ABSTRACT
BACKGROUND: Immune checkpoint inhibitors improve outcomes compared with chemotherapy in lung cancer. Tumor PD-L1 receptor expression is being studied as a predictive biomarker. The objective of this study was to assess the cost-effectiveness and economic impact of second-line treatment with nivolumab, pembrolizumab, and atezolizumab with and without the use of PD-L1 testing for patient selection. DESIGN: We developed a decision-analytic model to determine the cost-effectiveness of PD-L1 assessment and second-line immunotherapy versus docetaxel. The model used outcomes data from randomized clinical trials (RCTs) and drug acquisition costs from the United States. Thereafter, we used epidemiologic data to estimate the economic impact of the treatment. RESULTS: We included four RCTs (2 with nivolumab, 1 with pembrolizumab, and 1 with atezolizumab). The incremental quality-adjusted life year (QALY) for nivolumab was 0.417 among squamous tumors and 0.287 among non-squamous tumors and the incremental cost-effectiveness ratio (ICER) were $155 605 and $187 685, respectively. The QALY gain in the base case for atezolizumab was 0.354 and the ICER was $215 802. Compared with treating all patients, the selection of patients by PD-L1 expression improved incremental QALY by up to 183% and decreased the ICER by up to 65%. Pembrolizumab was studied only in patients whose tumors expressed PD-L1. The QALY gain was 0.346 and the ICER was $98 421. Patient selection also reduced the budget impact of immunotherapy. CONCLUSION: The use of PD-L1 expression as a biomarker increases cost-effectiveness of immunotherapy but also diminishes the number of potential life-years saved.
Subject(s)
Antineoplastic Agents, Immunological/therapeutic use , B7-H1 Antigen/metabolism , Biomarkers, Tumor/metabolism , Carcinoma, Non-Small-Cell Lung/drug therapy , Carcinoma, Non-Small-Cell Lung/metabolism , Cost-Benefit Analysis , Immunotherapy/methods , Lung Neoplasms/drug therapy , Antineoplastic Agents, Immunological/economics , Budgets , Carcinoma, Non-Small-Cell Lung/physiopathology , Drug Costs , Humans , Lung Neoplasms/metabolism , Lung Neoplasms/physiopathology , Quality-Adjusted Life Years , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Over the past 5 years, 55 new anticancer drugs have been launched worldwide. Considering the increasing costs of innovative treatments, both the number and the relevance of cost-effectiveness analyses have increased, meaningfully supporting decision making by stakeholders and policy makers. Notably, cost-effective treatments remain unavailable to patients because they are still unaffordable for a multitude of payers. OBJECTIVES: To discuss the differences between cost-effectiveness and affordability. METHODS: We reviewed the most relevant data on the divergences between cost-effectiveness and affordability. In addition, we included our recommendations to improve patients' access to innovative cancer therapies. RESULTS: The increasing costs of recently launched antineoplastic drugs, as high as $150 000 per year, represent a major barrier to patients' access to treatments globally. In Brazil, for example, patients' access to innovative treatments depends greatly on whether the individual has private health insurance. In the public health sector, patients' access to cost-effective innovative treatments varies according to the financial capacity of the facility, leading to inequalities within the same healthcare system. CONCLUSIONS: We conclude that because of the socioeconomic inequality mostly seen in lower and middle-income countries, it is difficult to define a cost-effectiveness threshold by region or a willingness-to-pay threshold affordable to the entire population. We consider that benchmark interventions might help to find an affordable willingness-to-pay threshold, and league table interventions might help policy makers, physicians, and the society to share the decision making.