Cost-Effectiveness Analysis of Biomarker-Guided Treatment for Metastatic Gastric Cancer in the Second-Line Setting

Abstract

Background. e 5-year survival rate of patients with metastatic gastric cancer (GC) is only 5%. However, trials have demonstrated promising antitumor activity for targeted therapies/immunotherapies among chemorefractory metastatic GC patients. Pembrolizumab has shown particular efficacy among patients with programmed death ligand-1 (PD-L1) expression and high microsatellite instability (MSI-H). e aim of this study was to assess the effectiveness and cost-effectiveness of biomarker-guided second-line GC treatment. Methods. We constructed a Markov decision-analytic model using clinical trial data. Our model compared pembrolizumab monotherapy and ramucirumab/paclitaxel combination therapy for all patients and pembrolizumab for patients based on MSI status or PD-L1 expression. Paclitaxel monotherapy and best supportive care for all patients were additional comparators. Costs of drugs, treatment administration, follow-up, and management of adverse events were estimated from a US payer perspective. e primary outcomes were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY over 60 months. Secondary outcomes were unadjusted life years (survival) and costs. Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty.Results. e most effective strategy was pembrolizumab for MSI-H patients and ramucirumab/paclitaxel for all other patients, adding 3.8 months or 2.0 quality-adjusted months compared to paclitaxel. However, this strategy resulted in a prohibitively high ICER of $1,074,620/QALY. e only cost-effective strategy was paclitaxel monotherapy for all patients, with an ICER of $53,705/ QALY. Conclusion. Biomarker-based treatments with targeted therapies/immunotherapies for second-line metastatic GC patients substantially improve unadjusted and quality-adjusted survival but are not cost-effective at current drug prices.

Immunotherapy and Targeted Therapy for Advanced Gastroesophageal Cancer: ASCO Guideline

“…One cost-effectiveness analysis on the topic of this guideline found that second-line treatment with targeted therapy or immunotherapy for patients with metastatic gastric cancer improved survival and quality-adjusted life years; however, costs were prohibitively expensive at a quality-adjusted lifeyear threshold of $100,000 in US dollars while single-agent paclitaxel was cost-effective at this threshold. 52 Of note, medication prices may vary markedly, depending on negotiated discounts and rebates. Patient out-of-pocket costs may vary depending on insurance coverage.…”

CCL21 activation of the MALAT1/SRSF1/mTOR axis underpins the development of gastric carcinoma

“…The heavy burden of GC remains a problem particularly in Asia, with studies indicating a five-year survival rate for only 5% of patients with GC [ 2 , 20 ]. More recently, novel immunological therapies have been considered crucial tools capable of treating patients with GC at different stages in addition to more traditional therapies such as surgery, radiotherapy, chemotherapy [ 21 ].…”

Assessing the risk-benefit profile of ramucirumab in patients with advanced solid tumors: A meta-analysis of randomized controlled trials

“…Whether such investment is warranted for the given risk-benefit profile is up to the individual regulatory and reimbursement agencies to decide, but analyses such as ours will be helpful for countries in priority setting in making such decisions. Cost-effectiveness analyses of ramucirumab also consistently reveal that ramucirumab is not cost-effective in various tumor types [ 26 , 27 ], including in the only biomarker-based approval of ramucirumab in hepatocellular cancer [28] . Indeed, ramucirumab has also been previously proposed as one of the low-value therapeutics in oncology with regards to its indication for gastric or gastroesophageal junction tumors [29] .…”