The effect of PD-L1 testing on the cost-effectiveness and economic impact of immune checkpoint inhibitors for the second-line treatment of NSCLC.

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.

Chylous ascites due to signet ring cell gastric adenocarcinoma.

UNLABELLED: "Chylous ascites is a rare presentation of peritoneal effusion. The signet ring cell gastric adenocarcinoma is also relatively rare presentation of gastric cancer. We present a quite rare case of chylous ascites associated with signet ring cell gastric adenocarcinoma. CASE REPORT: a 47-years-old Caucasian man presented to our emergency department with abdominal distention. The abdominal ultra-sound showed high volume ascites and the diagnostic paracentesis revealed milk-like peritoneal fluid rich in triglycerides. He was underwent to medium chain triglycerides based diet, total parenteric diet and treatment with somatostatin without response. Due to presented digestive hemorrhagic events, upper digestive endoscopy was performed and revealed signet ring cells gastric adenocarcinoma on biopsy. The patient died in disseminated intravascular coagulation context. CONCLUSION: chylous asicites is a rare presentation of ascites and it may be associated with abdominal neoplasm. The prompt diagnosis is important for optimize the etiology evaluation and therapeutically approach."