Cost Effectiveness of PD-L1-Based Test-and-Treat Strategy with Pembrolizumab as the First-Line Treatment for Metastatic NSCLC in Hong Kong

Abstract

Background Pembrolizumab, a monoclonal antibody against programmed death ligand 1 (PD-L1), is approved by several regulatory agencies for first-line treatment of metastatic non-small-cell lung cancer (NSCLC) with a PD-L1 tumor proportion score (TPS) ≥ 50% and no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase genomic tumor aberrations. This study was conducted from the perspective of the Hospital Authority in Hong Kong and aimed to evaluate the cost effectiveness of a biomarker (PD-L1) test-and-treat strategy (BTS), in which patients with a TPS ≥ 50% received pembrolizumab and other patients received platinum doublet chemotherapy versus all patients receiving platinum doublet chemotherapy. Methods The model used a partitioned survival approach to estimate the incremental cost-effectiveness ratio (ICER) expressed as the cost per quality-adjusted life-year (QALY) gained. The clinical efficacy, utility and safety data were derived from the KN024 trial. Costs and health outcomes were projected over a 10-year time horizon and discounted at 3% per year. Costs for drug acquisition, PD-L1 testing, drug administration and disease management were used. Sensitivity analyses were conducted to evaluate the robustness of results. Results The BTS approach led to an increase of 0.29 QALYs at an additional cost of Hong Kong dollars (HK$) 249,077 (US$31,933) compared with platinum doublet chemotherapy, resulting in an ICER of HK$865,189 (US$110,922) per QALY gained. This is lower than the World Health Organization cost-effectiveness threshold of three times the 2016 gross domestic product (GDP) per capita for Hong Kong of HK$1017,819 (US$130,490). Probabilistic sensitivity analyses showed a 59.4% chance that the ICER would be below this threshold. Conclusion First-line treatment with pembrolizumab in a BTS to identify patients with NSCLC with PD-L1 TPS ≥ 50% can be considered cost effective in Hong Kong compared with platinum doublet chemotherapy based on a three-times GDP per capita threshold. However, local data on clinical efficacy and safety were not available to estimate overall survival (OS) and progression-free survival (PFS) specific to patients with NSCLC in Hong Kong. Further, uncertainty is inherent in the survival projections/extrapolation of PFS and OS beyond the trial period, and future research may help to further inform these parameters.A programmed death ligand 1 (PD-L1) test-and-treat strategy for the use of pembrolizumab in patients undergoing first-line treatment for non-small-cell lung cancer (NSCLC) with PD-L1 expression ≥ 50% is associated with a gain of 0.29 quality-adjusted life-years (QALYs), at an additional total cost of Hong Kong dollars (HK$) 249,077 per patient compared with platinum doublet chemotherapy (incremental cost-effectiveness ratio [ICER] of HK$865,189 per QALY gained) (year 2016 values).Key cost-effectiveness drivers were the drug acquisition costs and projections of improved survival.The ICER was below the threshold of three times gross domestic product per capita fo...

Cost effectiveness of immune checkpoint inhibitors for treatment of non-small cell lung cancer: A systematic review

“…Treatments compared in each study varied across studies. Among studies analyzing the first-line treatment, most studies compared pembrolizumab with platinum-based chemotherapy based on KEYNOTE 024 [9] or KEYNOTE 042 trial [42] (N = 10) [23,25,26,28,32,34,36,38,40,41]. The remainders evaluated pembrolizumab plus chemotherapy versus chemotherapy alone or pembrolizumab alone, combination of atezolizumab and chemotherapy versus chemotherapy.…”

“…In the first-line treatment setting, studies were differentiated according to PD-L1 expression levels (PD-L1 � 50%; PD-L1 � 1%; all PD-L1 expression levels). For patients with PD-L1 � 50%, pembrolizumab could be a cost-effective first-line treatment compared with platinum-based chemotherapy from the perspective of US health care system or third-party payer [23,25], French healthcare system [28] and Hospital Authority in Hong Kong (China) [36], while not cost-effective in the UK [25,26], France [28] or China [34]. Four studies evaluated the cost-effectiveness of first-line treatments in PD-L1 � 1% patients [32,38,40,41].…”

<p>Economic Evaluations of Immune Checkpoint Inhibitors for Patients with Non-Small Cell Lung Cancer: A Systematic Review</p>

“…Four studies were conducted in China, and one of them was conducted in the Hong Kong region. Fourteen, 21,22,[24][25][26][27][28][29][30][31]34,[38][39][40] four, 33,[35][36][37] and three 12,23,32 studies focused on pembrolizumab, nivolumab, and atezolizumab, respectively. No study investigated durvalumab.…”

“…The expression of PD-L1 affects the selection of immune checkpoint inhibitors. Fourteen studies 21,22,[24][25][26][27][28][29][30][31]34,[38][39][40] mentioned positive PD-L1 or high level of PD-L1, whereas one studies 36 explored the cost-effectiveness of PD-L1 testing. The other studies were not clearly stated.…”

“…About half of the studies 12,[22][23][24][25][28][29][30][31]33,36,38,39 did not provide reasons for their selected decision-analytic model nor report heterogeneity. Most studies 12,[21][22][23][24][25][26][27][28][31][32][33][34]37,39,40 did not mention whether there was preference measurement and evaluation. Many studies 12,22,23,25,26,28,30,31,34,35,37,38,40 did not report currency, price date and conversion.…”