Abstract

Objective: Three immune checkpoint inhibitors (ICIs), pembrolizumab, atezolizumab and cemiplimab, have been successively approved as first-line treatments for advanced non-small-cell lung cancer (NSCLC) patients with programmed cell death ligand 1(PD-L1) expression of at least 50%. This study was designed to compare the cost-effectiveness of these three novel therapies in this patient population. Material and Methods: Using Markov model and network meta-analysis, we conducted separate cost-effectiveness analyses for cemiplimab, pembrolizumab and atezolizumab among advanced NSCLC patients with PD-L1 of at least 50% from the United States health care sector perspective. Health states included progression-free survival, progressive disease, end-stage disease, and death. Clinical efficacy and safety data were derived from phase III clinical trials and health state utilities and costs data were collected from published resources. Two scenario analyses were conducted to assess the impact of varying subsequent anticancer therapies on the cost-effectiveness of these 3 ICIs and cost-effectiveness of pembrolizumab combined with chemotherapy versus these 3 first-line ICI monotherapies. Results: In base case analysis, cemiplimab compared with pembrolizumab was associated with a gain of 0.44 quality-adjusted life-years (QALYs) and an increased cost of $23,084, resulting in an incremental cost-effectiveness ratio (ICER) of $52,998/QALY; cemiplimab compared with atezolizumab was associated with a gain of 0.13 QALYs and a decreased cost of $104,642, resulting in its dominance of atezolizumab. The first scenario analysis yielded similar results as our base case analysis. The second scenario analysis founded the ICERs for pembrolizumab plus chemotherapy were $393,359/QALY, $190,994/QALY and $33,230/QALY, respectively, compared with cemiplimab, pembrolizumab and atezolizumab. Conclusion: For advanced NSCLC patients with PD-L1 of at least 50%, cemiplimab was a cost-effective option compared with pembrolizumab and a dominant alternative against atezolizumab. Our scenario analysis results supported the cemiplimab plus chemotherapy as a second-line therapy and suggested an extended QALY but overwhelming cost linking to pembrolizumab plus chemotherapy.

Highlights

  • Lung cancer is the most common malignancy and the leading cause of cancer mortality worldwide (William et al, 2009)

  • In our base case analysis, treating patients with first-line cemiplimab monotherapy compared with first-line pembrolizumab and atezolizumab monotherapy were associated with improved survivals of 0.44 quality-adjusted life-year (QALY) and 0.13 QALYs, respectively

  • The results showed that first-line cemiplimab was a cost-effective option compared with firstline pembrolizumab (ICER $23,083/QALY), and a dominant alternative against first-line atezolizumab when the WTP threshold set as $100,000/QALY

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Summary

Introduction

Lung cancer is the most common malignancy and the leading cause of cancer mortality worldwide (William et al, 2009). Decision making on the standard first-line treatment for advanced NSCLC is personalized, based mainly on driver aberration types and programmed cell death ligand 1 (PD-L1) expression levels (Ettinger et al, 2021). Over the past few decades, treating NSCLC patients with traditional platinum-doublet chemotherapy has obtained unsatisfactory therapeutic effect, with a median overall survival (OS) of less than 1 year and a 5-year survival rate of nearly 18% (William et al, 2009). Immune checkpoint inhibitors (ICIs), as a novel class of anticancer drugs, have hold a great therapeutic potential on the management of advanced NSCLC patients, especially those with a high level of PD-L1 expression (Gridelli and Casaluce, 2018; Hanna et al, 2020)

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