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Background: Metastatic Merkel cell carcinoma (mMCC) has traditionally been managed with palliative chemotherapy regimens or best supportive care (BSC). Avelumab, a novel anti-programmed death-ligand 1 (PD-L1) human monoclonal antibody for mMCC treatment, is being studied in the pivotal JAVELIN Merkel 200 trial.Aim: Incorporating trial results, this analysis aimed to evaluate the cost-utility of avelumab in Taiwan.Methods and results: A de novo partitioned-survival model with three key health states related to survival (progression-free disease, progressed disease, and death) was applied in this study. The data of clinical efficacy, safety, and patient utilities were obtained from the JAVELIN Merkel 200 trial, literature review, and Taiwanese clinical expert opinion.Cost-utility analysis was performed, and results were presented as cost per qualityadjusted life year (QALY) gained. For treatment-naïve patients, the incremental costeffectiveness ratios (ICERs) for avelumab vs BSC and avelumab vs chemotherapy were US$44885.06 and US$42993.06 per QALY gained, respectively. As to treatmentexperienced mMCC patients, avelumab was associated with ICERs of US$27243.06 (vs BSC)/US$26557.43 (vs chemotherapy) per QALY gained. All ICERs remained consistently within the willingness-to-pay (WTP) threshold of US$53,333.33 per QALY gained. Conclusion:This study demonstrated avelumab to be a cost-effective treatment option for both treatment-experienced and treatment-naïve mMCC patients with very poor prognosis in Taiwan.

Objectives: To compare the hospital costs associated with powered and manual staplers used in lobectomy for lung cancer through video assisted thoracic surgery (VATS) in a Chinese tier III hospital. Methods: This retrospective cohort study included patients who received VATS lobectomy using powered stapler (POWERED Echelon Flex TM ENDOPATH ® ) and manual stapler (Echelon Flex TM ENDOPATH ® ) manufactured by the same company from January 2016 to December 2018 in a Chinese tier III hospital. The included patients were stratified by the stapler type for the comparisons of total hospital costs and classified hospital costs using Wilcoxon rank sum test. Additionally, multivariate generalized linear regression models were conducted to develop the prediction models for classified hospital costs using patient characteristics, stapler type, utilization of stapler, and unit price of stapler. The developed hospital costs prediction models were used to estimate the hospital costs associated with another popular manual stapler (VICTOR MEDICAL) in the same study cohort. Results: This study included 296 patients using powered stapler and 92 patients using manual stapler for VATS lobectomy for hospital costs comparisons, which identified significant differences in total hospital costs (median U64,322 vs. U67,298, p,0.001) and classified hospital costs for drugs (median U10,161 vs. U13,592, p,0.001) and surgery (median U8,257 vs. U 7,683, p,0.001). Based on the developed hospital costs prediction models and the unit price of another brand manual stapler (VICTOR MEDICAL), using ECHELON powered stapler were associated with U400 lower hospital costs for stapler, U2,948 lower for drugs, U1,003 lower for laboratory tests, and U4,411 lower for total hospital costs than the VICTOR MEDICAL manual stapler in the same study cohort. Conclusions: Using powered stapler of ECHELON for VATS lobectomy could be associated with lower total hospital costs than the manual staplers mainly used in a Chinese tertiary care hospital after full adjustment of confounding effects.

INTRODUCTION Patients with high risk medulloblastoma are treated either with high dose chemotherapy or hyperfractionated radiotherapy. Both approaches are not feasible in resource-limited countries. POG9031 trial has reported favourable outcome for high risk medulloblastoma using standard chemotherapy and radiotherapy only. Hence, we have adopted the protocol using chemotherapy first approach due to logistical reasons. OBJECTIVE To review the outcome of children diagnosed with high risk medulloblastoma in Hospital Kuala Lumpur. METHODS Patients diagnosed with high risk medulloblastoma between January 2015 and June 2018 treated using the chemotherapy first approach as per POG9031 protocol were identified. Data was then extracted and analysed. RESULTS Nine patients were identified, 3 boys and 9 girls. Median age was 9.3 years (range 2.6 – 15.9 years). Median follow up for survivors are 3.6 years. Five patients (55.6%) had macroscopic metastatic disease at diagnosis. All patients had significant residual disease post-op. Only 3 patients are disease free till last follow up, giving a 3 years event free survival of 16%. Of the 6 patients who had relapsed, 4 have died, giving a 3 years overall survival of 46%. Patients with no metastasis at diagnosis (M0) fared better with 3 years event free survival of 38%, but 3 years event free survival for patients with macroscopic metastatic disease (M+) was 0%. CONCLUSION Outcome of children with high risk medulloblastoma treated with chemotherapy first approach was dismal.