The importance of histology when evaluating the cost-effectiveness of pemetrexed plus cisplatin as first-line therapy for advanced non-small cell lung cancer

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e17533 Background: A recent randomized phase III study was the first to report survival differences between first-line platinum doublets based on non-small cell lung cancer (NSCLC) histology (Scagliotti et al, J Clin Oncol. 2008). Here, we estimate the cost-effectiveness of cisplatin/pemetrexed (Cis/Pem) compared to other common regimens in an overall NSCLC population and in histology subgroups. Methods: A semi-Markov model was developed to compare the two-year impact of Cis/Pem to cisplatin/gemcitabine (Cis/Gem), carboplatin/paclitaxel (Carb/Pac) and carboplatin/paclitaxel/bevacizumab (Carb/Pac/Bev) from the US payer perspective. Data from the randomized controlled clinical trial and a mixed treatment comparison model (Vansteenkiste et al, Proc. ITOC 2008) provided clinical inputs. Medicare reimbursement rates were used to determine drug costs. A retrospective claims database analysis was used to obtain estimates of other direct NSCLC-related costs, including drug administration and toxicity management. Nonsquamous histology subgroups explored were adenocarcinoma, large cell and not otherwise specified (NOS). Comparisons with Carb/Pac/Bev were limited to the nonsquamous histology subgroup. Results: In all patients regardless of histology, using Cis/Pem led to an incremental cost per life-year gained (LYG) of $104,577 vs. Cis/Gem and $231,291 vs. Carb/Pac. In the subset of patients with nonsquamous NSCLC (adenocarcinoma, large cell, or NOS), the incremental cost per LYG was $83,537 vs. Cis/Gem and $178,613 vs. Carb/Pac. Further specifying the population to include only those with adenocarcinoma or large cell NSCLC yielded an incremental cost per LYG of $72,325 vs. Cis/Gem and $132,547 vs. Carb/Pac. The incremental cost per LYG for Carb/Pac/Bev vs. Cis/Pem was more than $300,000. Conclusions: In an unselected advanced NSCLC population, Cis/Pem may not be considered cost-effective for first-line therapy; however, in its licensed indication of nonsquamous NSCLC, it can be considered cost-effective and even more so for patients with adenocarcinoma or large cell carcinoma. This analysis emphasizes the importance of histology in identifying the appropriate patient for Cis/Pem first-line chemotherapy. [Table: see text]