Cost-Effectiveness of Immune Checkpoint Inhibitors in Urothelial Carcinoma—A Review

Abstract

Over the last decade, an increasing number of immune checkpoint inhibitors (ICIs) have been assessed for therapeutic efficacy in urothelial carcinoma (UC). The high cost has prompted multiple cost-effectiveness analyses for the various disease stages, with no established consensus. We reviewed the literature to assess the available cost-effectiveness studies and summarize their findings. Studies were filtered for a calculated incremental cost-effectiveness ratio (ICER) to standardize comparison. Over 2600 articles were narrowed to eight primary investigations: one for BCG-refractory non-muscle invasive (NMI), one for neoadjuvant therapy in muscle-invasive (MI), and six for advanced disease. Cost-effectiveness was not achieved for NMI disease. Atezolizumab met the willingness-to-pay (WTP) threshold as neoadjuvant therapy for MI disease compared to chemotherapy, but with multiple limitations on the interpretation. Of the six studies on advanced disease, the results were mixed. This was at least partially attributable to varied methodologies including extrapolated time horizons, inconsistent cost inputs, and different WTP thresholds. Overall, the aggregate results were not compelling enough to establish ICIs as cost-effective compared to conventional chemotherapy. Value may improve with continued investigation into long-term outcomes, refined patient selection, and pricing discounts.

Cost-Effectiveness of Avelumab Maintenance Therapy Plus Best Supportive Care vs. Best Supportive Care Alone for Advanced or Metastatic Urothelial Carcinoma

“…The five-year OS rate for mUC is poor and recently a few studies in the US reported that only a small proportion of patients with mUC accepted subsequent lines therapy after first-line therapy, almost half of the patients did not accept treatments for advanced or metastatic disease ( 26 ). Therefore, maintenance treatment is particularly important which can reduce the recurrence rates for patients with mUC.…”

The Evolving Role of Checkpoint Inhibitors in the Treatment of Urothelial Carcinoma: A Literature Review of Practice-Changing Trials

“…A critical concern with immunotherapy/ICI therapy is that, despite its clear oncological benefits and therapeutic efficacy, cost-effectiveness analyses have not been compelling enough to recommend its use for all candidates [59]. Current socioeconomic constraints on healthcare have limited its use to advanced, metastatic diseases, and cost-benefit analyses comparing it to conventional chemotherapy and between different ICI agents have yielded mixed results.…”

Prioritizing potential circRNA biomarkers for bladder cancer and bladder urothelial cancer based on an ensemble model

“…Advanced disease or relapse of radical cystectomy is closely associated with the poor outcomes ( Nouhaud et al, 2021 ). The first-line therapy of metastatic bladder urothelial cancer usually adopts cisplatin-based combinations, and has been unaltered over the last decades ( Powles et al, 2021 ; Renner et al, 2021 ; Walia et al, 2021 ). Unfortunately, almost all patients with bladder urothelial cancer will finally progress and die from bladder cancer, despite their initial response to cisplatin-based combinations ( Bin Riaz et al, 2021 ; Lopez-Beltran et al, 2021 ).…”