Cost-effectiveness of pembrolizumab for advanced non-small cell lung cancer patients with varying comorbidity burden

Abstract

Objectives While previous cost-effectiveness studies on pembrolizumab in stage IV non-small cell lung cancer (NSCLC) have found these regimens to be cost-effective, their reliance on randomized controlled trial (RCT) data with strict inclusion criteria limits generalizability to patients with comorbidities. We estimated the cost-effectiveness of first-line pembrolizumab for patients with various comorbidities. Materials and methods In our base case analysis, we studied pembrolizumab plus chemotherapy (pembrolizumab combination therapy) versus chemotherapy alone. In a secondary analysis, we considered only patients with PD-L1 expression of at least 50% (PD-L1-high) and evaluated pembrolizumab monotherapy, pembrolizumab combination therapy, and chemotherapy alone. Microsimulation models were developed for the base case and the PD-L1-high analyses. To estimate outcomes of patients with differing comorbidities, we combined survival data from patients with few or no comorbidities from the RCTs with estimates from the general population obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Comorbidity burden level was divided into three groups based on the Charlson score (equal to 0, 1, or 2+); patients with various other specific comorbidities were also analyzed. Incremental cost-effectiveness ratios (ICER) were compared to a willingness-to-pay (WTP)

Real world data in the era of Immune Checkpoint Inhibitors (ICIs): Increasing evidence and future applications in lung cancer

“…According to our literature review, while safety and efficacy real world data in the main patients population was in line with data from -Any grade irAEs: 57% for ICI monotherapy and 33% for ICIchemotherapy -ORR in ICI monotherapy: 14% -ORR in ICI-chemotherapy: 67% -No evidence of viral reactivation AID = auto-immune disorder; BM = brain metastasis; ICI = immuno-checkpoint inhibitor; irAE = immune-related adverse event; ORR = overall response rate; OS = overall survival; PFS = progression free survival; PS = performance status; P = prospective study; R = retrospective study. RCTs, some criticism about ICIs cost-effectiveness and sustainability emerged [35,36].…”

“…In Spain such value is €75,000.00: LYG largely exceeds this threshold, pointing out once more the need of selecting patients with higher potential benefit from ICI. In this context, a more recent study estimated the cost-effectiveness of pembrolizumab according to comorbidities, defined with Charlson scoring system [34], using a model that combines clinical trial and real-world patient data [35]. Authors evaluated the incremental cost-effectiveness ratios (ICERs) compared to a willingness-to-pay-threshold of $100,000.00/quality-adjusted life-year (QALY).…”

“…When evaluating pembrolizumab, despite the survival improvement compared to chemotherapy alone, the treatment regimens were not cost-effective in any of the patient populations, mainly due to the shorter OS of real-world patients compared to that observed in clinical trials. ICERs were even higher for patients with relevant comorbidities, suggesting the need of price re-modulation in order to guarantee a fair cost-effectiveness, given the true effectiveness of pembrolizumab reported in the real-world setting [35]. In the context of economic evaluation, another interesting study focused on the budget impact of the switch from a weight-based to a fixed dose regimen of anti-PD-1 agents [36].…”

The Position of EGF Deprivation in the Management of Advanced Non-Small Cell Lung Cancer

“…Furthermore, there is a significant questioning in the literature regarding cost effectiveness of the combination of ICI + chemotherapy in PD-L1 low or negative tumors (70,71). The high cost of ICIs in contrast to its clinical impact could lead to negative pharmacoeconomic evaluations, even for rich countries like US, Japan, or Europe, but definitely for many middle and lowincome countries (72)(73)(74)(75). Therefore, some national and/or private health insurances might choose not to cover ICI + chemotherapy in patients with PD-L1 < 1%, at least until a significant price reduction for ICIs takes place.…”

The role of immunotherapy in fusion-driven lung cancer

“…Collectively, this means there is a significant cohort of fusiondriven NSCLC patients, that are likely to be exposed to immune checkpoint inhibition whether as first-line therapy or in the resistant setting. Recent cost-effectiveness analyses have questioned the value of immune checkpoint inhibition in various diverse healthcare settings [33][34][35]. In a cohort of patients in whom there is limited efficacy, exposing patients to ineffective and expensive therapies that are not without toxicity is also of concern.…”