Are immune checkpoint inhibitors only cost effective in NSCLC patients expressing PD-L1?
- Programmed death-ligand 1 (PD-L1) is associated with longer progression-free survival for some patients with non-small cell lung cancer (NSCLC),
- Treatment with immune checkpoint inhibitors, although effective, is an expensive treatment choice
- The use of predictive PD-L1 biomarkers could increase cost effectiveness and reduce economic burden
Immunotherapies have been a key focus of this year’s European Society for Medical Oncology Congress. But are they a cost effective option for all patient subtypes? Dr Ramon de Mello, Medical Oncologist and Professor of the Department of Biomedical Science, University of Algarve, Portugal, shared important research on the costs of immune checkpoint inhibitors for NSCLC, taking into account PD-L1 expression.
“NSCLC is a very aggressive disease,” Dr de Mello began. He went on to explain that in the last decade “standard chemotherapy was the only option to treat this disease.” Immunotherapy, however, “is emerging as a new cornerstone of this cancer treatment. The results are very impressive.”
“If you treat all patients with immunotherapy, it is really not cost effective,”
Dr Ramon de Mello, Medical Oncologist and Professor, Department of Biomedical Science, University of Algarve, Portugal
Recent clinical trials have shown promising outcomes in terms of overall and progression-free survival, however treatment with immune checkpoint inhibitors is an expensive option. It raises the important question of whether the treatment is effective enough in all patient subgroups to justify the expense. Answering this question is particularly important for countries that are less economically developed.
For this reason, Dr de Mello and his team investigated the cost effectiveness of immune checkpoint inhibitors in Brazil and the US. As part of the analysis, the team determined whether PD-L1 expression, the key molecular target for immune checkpoint inhibitors, is correlative with increased cost effectiveness.
A decision-analytic model was used to investigate the cost effectiveness of nivolumab and pembrolizumab, second line, versus docetaxel. Data were analysed from three randomised clinical trials (two nivolumab; squamous and non-squamous NSCLC, one pembrolizumab). Disease burden was measured using quality-adjusted life-years (QALY) and costs by incremental cost-effectiveness ratios (ICER).
Results showed that patients treated with nivolumab saw an incremental QALY of 0.23 (squamous) and 0.12 (non-squamous). ICER for nivolumab was US $128,000 (squamous) and US $121,000 (non-squamous).
QALY was improved incrementally for patients with PD-L1 expression levels of >5% and >10% in those of squamous histology (by 15% and 18%, respectively). For those with non-squamous NSCLC, QALY was improved incrementally for patients with >1%, >5% and >10% PD-L1 expression (by 67%, 157% and 137%, respectively).
In patients treated with pembrolizumab, all of whom had ≥1% PD-L1 expression, the incremental QALY was 0.13 and the ICER was US $116,000. Patients with PD-L1 expression of >50% showed improved QALY (by 18%).
“We found that if you analysed patients’ treatment with immunotherapy and also their PD-L1 expression, the patients with >1% PD-L1 expression could be more cost effective,” Dr de Mello explained.
An economic impact estimate for Brazil showed that PD-L1 expression of >1% with nivolumab or pembrolizumab made treatment 46% and 34% more cost effective in terms of life-years saved. In patients with PD-L1 expression >50% receiving pembrolizumab, treatment was 72% more cost effective.
Dr de Mello reflected on how the analysis could affect future treatment choices for NSCLC, stating that healthcare professionals could use the analysis to rationalise patients most suitable for treatment with immune checkpoint inhibitors.
“If you treat all patients with immunotherapy,” Dr de Mello said, summarising the US-based results, “it is really not cost effective.” As is expected, due to the agents’ mechanisms of action, treating patients expressing >50% PD-L1 was found to be particularly cost effective.
The balance between finding high-quality clinical care while saving excessive costs is an important challenge for clinicians. The work Dr de Mello carried out will surely be a useful reference for assessing treatment choices for NSCLC in economically developed and undeveloped countries alike.
Based on Aguiar Junior P, de Mello R et al. Cost effectiveness and estimate of economical impact of immune checkpoint inhibitors for NSCLC relative to PD-L1 expression (1224P). Presented on Saturday 8 October 2016.
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