Abstract
Immune checkpoint inhibitors improve outcomes compared with chemotherapy in lung cancer. Tumor PD-L1 receptor expression is being studied as a predictive biomarker. The objective of this study was to assess the cost-effectiveness and economic impact of second-line treatment with nivolumab, pembrolizumab, and atezolizumab with and without the use of PD-L1 testing for patient selection. We developed a decision-analytic model to determine the cost-effectiveness of PD-L1 assessment and second-line immunotherapy versus docetaxel. The model used outcomes data from randomized clinical trials (RCTs) and drug acquisition costs from the United States. Thereafter, we used epidemiologic data to estimate the economic impact of the treatment. We included four RCTs (2 with nivolumab, 1 with pembrolizumab, and 1 with atezolizumab). The incremental quality-adjusted life year (QALY) for nivolumab was 0.417 among squamous tumors and 0.287 among non-squamous tumors and the incremental cost-effectiveness ratio (ICER) were $155 605 and $187 685, respectively. The QALY gain in the base case for atezolizumab was 0.354 and the ICER was $215 802. Compared with treating all patients, the selection of patients by PD-L1 expression improved incremental QALY by up to 183% and decreased the ICER by up to 65%. Pembrolizumab was studied only in patients whose tumors expressed PD-L1. The QALY gain was 0.346 and the ICER was $98 421. Patient selection also reduced the budget impact of immunotherapy. The use of PD-L1 expression as a biomarker increases cost-effectiveness of immunotherapy but also diminishes the number of potential life-years saved.
Highlights
Lung cancer is the most common cause of cancer-related death in the United States and the world [1, 2]
The model compared three main strategies: (i) tumor sample not tested for PD-L1 expression and all patients treated with docetaxel, (ii) tumor sample not tested for PD-L1 expression and all patients treated with immunotherapy, and (iii) patients treated according to their PD-L1 status: immunotherapy for patients with PD-L1 expression of 1% or more and docetaxel for patients without PD-L1 expression (Figure 1)
In the base case of patients with squamous histology, the qualityadjusted life year (QALY) gained with nivolumab was 0.417, and the corresponding incremental cost-effectiveness ratio (ICER) was USD 155 605
Summary
Lung cancer is the most common cause of cancer-related death in the United States and the world [1, 2]. Despite innovative drug development in the past two decades, there are few options for second-line treatment and the most commonly used agent in the United States before the advent of immune checkpoint inhibitors was docetaxel [4]. Immune checkpoint inhibitors improve outcomes compared with chemotherapy in lung cancer. The objective of this study was to assess the cost-effectiveness and economic impact of second-line treatment with nivolumab, pembrolizumab, and atezolizumab with and without the use of PD-L1 testing for patient selection. The incremental qualityadjusted life year (QALY) for nivolumab was 0.417 among squamous tumors and 0.287 among non-squamous tumors and the incremental cost-effectiveness ratio (ICER) were $155 605 and $187 685, respectively. Conclusion: The use of PD-L1 expression as a biomarker increases cost-effectiveness of immunotherapy and diminishes the number of potential life-years saved.
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