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- Title
Cost-effectiveness of Pembrolizumab Plus Axitinib Vs Nivolumab Plus Ipilimumab as First-Line Treatment of Advanced Renal Cell Carcinoma in the US.
- Authors
Watson, Tina R.; Gao, Xin; Reynolds, Kerry L.; Kong, Chung Yin
- Abstract
This economic evaluation compares the cost-effectiveness of pembrolizumab-axitinib vs nivolumab-ipilimumab for treatment of advanced renal cell carcinoma (ARCC) in the US. Key Points: Question: Is pembrolizumab-axitinib cost-effective as first-line treatment of advanced renal cell carcinoma compared with nivolumab-ipilimumab, the other preferred first-line regimen? Findings: In this economic evaluation using a microsimulation model, pembrolizumab-axitinib provided incremental benefit over nivolumab-ipilimumab by a measure of quality-adjusted life-years but was not cost-effective at a willingness-to-pay threshold of $100 000 per quality-adjusted life-year. Meaning: The findings suggest that pembrolizumab-axitinib may be a valuable therapy for advanced renal cell carcinoma but may become more cost-effective with price reductions. Importance: Checkpoint inhibitor combination therapy represents a major advance in the first-line treatment of advanced renal cell carcinoma. Pembrolizumab-axitinib and nivolumab-ipilimumab have become standard of care options after demonstrating clinical efficacy against sunitinib in separate phase 3 trials. The cost-effectiveness of these regimens is unknown. Objective: To evaluate the cost-effectiveness of pembrolizumab-axitinib and nivolumab- ipilimumab in the first-line treatment of advanced renal cell carcinoma. Design, Setting, and Participants: For this economic evaluation, a primary microsimulation model was developed and run between August and December 2019. Separate analyses were conducted for an intermediate- and poor-risk patient population (base case) and a favorable-risk population (exploratory analysis) because prognosis is known to differ between risk groups; 100 000 patients with advanced renal cell carcinoma were simulated in each treatment arm. Survival, treatment regimens, and other relevant conditions were based on data from the phase 3 KEYNOTE-426 and CheckMate214 clinical trials. The study perspective was the US health care sector. Main Outcomes and Measures: An incremental cost-effectiveness ratio was calculated for each of the 2 analyses and compared with a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results: Pembrolizumab-axitinib was estimated to add 0.60 QALYs compared with nivolumab-ipilimumab in the base case analysis (3.66 vs 3.05 QALYs) and 0.25 QALYs compared with nivolumab-ipilimumab in the exploratory analysis (4.55 vs 4.30 QALYs), and was more costly (base case analysis: $562 927 vs $458 961; exploratory analysis: $589 035 vs $470 403). The incremental cost-effectiveness ratio was $172 532 per QALY in the base case analysis and $468 682 per QALY in the exploratory analysis. One-way sensitivity analyses revealed that the base case model was most sensitive to first-line drug prices (incremental cost-effectiveness ratio at upper limit of nivolumab price and lower limits of axitinib and pembrolizumab prices: $89 983, $102 287, and $114 943 per QALY, respectively). The exploratory analysis model was most sensitive to overall survival rates (incremental cost-effectiveness ratio at lower limit of pembrolizumab-axitinib rate and upper limit of nivolumab-ipilimumab rate: $278 644 and $285 684 per QALY, respectively). Conclusions and Relevance: The findings suggest that pembrolizumab-axitinib treatment is associated with greater QALYs compared with nivolumab/ipilimumab treatment in patients with advanced renal cell carcinoma but may not be cost-effective. Price reductions may make the cost of pembrolizumab-axitinib proportional to its clinical value and less financially burdensome to the US health care system.
- Subjects
UNITED States; NIVOLUMAB; ANTINEOPLASTIC agents; COST effectiveness; IMMUNOTHERAPY; MONOCLONAL antibodies; RENAL cell carcinoma; RESEARCH; SURVIVAL; QUALITY-adjusted life years; DATA analysis software
- Publication
JAMA Network Open, 2020, Vol 3, Issue 10, pe2016144
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2020.16144