The effect of PD-L1 testing on the cost-effectiveness and economic impact of immune checkpoint inhibitors for the second-line treatment of NSCLC

The frequency of high PD-L1 expression is low in lung adenocarcinoma patients from Northeast Brazil

Background

As Immune checkpoint inhibitors (ICPIs) are changing the standard-care in lung cancer with good clinical activities and durable responses, its indication must be based on the appropriate patient selection once only a fraction of patients has a response to these costly drugs. In larger cohorts the expression of programmed cell death–ligand 1 (PD-L1) has been associated with good clinical response of ICPIs in lung adenocarcinoma where the rate of high PD-L1 expression (defined as PD-L1tumor proportion score ≥ 50%) is ~ 30%, but once rare studies are available addressing the frequency of PD-L1 in populations outside those cohorts, we aimed to report the prevalence of PD-L1 and the frequency of patients with high PD-L1 expression utilizing data from a major pathology laboratory in Northeastern Brazil.

Methods

We retrospectively evaluated the PD-L1 expression in 158 surgically resected primary lung adenocarcinoma including 158 with anaplastic lymphoma kinase (ALK) expression. PD-L1 and ALK expression were evaluated by immunohistochemical analysis with the SP263 and D5F3 assays, respectively.

Results

Of the 158 samples analyzed, 94 (59.5%) had a PD-L1 tumor proportion score (TPS) < 1%, 38 (24.0%) had a PD-L1 TPS of 1–49% and 26 (16.5%) had a PD-L1 TPS of ≥50%. ALK expression was detected in 21 (13.3%) of the 158 tumor samples and 5 (3.2%) of them had a PD-L1 TPS of ≥50%.

Conclusion

The frequency of strong PD-L1 expression was lower than that previously reported in the trials where PD-L1 expression was used as a biomarker for patient selection. Also, considering that a subset of patients with ALK positivity had a strong PD-L1 expression, further studies will be required to examine the efficacy of PD-1/PD-L1 inhibitors in such patients.

Influence of Vitamin D in Advanced Non-Small Cell Lung Cancer Patients Treated with Nivolumab

Nivolumab is one of the most commonly used monoclonal antibodies for advanced non-small cell lung cancer treatment, to the extent that the presence of its anti-antibody is considered a negative prognostic factor. Vitamin D (VD) modulates expression of the genes involved in drug metabolism and elimination. Immune system regulation and immunodeficiency is frequent in non-small cell lung cancer patients. To date, no data have been reported about the relationship between nivolumab and VD. The aim of this study was to quantify plasma 25-hydroxyVD (25-VD) and 1,25-VD, nivolumab, and its anti-antibody before starting treatment (baseline) and at 15, 45 and 60 days of therapy. VD-pathway-associated gene single nucleotide polymorphisms (SNPs) were also evaluated. Molecules were quantified through enzyme-linked immunosorbent assay, and SNPs through real-time PCR. Forty-five patients were enrolled. Median nivolumab concentrations were 12.5 μg/mL, 22.3 μg/mL and 27.1 μg/mL at 15, 45 and 60 days respectively. No anti-nivolumab antibodies were found. Correlations were observed between nivolumab concentrations and 25-VD levels. Nivolumab concentrations were affected by VD-pathway-related gene SNPs. VDBP AC/CC genotype and baseline 25-VD < 10 ng/mL predicted a nivolumab concentration cut-off value of <18.7 μg/mL at 15 days, which was associated with tumor progression. This is the first study showing VD marker predictors of nivolumab concentrations in a real-life context of non-small cell lung cancer treatment.

Lung cancer costs by treatment strategy and phase of care among patients enrolled in Medicare

Background

We studied trends in lung cancer treatment cost over time by phase of care, treatment strategy, age, stage at diagnosis, and histology.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for years 1998‐2013, we allocated total and patient‐liability costs into the following phases of care for 145 988 lung cancer patients: prediagnosis, staging, surgery, initial, continuing, and terminal. Patients served as self‐controls to determine cancer‐attributable costs based on individual precancer diagnosis healthcare costs. We fit linear regression models to determine cost by age and calendar year for each stage at diagnosis, histology, and treatment strategy and presented all costs in 2017 US dollars.

Results

Monthly healthcare costs prior to lung cancer diagnosis were $861 for a 70 years old in 2017 and rose by an average of $17 per year (P < 0.001). Surgery in 2017 cost $30 096, decreasing by $257 per year (P = 0.007). Chemotherapy and radiation costs remained stable or increased for most stage and histology groups, ranging from $4242 to $8287 per month during the initial six months of care. Costs during the final six months of life decreased for those who died of lung cancer or other causes.

Conclusions

Cost‐effectiveness analyses of lung cancer control interventions in the United States have been using outdated and incomplete treatment cost estimates. Our cost estimates enable updated cost‐effectiveness analyses to determine the benefit of lung cancer control from a health economics point of view.

Organ-specific response to nivolumab in patients with non-small cell lung cancer (NSCLC)

BACKGROUND

Response to immune checkpoint inhibitors depends on tumor intrinsic properties and also on host factors in the tumour microenvironment including the presence of immune cells (IC). We hypothesized that nivolumab efficacy varies across different metastatic sites.

METHODS

We retrospectively analyzed computed tomography scans of patients with metastatic non-small cell lung carcinoma (NSCLC) receiving nivolumab. RECIST 1.1 criteria were applied to assess the overall response rate (ORR) and organ-specific response rate (OSRR).

RESULTS

We analyzed 52 patients including 44% females, 58% adenocarcinoma and 8% never smokers. Involved organs had target-lesions in the lung (42%), liver (25%), lymph nodes (56%) and soft tissue (13%) and non-target lesions in the bones (23%). ORR and disease control rate (DCR) were 20% and 45%, respectively. Median overall survival, progression-free survival and duration of response were 11.9, 2.3 and 10.3 months. OSRR and organ-specific DCR (OSDCR) were 28% and 90% in lymph nodes, 8% and 54 in the liver, and 9% and 55% in lung metastases. Nine out of 12 patients with bone metastases had progressive lesions. The cumulative incidence probability of organ-specific progression at 6 months was 14% in lymph nodes, 42% in the liver, 36% in lung metastases and 26% in the primary tumor, 29% in soft tissue and 33% in adrenal metastases.

CONCLUSION

In conclusion, the efficacy of immunotherapy is dependent on the metastatic location. Treatment appears more active in lymph nodes compared to other organ sites such as liver, adrenals and bone. Future strategies may include additional local treatment in case of oligoprogression in these organs in patients with otherwise sustained treatment benefit.

A systematic review of the cost and cost-effectiveness studies of immune checkpoint inhibitors

Background

Escalating healthcare costs are necessitating the practice of value-based oncology. It is crucial to critically evaluate the economic impact of influential but expensive therapies such as immune checkpoint inhibitors (ICIs). To date, no systematic assessment of the cost-effectiveness (CE) of ICIs has been performed.

Methods

PRISMA-guided systematic searches of the PubMed database were conducted. Studies of head/neck (n = 3), lung (n = 5), genitourinary (n = 4), and melanoma (n = 8) malignancies treated with ICIs were evaluated. The reference willingness-to-pay (WTP) threshold was $100,000/QALY.

Results

Nivolumab was not cost-effective over chemotherapy for recurrent/metastatic head/neck cancers (HNCs). For non-small cell lung cancer (NSCLC), nivolumab was not cost-effective for a general cohort, but increased PD-L1 cutoffs resulted in CE. Pembrolizumab was cost-effective for both previously treated and newly-diagnosed metastatic NSCLC. For genitourinary cancers (GUCs, renal cell and bladder cancers), nivolumab and pembrolizumab were not cost-effective options. Regarding metastatic/unresected melanoma, ipilimumab monotherapy is less cost-effective than nivolumab, nivolumab/ipilimumab, and pembrolizumab. The addition of ipilimumab to nivolumab monotherapy was not adequately cost-effective. Pembrolizumab or nivolumab monotherapy offered comparable CE profiles.

Conclusions

With limited data and from the reference WTP, nivolumab was not cost-effective for HNCs. Pembrolizumab was cost-effective for NSCLC; although not the case for nivolumab, applying PD-L1 cutoffs resulted in adequate CE. Most data for nivolumab and pembrolizumab in GUCs did not point towards adequate CE. Contrary to ipilimumab, either nivolumab or pembrolizumab is cost-effective for melanoma. Despite these conclusions, it cannot be overstated that careful patient selection is critical for CE. Future publication of CE investigations and clinical trials (along with longer follow-up of existing data) could substantially alter conclusions from this analysis.

Clinical significance of PD-1/PD-Ls gene amplification and overexpression in patients with hepatocellular carcinoma

Background: The remarkable clinical activity of PD-1 antibody in advanced hepatocellular carcinoma (HCC) highlights the importance of PD-1/PD-L1-mediated immune escape as therapeutic target in HCC. However, the frequency and prognostic significance of PD-Ls genetic alterations in HCC remain unknown.

Methods: Fluorescence in situ hybridization were used to determine PD-Ls genetic alterations, and qPCR data coupled with immunofluorescence were used to measure the mRNA and protein levels of PD-Ls. Clinical relevance and prognostic value of 9p24.1 genetic alterations were investigated on tissue microarray containing three independent cohorts of 578 HCC patients. The results were further validated in an independent cohort of 442 HCC patients from The Cancer Genome Atlas (TCGA) database.

Results: In total, 7.1%-15.0% for amplification and 15.8%-31.3% for polysomy of 9p24.1 were revealed in three cohorts of HCC patients, similar to the objective response rate of PD-1 antibody in HCC. Patients with 9p24.1 genetic alterations significantly and independently correlated with unfavorable outcomes than those without. FISH and qPCR data coupled with immunofluorescence revealed that genetic alterations of 9p24.1 robustly contributed to PD-L1 and PD-L2 upregulation. In addition, increased expression of PD-L1 instead of PD-L2 also predicted poor survival by multivariate analyses. Meanwhile, high infiltration of PD-1⁺ immune cells also indicated dismal survival in HCC.

Conclusions: Amplification or higher expression of PD-L1 significantly and independently correlated with unfavorable survival in HCC patients, authenticating the PD-1/PD-L1 axis as rational immunotherapeutic targets for HCC.

Noninvasive imaging of the PD-1:PD-L1 immune checkpoint: Embracing nuclear medicine for the benefit of personalized immunotherapy

Molecular imaging of the immune checkpoint receptor PD-1 and its ligand PD-L1 is increasingly investigated as a strategy to guide and monitor PD-1:PD-L1-targeted immune checkpoint therapy. We provide an overview of the current state-of-the-art on PD-1- and PD-L1-specific imaging agents for quantitative, real-time assessment of PD-1:PD-L1 expression in the tumor environment and discuss their potential for clinical translation.

Cost-Effectiveness of Osimertinib for EGFR Mutation-Positive Non-Small Cell Lung Cancer after Progression following First-Line EGFR TKI Therapy

OBJECTIVE

The aim of this study was to investigate the cost-effectiveness of osimertinib for the treatment of advanced NSCLC with an EGFR T790M mutation after the failure of first-line EGFR tyrosine kinase inhibitor (TKI) therapy.

METHODS

A mathematical model was established by combining a decision tree and the Markov approach to project the cost-effectiveness of osimertinib versus standard chemotherapy for the treatment of patients who harbor an EGFR T790M mutation and have disease progression after first-line EGFR TKI therapy with or without metastases to the central nervous system. The clinical and outcome data were derived from randomized clinical trials and published reports. The health outcome data included quality-adjusted life-years (QALY). The cost data were estimated from the perspectives of the payer in the United States and the health care system in the People's Republic of China. All costs and incremental cost-effectiveness ratios (ICERs) were presented in 2017 U.S. dollars. Sensitivity and scenario analyses with three different settings of T790M mutation testing were performed.

RESULTS

Compared with chemotherapy, molecular testing in plasma and tissue followed by osimertinib treatment yielded an additional 0.359 and 0.313 QALYs in the entire U.S. population and the population of those with central nervous system metastases and an EGFR T790M mutation. For these populations, the incremental costs were $83,515 and $74,924 per patient, respectively, and the ICERs were $232,895 and $239,274 per QALY, respectively. For the entire Chinese population and the Chinese population with central nervous system metastases, the ICERs were $48,081 and $53,244 per QALY, respectively. For those with a known T790M mutation, the ICERs of osimertinib over chemotherapy also exceeded the willingness-to-pay threshold. The most influential parameter was the price of osimertinib.

CONCLUSION

Osimertinib treatment for T790M mutation NSCLC is unlikely to be cost-effective from the perspectives of the United States and the People's Republic of China. If the price of osimertinib could be decreased, the economic outcome might become favorable.