Cost-Effectiveness of Initial Versus Delayed Lanreotide for Treatment of Metastatic Enteropancreatic Neuroendocrine Tumors

Abstract

Background: The Controlled Study of Lanreotide Antiproliferative Response in Neuroendocrine Tumors (CLARINET) trial showed prolonged progression-free survival in patients initially treated with lanreotide versus placebo. We evaluated the cost-effectiveness of upfront lanreotide versus active surveillance with lanreotide administered after progression in patients with metastatic enteropancreatic neuroendocrine tumors (NETs), both of which are treatment options recommended in NCCN Clinical Practice Guidelines in Oncology for Neuroendocrine and Adrenal Tumors. Methods: We developed a Markov model calibrated to the CLARINET trial and its extension. We based the active surveillance strategy on the CLARINET placebo arm. We calculated incremental cost-effectiveness ratios (ICERs) in dollars per quality-adjusted life-year (QALY). We modeled lanreotide’s cost at $7,638 per 120 mg (average sales price plus 6%), used published utilities (stable disease, 0.77; progressed disease, 0.61), adopted a healthcare sector perspective and lifetime time horizon, and discounted costs and benefits at 3% annually. We examined sensitivity to survival extrapolation and modeled octreotide long-acting release (LAR) ($6,183 per 30 mg). We conducted one-way, multiway, and probabilistic sensitivity analyses. Results: Upfront lanreotide led to 5.21 QALYs and a cost of $804,600. Active surveillance followed by lanreotide after progression led to 4.84 QALYs and a cost of $590,200, giving an ICER of $578,500/QALY gained. Reducing lanreotide’s price by 95% (to $370) or 85% (to $1,128) per 120 mg would allow upfront lanreotide to reach ICERs of $100,000/QALY or $150,000/QALY. Across a range of survival curve extrapolation scenarios, pricing lanreotide at $370 to $4,000 or $1,130 to $5,600 per 120 mg would reach ICERs of $100,000/QALY or $150,000/QALY, respectively. Our findings were robust to extensive sensitivity analyses. The ICER modeling octreotide LAR is $482,700/QALY gained. Conclusions: At its current price, lanreotide is not cost-effective as initial therapy for patients with metastatic enteropancreatic NETs and should be reserved for postprogression treatment. To be cost-effective as initial therapy, the price of lanreotide would need to be lowered by 48% to 95% or 27% to 86% to reach ICERs of $100,000/QALY or $150,00/QALY, respectively.

Computing the Cost of Care per Patient per Day for Patients With Metastatic Neuroendocrine Neoplasms

“…We identified systemic therapy, specifically somatostatin analogs, as the primary driver of high cost in this population of patients, in line with findings from previous studies from other countries. [24][25][26] Our study adds to the growing body of literature 21,24,26,28 that supports careful consideration of limiting the upfront use of somatostatin analogs, particularly in patients with low-grade disease, to optimize high value care. Future studies using this methodology should incorporate the cost of PRRT to reflect the current state of metastatic NEN treatment, study the impact of insurance type on the CCPD and survival, and aim to capture costs at other institutions or health care systems for comparison to identify best practices for delivering highvalue care.…”

“…Although there is literature aimed at assessing the costeffectiveness of various NEN-specific therapeutics [18][19][20][21][22][23] and the economic burden of NENs to patients and families, 9,10,17,24 the overall body of evidence is sparse. [5][6][7] This study demonstrates a novel and effective approach to assessing the cost of care for metastatic NENs at an academic center via the CCPD methodology.…”

“…A study by Barnes et al investigated the cost-effectiveness of upfront lanreotide use in patients with grade 1-2, nonfunctioning gastroenteropancreatic NENs, which showed that upfront lanreotide results in similar quality of life compared with active surveillance followed by lanreotide upon progression. 21 At current prices, lanreotide was not deemed to be cost-effective. 21 Our findings and those of the study by Barnes et al 21 support the need for further research to elucidate the cost-effectiveness of somatostatin analogs.…”

“…21 At current prices, lanreotide was not deemed to be cost-effective. 21 Our findings and those of the study by Barnes et al 21 support the need for further research to elucidate the cost-effectiveness of somatostatin analogs.…”

Benchmark Method for Cost Computations Across Health Care Systems: Cost of Care per Patient per Day in Breast Cancer Care

“…The CCPD builds upon techniques developed in the Medicare-SEER database and extends the methodology to We are employing our methodology to study cancer care value in neuroendocrine tumors, in prostate cancer, and across systems in breast cancer. 19,20 We acknowledge that the fee schedule may not accurately reflect actual costs and charges and often bundles payments together with one charge, but the fee schedule has the advantage of being publicly available, updated yearly, and includes a cost adjustment for both geographic regions.…”