Abstract
ObjectiveOur previous economic assessment found that nivolumab was not cost-effective for Chinese patients with advanced non-small cell lung cancer (NSCLC) and without EGFR mutations or ALK translocations, when compared with the standard second-line drug docetaxel. However, a greater survival benefit with nivolumab was observed for patients with 1% or greater tumor programmed death ligand 1 (PD-L1) expression. In view of this, we designed the present analysis to explore whether it is cost-effective to use the PD-L1 test to guide second-line nivolumab treatment in China.Material and MethodsA Markov model was established to project the lifetime costs and quality-adjusted life-years (QALYs) of three second-line treatment strategies: nivolumab and docetaxel (strategies without a PD-L1 test) and PD-L1 test-based strategy. Deterministic and probabilistic sensitivity analyses were performed to examine the robustness of our results. Additional price reduction and willingness-to-pay (WTP) threshold scenario analyses were performed to explore the impact of economic and health policies with Chinese characteristics on our results.ResultsThe PD-L1 test-based strategy costs approximately CNY 194,607 (USD 28,210) or more and yielded an additional 0.27 QALYs compared to the docetaxel strategy without a PD-L1 test, equating an incremental cost-effectiveness ratio (ICER) of CNY 731,089 (USD 105,978)/QALY. Deterministic sensitivity analyses showed that the price of nivolumab was the strongest source of variation in the ICERs. Probability sensitivity analysis showed that the probability for the PD-L1 test-based strategy being cost-effective increases with the increase of WTP thresholds.ConclusionFrom the perspective of the Chinese healthcare system, using a PD-L1 test to guide second-line nivolumab treatment was not cost-effective. The National Healthcare Security Administration negotiation on the price reduction of nivolumab was found to be the most effective action to improve its cost-effectiveness in China.
Highlights
Lung cancer remains a major public health problem and the most commonly diagnosed cancer in China that contributes to 27% of all cancer-related deaths [1]
The crucial evidence underpinning the approval of nivolumab was yielded from the CheckMate 078 Phase III clinical trials, in which nivolumab was found that significantly improved the overall survival (OS) in Non-small cell lung cancer (NSCLC) patients compared with docetaxel [8]
We explored the probability that the programmed death ligand 1 (PD-L1) test-based strategy (C) is cost-effective when compared with alternative treatment strategies under different WTPs (3 × per capita gross domestic product (GDP) value of each province-level administrative unit)
Summary
Lung cancer remains a major public health problem and the most commonly diagnosed cancer in China that contributes to 27% of all cancer-related deaths [1]. >Nivolumab as the first programmed death 1 (PD-1) ICI, was officially authorized by the Chinese State Food and Drug Administration (SFDA) as a second-line therapy for NSCLC in June 2018 [7]. This study found that the nivolumab therapy was more effective in treating advanced NSCLC with a programmed death ligand 1 (PD-L1) tumor proportion score (TPS) ≥1% (the median OS: 12.3) [8]. The National Comprehensive Cancer Network (NCCN) guidelines of the United States recommend routine testing for PD-L1 expression in patients with diagnosed advanced NSCLC, and PD-L1 expression has been demonstrated as a reliable biomarker to predict benefits from immunotherapy [9, 10], there is lack of such recommendation in relevant Chinese treatment guidelines [11]
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