = 0.79 (0.62–1.00); P = 0.05) and moderate RI (HR = 0.62 (0.45–0.85); P 〈 0.01). A PFS benefit was also seen with continuous Rd vs. Rd18 (a secondary comparison) in pts with mild RI and moderate RI (P 〈 0.01 for both). An interim OS benefit with continuous Rd vs. MPT was observed in most renal subgroups. Similar results were observed between Rd18 and MPT in terms of PFS or interim OS in any of the renal subgroups. Continuous Rd, compared with Rd18 or MPT, extended time to 2nd AMT in most renal groups except severe RI (CrCl 〈 30mL/min) (Table 2). Improvement in RI was observed more frequently in pts treated with continuous Rd than those with Rd18 or MPT: improvement of mild RI, 48%, 43%, and 48%, respectively; of moderate RI, 67% 61%, and 62%; and of severe RI, 64%, 59%, and 56%. Overall, 〈 5% of pts in any Tx group experienced a worsening in renal function status during Tx (continuous Rd 2.2%; Rd18 2.8%; MPT 2.7%). The most common grade 3–4 adverse events (AEs) for these Txs were anemia, neutropenia, thrombocytopenia, deep-vein thrombosis/pulmonary embolism (DVT/PE), and peripheral sensory neuropathy (Table 3). Tx discontinuation due to AEs increased in pts with moderate and severe RI, regardless of the type of Tx (Table 3). Conclusions: PFS, OS (at interim analysis), and time to 2nd AMT outcomes generally improved continuous Rd vs. Rd18 or MPT in transplant-ineligible NDMM pts with normal renal function, and in those with mild or moderate RI. The small number of pts in the severe RI group precluded a meaningful conclusion. Continuous Rd was generally well tolerated and renal function improved in the majority of pts during Tx with continuous Rd vs. Rd18 or MPT. Disclosures Dimopoulos: Celgene Corporation: Consultancy, Honoraria. Off Label Use: Lenalidomide used in newly diagnosed multiple myeloma patients. Roussel:Celgene: Consultancy, Lecture fees Other, Research Funding. van der Jagt:Celgene Corporation: Research Funding. Jaccard:Celgene Corporation: Honoraria, Research Funding. Tosikyan:Celgene: Consultancy. Karlin:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Sandoz: Honoraria, Membership on an entity's Board of Directors or advisory committees. Bensinger:Celgene Corporation: Consultancy, Research Funding. Schots:Celgene: Research Funding. Chen:Celgene Corporation: Employment. Marek:Celgene Corporation: Employment, Equity Ownership. Ervin-Haynes:Celgene Corporation: Employment. Facon:Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Description: Background Although diagnostic and treatment delays in solid tumors are known to negatively impact on outcomes, little is known with respect to hematological malignancies. Diffuse Large B-Cell Lymphoma may present with a wide array of symptoms, thus rendering initial diagnosis challenging and time consuming. We evaluated disease-specific, patient-related and socioeconomic factors leading to delays in DLBCL diagnosis and treatment and the respective impact on overall and progression-free survival. Methods A comprehensive clinical database of patients with a new diagnosis or new presentation of transformed DLBCL treated at our center between 2002 and 2010 was utilized. A total 278 patients were included. All patients received at least one cycle of Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone (R-CHOP) immuno-chemotherapy. We defined various time intervals based on Cancer Care Ontario guidelines as follows: patient associated delay – time from symptoms onset to first known contact with a primary care physician (PCP); diagnostic delay – 〉6 weeks from first PCP contact to initial hematology consultation; and treatment delay – 〉4 weeks from first hematology consultation to chemotherapy initiation. Results In the population studied (n=278), the median age was 63 and 46% were female. Patients waited a median of 4 weeks (IQR 2-13) before seeking medical attention. A further median of 8 weeks (IQR 4-17) was required for the PCP to diagnose DLBCL or at least to achieve enough clinical suspicion for referral to hematology. From initial hematology consult, a median of 3 weeks (IQR 1-4) elapsed until chemotherapy initiation. In univariate analyses, patients who lacked bone marrow involvement (p=.005), had lower IPI scores (p=.031), higher Charlson comorbidity index (p=.048) and who had initiation of treatment in the outpatient setting (vs. inpatient; p=.021), were more likely to experience diagnostic delays 〉6 weeks. In multivariable logistic regression analysis, bone marrow involvement (OR=0.41, p=.018), Charlson comorbidity index (OR=1.42, p=.017) and requirement for urgent inpatient chemotherapy administration (OR=0.40, p=.012) remained associated with diagnostic delays. With respect to treatment delays, in univariate analyses, patients who did not have a pathology diagnosis at the time of initial hematology consultation (p4 weeks. On multivariable analysis, lack of pathological diagnosis at the time of hematology referral was the only factor that remained associated with treatment delays (OR=8.25, p

Description: Introduction The use of surveillance CT imaging in patients with DLBCL in remission is neither effective to detect recurrence nor cost-effective. The ASH Choosing Wisely (CW) campaign, in particular, emphasizes the lack of benefit in imaging beyond 2-years of completion of therapy. We sought to describe the practice of surveillance imaging and predictors of this practice. Methods We used population-based health system administrative databases from Ontario, Canada. We studied a cohort of all adult patients ≥18 with diffuse large B-cell lymphoma who received R-CHOP therapy for curative intent between January 1, 2004 to June 30, 2011. Based on the CW campaign, we defined an index date of 2-years after the last dose of R-CHOP as the time-frame beyond which surveillance CT imaging would be inappropriate. The cumulative incidence of receiving CT scans within 3 years after the index date (i.e. from 2- to 5-years beyond the end of treatment) represented the primary outcome of interest (established within the Ontario Health Insurance Program database). To ensure that only surveillance scans in asymptomatic patients were captured, patients were censored 6 months prior to development of recurrent disease or a new cancer diagnosis, further chemotherapy/radiation, or if they died (censored at time of death). Predictor characteristics included baseline comorbidities (John Hopkins weighted Aggregated Diagnosis Groups (ADG) comorbidity score) and income quintile (linkage of the patient postal code to Statistics Canada Census data on average household income by postal code). Results The cohort consisted of 2,838 patients treated with R-CHOP during the study period. Median age at time of first R-CHOP dosing was 63 years (IQR 52-72) and the median number of cycles received was 6 (IQR 6-8). The cumulative incidence of receiving CT imaging from the index date (2-years from end of treatment) to 3-years beyond the end of treatment was 40.1% (95% CI 38.3%-41.9%). The cumulative incidence of imaging from the index date to 5-years beyond the end of treatment was 55.6 % (95% CI 53.7%-57.5%). During the follow-up period, patients ≥65 were more likely to receive imaging than those aged

Description: Introduction: The biology of myelodysplastic syndrome (MDS) is poorly understood, and treatment options are limited. Thus, most MDS patients require chronic red blood cell transfusion, and many develop secondary iron overload. Although the pathophysiological consequences of iron overload to the heart, liver, and endocrine organs have been well characterized, its effects on haematopoiesis have not been studied. However, it has been observed that chelation therapy in iron-overloaded MDS patients may result in reduction of transfusion requirements, and recent studies have suggested a correlation between the use of iron chelation therapy and improvement in leukaemia-free survival in MDS. At the cellular level, iron toxicity is mediated in large part via the generation of reactive oxygen species (ROS). It has been shown in animal models that accumulation of ROS leads to senescence of haematopoietic stem cells, and that ROS cause DNA damage and promote the development of malignancy. These effects of ROS may be particularly important in MDS, in which haematopoiesis is already severely compromised and genetic instability is a striking feature. Hypothesis: We hypothesize that iron overload secondary to transfusion leads to increased levels of intracellular ROS in early haematopoeitic cells in MDS. The increase in intracellular ROS in MDS would be predicted to lead further impairment of haematopoiesis via stem cell exhaustion and while promoting accumulation of DNA damage by myelodysplastic stem cells and early progenitors, thus accelerating progression of MDS to acute leukaemia. Results: To test this hypothesis, we examined the relationship between transfusion-related iron overload and ROS content of CD34+ bone marrow cells in MDS. ROS content was measured in CD34+ cells by flow cytometry in bone marrow aspirates from 34 consecutive MDS patients (CMML=4, MDS/MPD=2, RA=4, RARS=3, RCMD=2, RAEB 1=6, RAEB 2=12, RAEB-t/AML=1). The patients represented a wide range of prior transfusion burden (0-〉300 units PRBC) and serum ferritin levels (11-〉10000 μg/L). ROS was strongly correlated with serum ferritin concentration for patients with iron overload (serum ferritin 〉1000 μg/L; n=14, R=0.733, p

Description: Introduction The effectiveness of bortezomib for induction treatment prior to ASCT in multiple myeloma (MM) patients has been demonstrated in a number of randomized, open-label phase III trials, including the IFM 2005-01 trial (Harousseau et al., J Clin Oncol 2010;28(30):4621-9). This trial showed that the addition of bortezomib as part of an induction treatment prior to ASCT resulted in statistically significant improvements in post-induction response rates and longer progression-free survival (PFS) compared to a non-bortezomib containing regimen (NBCR). The objective of this study was to assess the cost-utility of a bortezomib-containing regimen (BCR) vs. a NBCR for induction treatment in previously untreated MM patients prior to ASCT from a Canadian public payer perspective, based on the results of the IFM 2005-01 study. Methods A Markov model was developed to estimate the cost-utility over a lifetime horizon (50 years) in previously untreated MM patients undergoing induction and ASCT. The model simulated disease progression of patients with previously untreated MM through three health states: “progression-free”, “progression” and “death”, with all patients beginning in the progression-free state. The PFS and overall survival (OS) curves from the IFM 2005-01 trial were extrapolated beyond the study follow-up period to estimate the timeframe spent in each health state. Each health state was associated with a utility value and direct medical costs. Utilities for the progression-free and progression health states were derived from a previous cost-utility analysis for bortezomib and were 0.81 and 0.645, respectively (Hornberger et al., Eur J Haematol 2010;85(6):484-91). Transition probabilities between health states were estimated by calibrating the model to the PFS and OS curves from the IFM 2005-01 trial. In the base case, transition probabilities beyond the trial follow-up period were conservatively assumed to be equal for both treatment groups. Medical resource utilization was estimated using the IFM 2005-01 trial, and supplemented by published literature and clinical advisors. Clinical advisors also provided input on management of adverse events (〉 grade 3) and treatment of patients who progressed after induction and ASCT. Resource costs were estimated using Canadian sources ($CAN 2012) and costs and outcomes were discounted at 5% annually. Because patients in each group incurred similar costs (i.e. cost of an ASCT), only incremental costs between the two arms were included in the analysis. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to test the robustness of the model. Results The mean total MM-related cost over the lifetime analysis in the model was $68,800 per patient treated with a BCR and $47,000 per patient treated with a NBCR. Addition of bortezomib to the induction regimen increased costs by $21,700 (see table). Over the model lifetime, a delay in progression with a BCR led to 0.25 years of additional survival compared to a NBCR and a quality-adjusted life-year (QALY) gain of 0.22 years. The incremental cost-utility ratio for induction using a BCR compared to a NBCR approach was $99,200/QALY. Sensitivity analyses identified the major factors impacting the cost-utility ratio as: transition probabilities beyond the trial follow-up period, discounting, utilities and bortezomib costs. The probability of a BCR being cost-effective compared to a NBCR was 43.9% at a threshold of $100,000/QALY. Conclusions A number of phase 3 trials have demonstrated the effectiveness of bortezomib as part of an induction regimen prior to ASCT. This analysis indicates that, from a Canadian perspective, induction treatment with a BCR in previously untreated MM patients prior to ASCT can be cost-effective at conventional decision thresholds with a cost-utility ratio of $99,200/QALY. Disclosures: Kouroukis: Janssen Inc.: Honoraria. White:Janssen Inc.: Consultancy, Honoraria. Kruse:OptumInsight: Employment. Lawrence:OptumInsight: Employment. Trambitas:Janssen Inc.: Employment.

Description: Background Follicular lymphoma is the most common indolent lymphoma, with median survival over 10 years. A large proportion of patients present with advanced, but asymptomatic disease. Three randomized controlled trials in the last 25 years have confirmed there is no detriment to deferred chemotherapy vs. upfront treatment with respect to overall survival in such patients. However, these studies were all comparing upfront toxic regimens. Single agent rituximab (R) is associated with less side-effects, thus there are advantages to giving it upfront and significantly delaying further more toxic and expensive treatments. Recently, Ardeshna et al. (2010) compared upfront rituximab to watchful waiting in asymptomatic stage II-IV follicular lymphoma, and demonstrated significant improvement in time to initiation of next treatment (TTINT). We performed a cost-effectiveness analysis comparing the two strategies. Methods We developed a Markov decision-analytic model to compare upfront R-induction (RI) X 4 weekly doses vs. a watch and wait (WW) strategy for a hypothetical cohort of 60 year old patients newly-diagnosed with asymptomatic low burden advanced stage follicular lymphoma. The model simulates the clinical course of patients over a lifetime horizon, with the end-points of quality-adjusted life years (QALYs) and incremental cost effectiveness ratio (ICER). The baseline probabilities used in the model were derived from a systematic review of published studies. Key health states include PF1 (progression-free 1), PD1 (1st progressive disease needing treatment), R-maintenance (2-year state progression-free post-PD1 receiving R q3mo), PF2 (post 2 years of R-maintenance), PD2/3/4 (subsequent progressions requiring salvage), PF3/4/5 (subsequent PF states post-salvage), palliation and death. The probabilities of transitioning from one state to another were evaluated on a 6-month cycle. The model incorporated data on health state utilities, which were derived from the literature. Direct costs were collected from a Canadian public health payer's perspective. Resource utilization was based on guidelines, literature and expert opinion. Cost information was obtained from hospital, provincial and national costing sources, as well as the literature, and presented in 2012 Canadian dollars. Costs and effects were discounted at 5%. All patients were assumed to be treated with bendamustine and rituximab (BR) upon PD1, followed by 2 years of R-maintenance. Patients were treated with a maximum of 3 lines of salvage therapy, after which they entered palliation for maximum of 2 cycles. Results The quality-adjusted life expectancy was 6.70 QALYs for the RI strategy vs. 6.66 QALYs for the WW strategy, yielding an expected benefit from RI of 0.04 QALYs. Over a lifetime horizon, the total cost of the RI arm is $59061 and $74531 for the WW arm. The RI strategy dominates, as it is $15469 cheaper than the WW approach (Table 1). In one-way sensitivity analyses of key variables, effectiveness was sensitive to probability of PD2, PF4, age and time horizon. The model particularly favours RI in people under the age of 65. However, even at extreme end values for these variables that remain reasonable from the literature, the largest effectiveness difference in favour of WW is 0.06 QALYs (22 days) over the lifetime horizon. Thus overall the difference in either direction is minimal, demonstrating that the quality-adjusted life expectancy is essentially equivalent between the two strategies. Probabilistic sensitivity analyses (10 000 simulations) were performed. For the commonly accepted willingness to pay threshold of $50000, RI is the more cost-effective strategy 82% of the time (figure 1). Conclusions In conclusion, rituximab monotherapy as an induction strategy for asymptomatic advanced stage follicular lymphoma is the dominant strategy from a cost-utility perspective over the standard watch and wait strategy, with neutral overall effectiveness, but significant cost minimization of fifteen thousand dollars per patient over the lifetime horizon. Particularly, it is the optimal strategy in patients under the age of 65 and should be recommended. Disclosures: No relevant conflicts of interest to declare.