Cost-Effectiveness of Frontline Treatment for Advanced Renal Cell Carcinoma in the Era of Immunotherapies

Abstract

Background: Recent randomized controlled trials have demonstrated that immune checkpoint inhibitors (ICIs) improve patient outcomes, but whether these novel agents are cost-effective for untreated advanced renal cell carcinoma (aRCC) remains unclear.Materials and Methods: A microsimulation model was created to project the healthcare costs and outcomes of six strategies (lenvatinib-plus-pembrolizumab, nivolumab-plus-cabozantinib, nivolumab-plus-ipilimumab, pembrolizumab-plus-axitinib, avelumab-plus-axitinib, and sunitinib monotherapy) for patients with aRCC. Transition probability of patients was estimated from CLEAR, CheckMate 9ER, CheckMate 214, KEYNOTE-426, JAVELIN Renal 101, and other data sets by using parametric survival modeling. Lifetime direct medical costs, life years (LYs), quality-adjusted LYs (QALYs), and incremental cost-effectiveness ratios (ICERs) were estimated from a United States payer perspective. One-way and probabilistic sensitivity analyses were performed, along with multiple scenario analyses, to evaluate model uncertainty.Results: Of the six competing strategies, nivolumab-plus-cabozantinib yielded the most significant health outcomes, and the sunitinib strategy was the least expensive option. The cost-effective frontier consisted of the nivolumab-plus-cabozantinib, pembrolizumab-plus-axitinib, and sunitinib strategies, which displayed the ordered ICERs of $81282/QALY for pembrolizumab-plus-axitinib vs sunitinib and $453391/QALY for nivolumab-plus-cabozantinib vs pembrolizumab-plus-axitinib. The rest of the strategies, such as lenvatinib-plus-pembrolizumab, nivolumab-plus-ipilimumab, and avelumab-plus-axitinib, were dominated. The cost of sunitinib drove the model most influentially.Conclusions: For aRCC, the pembrolizumab-plus-axitinib strategy is likely to be the most cost-effective alternative at the willingness-to-pay threshold of $100,000.

Cost-Effectiveness of Lenvatinib Plus Pembrolizumab or Everolimus as First-Line Treatment of Advanced Renal Cell Carcinoma

“…Li et al. ( 16 ) constructed a network meta-analysis (NMA) and microscopic decision tree model for cost-effective analysis of the advanced first-line renal cell cancer. The health benefit of lenvatinib plus pembrolizumab was 2.61 QALY, and ICER did not dominate compared with sunitinib.…”

“…The model period was five years, and the study model only calculated direct medical costs, including drug costs, adverse event management costs, subsequent treatment costs after disease progression, follow-up costs, and hospital service program costs. The incidence of adverse events was estimated from the CLEAR ( 13 ) randomized controlled trial study, and the utility values were extracted from previous studies ( 14 – 16 ). The cost unit is expressed in local currency.…”

“…Health utility scores were collected from the public literature ( 14 , 16 , 26 ). The PFS status utility was 0.82 for the lenvatinib plus pembrolizumab or everolimus groups and 0.73 for the sunitinib group, while the PD status utility was 0.66.…”

Economic evaluation of first-line nivolumab plus cabozantinib for advanced renal cell carcinoma in China

“…The model mainly calculates direct medical costs and the adverse event rate was taken from the CheckMate9ER RCT study. Utility values were derived from previous studies ( 22 ). According to the China Guidelines for Pharmacoeconomic Evaluation issued by the Chinese Pharmaceutical Association, we discounted the cost and utility values by 5% per year.…”

“…Health utility values were obtained from the literature. We assumed a PFS status utility of 0.82 for nivolumab plus cabozantinib, a PFS utility of 0.73 for sunitinib, and a PD status utility of 0.66 ( 22 ). Our model included the ≥3-grade treatment related to AE with an incidence above 5%, as reported in the CheckMate9ER trial.…”