Abstract
ObjectiveAdvanced renal cell carcinoma (RCC) is commonly treated with vascular endothelial growth factor or mammalian target of rapamycin inhibitors. As new therapies emerge, interest grows in gaining a deeper understanding of treatment sequences. Recently, we developed a patient-level, discretely integrated condition event (DICE) simulation to estimate survival and lifetime costs for various cancer therapies, using a US payer perspective. Using this model, we explored the impact of treatments such as nivolumab and cabozantinib, and compared the clinical outcomes and cost consequences of commonly used treatment algorithms for patients with advanced RCC.MethodsIncluded treatment sequences were pazopanib or sunitinib as first-line treatment, followed by nivolumab, cabozantinib, axitinib, pazopanib or everolimus. Efficacy inputs were derived from the CheckMate 025 trial and a network meta-analysis based on available literature. Safety and cost data were obtained from publicly available sources or literature.ResultsBased on our analysis, the average cost per life-year (LY) was lowest for sequences including nivolumab (sunitinib → nivolumab, $75,268/LY; pazopanib → nivolumab, $84,459/LY) versus axitinib, pazopanib, everolimus and cabozantinib as second-line treatments. Incremental costs per LY gained were $49,592, $73,927 and $30,534 for nivolumab versus axitinib, pazopanib and everolimus-containing sequences, respectively. The model suggests that nivolumab offers marginally higher life expectancy at a lower cost versus cabozantinib-including sequences.ConclusionTreatment sequences using nivolumab in the second-line setting are less costly compared with sequential use of targeted agents. In addition to efficacy and safety data, cost considerations may be taken into account when considering treatment algorithms for patients with advanced RCC.
Highlights
Kidney cancer is responsible for 2.4% of all adult malignancies, with approximately 338,000 new cases and 114,000 deaths annually [1]
The model suggests that nivolumab offers marginally higher life expectancy at a lower cost versus cabozantinibincluding sequences
Treatment sequences using nivolumab in the second-line setting are less costly compared with sequential use of targeted agents
Summary
Kidney cancer is responsible for 2.4% of all adult malignancies, with approximately 338,000 new cases and 114,000 deaths annually [1]. In the pre-targeted therapy era, median survival for people with metastatic RCC was ~8 months with no treatment [4] or ~13 months with immunotherapy [5]. Treatment of advanced RCC has evolved with the development of targeted therapies including vascular endothelial growth factor receptor tyrosine kinase inhibitors (TKIs), such as bevacizumab, sunitinib, sorafenib, pazopanib, axitinib, cabozantinib and lenvatinib or mammalian target of rapamycin inhibitors, such as everolimus and temsirolimus [6]. In a phase III clinical trial, cabozantinib improved PFS (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.45–0.75; P
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