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Özdemir D, Büssgen M. Effectiveness and cost-effectiveness of combination therapy versus monotherapy in malignant melanoma. J Pharm Policy Pract 2023; 16:106. [PMID: 37749653 PMCID: PMC10521452 DOI: 10.1186/s40545-023-00611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 09/16/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Until 2010, stage III or IV malignant melanoma (MM) had a poor prognosis. The discovery of immune checkpoint inhibitors (ICIs) in 2011 changed the treatment landscape. Promising results in patient survival with a checkpoint inhibitor prompted research into combination therapies. In 2016, the first combination therapy has been approved as first-line therapy for advanced MM. OBJECTIVE The aim of this work is to investigate to what extent combination therapy is (cost-)effective compared to monotherapy in stage III or IV MM. METHODS A systematic literature search was performed (Web of Science, PubMed, PubPharm, EconLit, and Cochrane Library); searching for publications published over the past decade that examine the cost-effectiveness in terms of cost/QALY and the effectiveness in terms of survival and response of combination therapy in comparison to monotherapy in stage III or IV MM patients. RESULTS A total of 11 randomized controlled trials (RCTs) and five cost-utility analyses met our inclusion criteria. Nine clinical trials demonstrated superiority of combination therapy over monotherapy. The combination of B-rapidly accelerated fibrosarcoma (BRAF) protein and mitogen-activated kinase (MEK) protein inhibitors is not cost-effective in any country. Three analyses demonstrate the cost-effectiveness of combination therapy with ICI compared to monotherapy. CONCLUSION Combination therapy is more effective compared to monotherapy. While combined ICIs are cost-effective compared to monotherapy, this is not the case for the combination of BRAF and MEK inhibitors.
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Affiliation(s)
| | - Melanie Büssgen
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany.
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Iliadou V, Athanasakis K. Sensitivity Analysis in Economic Evaluations of Immuno-Oncology Drugs: A Systematic Literature Review. Value Health Reg Issues 2023; 37:23-32. [PMID: 37207531 DOI: 10.1016/j.vhri.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVES This study aimed to review, assess, and report the characteristics and strategies of sensitivity analyses (SAs) that were performed in the context of published economic evaluations of immuno-oncology drugs. METHODS The systematic literature search was conducted in Scopus and MEDLINE for articles published from 2005 to 2021. Study selection, based on a predefined set of criteria, was performed by 2 reviewers independently. We included economic evaluations of Food and Drug Administration-approved immuno-oncology drugs that were published in English and assessed the accompanying SAs on a set of items, including the range justification of the baseline parameters within the deterministic SA, the provisions for the correlation/overlay between parameters, and the justification of the chosen parameter distribution for the probabilistic SA, among others. RESULTS A total of 98 of 295 publications met the inclusion criteria. A total of 90 studies included a one-way and probabilistic SA and 16 of 98 studies had one-way and scenario analysis, alone or together with probabilistic analysis. Most studies provide explicit references as to the choice of parameters and values; nevertheless, there is a lack of a reference of correlation/overlay between parameters in most of the evaluations. In 26 of 98 studies, the most influential parameter for the incremental cost-effectiveness ratio was the under-evaluation drug cost. CONCLUSIONS Most of included articles contained an SA that was implemented according to commonly accepted published guidance. The under-evaluation drug cost, the estimates of progression-free survival, the hazard ratio for overall survival, and the time horizon of the analysis seem to play an important part in the robustness of the outcomes.
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Affiliation(s)
- Vasiliki Iliadou
- Laboratory for Health Technology Assessment, Department of Public Health Policy, University of West Attica, Attiki, Athens, Greece.
| | - Kostas Athanasakis
- Laboratory for Health Technology Assessment, Department of Public Health Policy, University of West Attica, Attiki, Athens, Greece
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Zhang S, Bensimon AG, Xu R, Jiang R, Greatsinger A, Zhang A, Fukunaga-Kalabis M, Krepler C. Cost-Effectiveness Analysis of Pembrolizumab as an Adjuvant Treatment of Resected Stage IIB or IIC Melanoma in the United States. Adv Ther 2023; 40:3038-3055. [PMID: 37191852 PMCID: PMC10271902 DOI: 10.1007/s12325-023-02525-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Pembrolizumab was approved in the US as adjuvant treatment of patients with stage IIB or IIC melanoma post-complete resection, based on prolonged recurrence-free survival vs. placebo in the Phase 3 KEYNOTE-716 trial. This study aimed to evaluate the cost-effectiveness of pembrolizumab vs. observation as adjuvant treatment of stage IIB or IIC melanoma from a US health sector perspective. METHODS A Markov cohort model was constructed to simulate patient transitions among recurrence-free, locoregional recurrence, distant metastasis, and death. Transition probabilities from recurrence-free and locoregional recurrence were estimated via multistate parametric modeling based on patient-level data from an interim analysis (data cutoff date: 04-Jan-2022). Transition probabilities from distant metastasis were based on KEYNOTE-006 data and network meta-analysis. Costs were estimated in 2022 US dollars. Utilities were based on applying US value set to EQ-5D-5L data collected in trial and literature. RESULTS Compared to observation, pembrolizumab increased total costs by $80,423 and provided gains of 1.17 quality-adjusted life years (QALYs) and 1.24 life years (LYs) over lifetime, resulting in incremental cost-effectiveness ratios of $68,736/QALY and $65,059/LY. The higher upfront costs of adjuvant treatment were largely offset by reductions in costs of subsequent treatment, downstream disease management, and terminal care, reflecting the lower risk of recurrence with pembrolizumab. Results were robust in one-way sensitivity and scenario analyses. At a $150,000/QALY threshold, pembrolizumab was cost-effective vs. observation in 73.9% of probabilistic simulations that considered parameter uncertainty. CONCLUSION As an adjuvant treatment of stage IIB or IIC melanoma, pembrolizumab was estimated to reduce recurrence, extend patients' life and QALYs, and be cost-effective versus observation at a US willingness-to-pay threshold.
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Affiliation(s)
- Shujing Zhang
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA.
| | | | - Ruifeng Xu
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA
| | - Ruixuan Jiang
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA
| | | | | | | | - Clemens Krepler
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA
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Cartun Z, Kunz WG, Heinzerling L, Tomsitz D, Guertler A, Westphalen CB, Ricke J, Weir W, Unterrainer M, Mehrens D. Cost-effectiveness of Response-Adapted De-escalation of Immunotherapy in Advanced Melanoma. JAMA Dermatol 2022; 158:1387-1393. [PMID: 36260321 PMCID: PMC9582967 DOI: 10.1001/jamadermatol.2022.4556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/30/2022] [Indexed: 01/13/2023]
Abstract
Importance Combination immunotherapy with nivolumab and ipilimumab has markedly improved outcomes for patients with advanced melanoma. However, these therapies pose a considerable financial burden to both patients and the health care system. The ADAPT-IT trial demonstrated comparable progression-free and overall survival for patients with response-adapted ipilimumab discontinuation compared with standard of care (SOC). Objective To determine the cost-effectiveness of ipilimumab discontinuation for patients with interim imaging-confirmed tumor response in the treatment of advanced melanoma. Design, Setting, and Participants This cost-effectiveness analysis was performed using data from the ADAPT-IT (follow-up of 33 months) and CheckMate 067 (follow-up of 6.5 years) trials, as well as published literature over the ADAPT-IT trial duration of 33 months. The analysis was performed in a US setting from a US-payer perspective, and the willingness-to-pay (WTP) threshold was set at $100 000/quality-adjusted life-year (QALY). A total of 355 patients with previously untreated melanoma (unresectable stage III or IV metastatic melanoma) were included. Exposure Response-adapted ipilimumab discontinuation compared with SOC therapy. Main Outcomes and Measures The primary outcomes of the CheckMate trial were overall survival and progression-free survival, while that of ADAPT-IT was objective response. This informed a decision model to estimate lifetime costs and QALYs associated with both strategies. Incremental cost, effectiveness, and cost-effectiveness ratio were assessed. Sensitivity and scenario analyses were performed to account for variability in trials and input parameters. Results Of the 355 patients included in the analysis, 41 patients were from the ADAPT-IT trial (median age, 65 years; 28 [68%] male) and 314 patients from the CheckMate 067 trial (median age, 61 years; 206 [66%] male). Response-adapted treatment was the cost-effective option in 94.0% of scenarios based on Monte Carlo simulations, with a dominant incremental cost-effectiveness ratio and an incremental net monetary benefit of $28 849 compared with SOC therapy. Cost savings were estimated at $19 891 per patient compared with SOC. In scenario analyses, current SOC was only considered as a cost-effective option under best survival assumptions and if the willingness-to-pay threshold exceeded $630 000/QALY. Conclusions and Relevance This economic evaluation demonstrated that response-adapted treatment de-escalation in patients with advanced melanoma may lead to considerable savings in health care costs and could represent the most cost-effective strategy across various resource settings. Future trials should aim to provide further evidence on noninferiority.
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Affiliation(s)
- Zachary Cartun
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Department of Radiology, University of Massachusetts Medical School, Worcester
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
- Department of Dermatology and Allergology, University Hospital Erlangen, Friedrich Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dirk Tomsitz
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Anne Guertler
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - C. Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - William Weir
- Department of Radiology, University of Massachusetts Medical School, Worcester
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Dirk Mehrens
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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Li T, Fu X, Liu B, Wang X, Li J, Zhu P, Niu X, Bai J, Liu Y, Lu X, Yu ZL. Luteolin binds Src, promotes STAT3 protein ubiquitination and exerts anti-melanoma effects in cell and mouse models. Biochem Pharmacol 2022; 200:115044. [PMID: 35460630 DOI: 10.1016/j.bcp.2022.115044] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 02/07/2023]
Abstract
Signal transducer and activator of transcription 3 (STAT3) has been proposed as a target for melanoma prevention. Luteolin, a bioactive flavonoid abundant inmedicinal herbs, has been reported to have anti-melanoma activity in vitro. However, its in vivo anti-melanoma effects and underlying mechanisms have not been fully elucidated. In this study, ten cell lines and two mouse models (B16F10 allograft and A375 xenograft models) were used for assessing the in vitro and in vivo anti-melanoma effects of luteolin. A STAT3 over-activated stable A375 cell line was used to determine the contribution of STAT3 signaling in luteolin's anti-melanoma effects. Results showed that luteolin dose-dependently reduced viability of melanoma cells. Luteolin also induced apoptosis in, and suppressed migration and invasion of, A375 and B16F10 melanoma cells. Mechanistically, luteolin inhibited phosphorylation of STAT3 and Src (an upstream kinase of STAT3), accelerated ubiquitin-proteasome pathway-mediated STAT3 degradation, and downregulated the expression of STAT3-targeted genes involved in cell survival and invasion in melanoma cells. Molecular modelling and surface plasmon resonance imaging showed that luteolin stably bound to the protein kinase domain of Src. Animal studies demonstrated that prophylactic administration of luteolin restrained melanoma growth and Src/STAT3 signaling in both A375 and B16F10 melanoma-bearing mice. Moreover, luteolin's anti-melanoma effects were diminished by STAT3 over-activation in A375 cells. Our findings indicate that luteolin inhibits STAT3 signaling by suppressing STAT3 activation and promoting STAT3 protein degradation in melanoma cells, thereby exhibiting anti-melanoma effects. This study provides further pharmacological groundwork for developing luteolin as a chemopreventive agent against melanoma.
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Affiliation(s)
- Ting Li
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Xiuqiong Fu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Bin Liu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Xueyu Wang
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Junkui Li
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Peili Zhu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Xiaodi Niu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Jingxuan Bai
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Yuxi Liu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China
| | - Xinshan Lu
- Shaanxi Engineering Laboratory for Food Green Processing and Safety Control, College of Food Engineering and Nutritional Science, Shaanxi Normal University, Xi'an, China
| | - Zhi-Ling Yu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, China; Development Centre for Natural Health Products, HKBU Institute for Research and Continuing Education, Shenzhen, China.
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Kamusheva M, Georgieva V, Marinov L, Boncheva E, Milushewa P, Grigorova P, Marinov K, Petrova G. Volume and trends of adalimumab and pembrolizumab reimbursed market: the Bulgarian perspective. BIOTECHNOL BIOTEC EQ 2022. [DOI: 10.1080/13102818.2021.2019116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Maria Kamusheva
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Viktoria Georgieva
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Lyubomir Marinov
- Department of Pharmacology, Pharmacotherapy and Toxicology, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Elka Boncheva
- Department of Health Policy and Management, Faculty of Public Health, Medical University of Sofia, Sofia, Bulgaria
| | - Petya Milushewa
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Plamena Grigorova
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Kalin Marinov
- Department of International Economic Relations and Business, Faculty of International Economics and Politics, University of National and World Economy, Sofia, Bulgaria
| | - Guenka Petrova
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
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Mulder EEAP, Smit L, Grünhagen DJ, Verhoef C, Sleijfer S, van der Veldt AAM, Uyl-de Groot CA. Cost-effectiveness of adjuvant systemic therapies for patients with high-risk melanoma in Europe: a model-based economic evaluation. ESMO Open 2021; 6:100303. [PMID: 34781194 PMCID: PMC8599106 DOI: 10.1016/j.esmoop.2021.100303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The introduction of adjuvant systemic treatment has significantly improved recurrence-free survival in patients with resectable high-risk melanoma. Adjuvant treatment with immune checkpoint inhibitors and targeted therapy, however, substantially impacts health care budgets, while the number of patients with melanoma who are treated in the adjuvant setting is still increasing. To evaluate the socioeconomic impact of the three adjuvant treatments, a cost-effectiveness analysis (CEA) was carried out. MATERIALS AND METHODS Data were obtained from the three pivotal registration phase III clinical trials on the adjuvant treatment of patients with resected high-risk stage III in melanoma (KEYNOTE-054, CheckMate 238, and COMBI-AD). For this CEA, a Markov model with three health states (no evidence of disease, recurrent/progressive disease, and death) was applied. From a societal perspective, different adjuvant strategies were compared according to total costs, life years (LYs), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. To evaluate model uncertainty, sensitivity analyses (deterministic and probabilistic) were carried out. RESULTS In the adjuvant setting, total costs (per patient) were €168 826 for nivolumab, €194 529 for pembrolizumab, and €211 110 for dabrafenib-trametinib. These costs were mainly determined by drug acquisition costs, whereas routine surveillance costs varied from €126 096 to €134 945. Compared with routine surveillance, LYs improved by approximately 1.41 for all therapies and QALYs improved by 2.02 for immune checkpoint inhibitors and 2.03 for targeted therapy. This resulted in incremental cost-effectiveness ratios of €21 153 (nivolumab), €33 878 (pembrolizumab), and €37 520 (dabrafenib-trametinib) per QALY gained. CONCLUSIONS This CEA compared the three EMA-approved adjuvant systemic therapies for resected stage III melanoma. Adjuvant treatment with nivolumab was the most cost-effective, followed by pembrolizumab. Combination therapy with dabrafenib-trametinib was the least cost-effective. With the increasing number of patients with high-risk melanoma who will be treated with adjuvant treatment, there is an urgent need to reduce drug costs while developing better prognostic and predictive tools to identify patients who will benefit from adjuvant treatment.
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Affiliation(s)
- E E A P Mulder
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - L Smit
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - A A M van der Veldt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C A Uyl-de Groot
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Koelblinger P, Hoellwerth M, Dernoscheg MT, Koch L, Richtig E, Wanner M, Nguyen VA, Ostermann H, Bauer JW, Laimer M. Adjuvante Anti‐PD‐1‐Antikörpertherapie bei Stadium‐III/IV‐Melanom: Anwendungsdaten aus der klinischen Routine und gesundheitsökonomische Aspekte. J Dtsch Dermatol Ges 2021; 19:1186-1200. [PMID: 34390157 DOI: 10.1111/ddg.14511_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/10/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Koelblinger
- Universitätsklinik für Dermatologie und Allergologie, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Magdalena Hoellwerth
- Universitätsklinik für Dermatologie und Allergologie, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | | | - Lukas Koch
- Universitätsklinik für Dermatologie, Medizinische Universität Graz, Graz, Österreich
| | - Erika Richtig
- Universitätsklinik für Dermatologie, Medizinische Universität Graz, Graz, Österreich
| | - Marina Wanner
- Universitätsklinik für Dermatologie und Allergologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Van-Anh Nguyen
- Universitätsklinik für Dermatologie und Allergologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | | | - Johann W Bauer
- Universitätsklinik für Dermatologie und Allergologie, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Martin Laimer
- Universitätsklinik für Dermatologie und Allergologie, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
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9
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Koelblinger P, Hoellwerth M, Dernoscheg MT, Koch L, Richtig E, Wanner M, Nguyen VA, Ostermann H, Bauer JW, Laimer M. Adjuvant anti-PD-1 antibody treatment in stage III/IV melanoma: real-world experience and health economic considerations. J Dtsch Dermatol Ges 2021; 19:1186-1198. [PMID: 34255435 DOI: 10.1111/ddg.14511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Anti-programmed death 1 (PD-1) antibodies have evolved as a new standard of care in the adjuvant treatment of completely resected melanoma. Real-world data on treatment efficacy and safety as well as cost-effectiveness are still limited. PATIENTS AND METHODS Treatment outcomes were retrospectively analyzed in a continuous patient cohort receiving adjuvant nivolumab (91 patients) or pembrolizumab (9 patients). Based on the obtained clinical data, a semi-Markov model was developed to evaluate cost-effectiveness. RESULTS After a median follow-up of 11.5 months, disease recurrence was observed in 39 patients (39 %). The site of first recurrence was locoregional in 17, distant in 19, and combined locoregional and distant in three patients. Twelve-month estimates for recurrence- and distant-metastasis-free survival were 64.8 % and 77.4 %, respectively. Sixteen patients experienced grade 3 or 4 treatment-related adverse events, while 22 patients discontinued treatment due to adverse events. The base-case Markov model yielded an incremental cost-effectiveness ratio of 13,330 € per quality-adjusted life year for adjuvant anti-PD-1 antibody treatment compared to a simulated observation cohort. CONCLUSIONS Real-world outcomes of adjuvant anti-PD-1 antibody therapy in completely resected melanoma appear comparable to clinical trial data. Moreover, our data suggests this treatment strategy to be cost-effective according to Austrian health economic standards.
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Affiliation(s)
- Peter Koelblinger
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
| | - Magdalena Hoellwerth
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
| | | | - Lukas Koch
- Department of Dermatology, Medical University Graz, Graz, Austria
| | - Erika Richtig
- Department of Dermatology, Medical University Graz, Graz, Austria
| | - Marina Wanner
- Department of Dermatology, Venerology and Allergology, Medical University Innsbruck, Innsbruck, Austria
| | - Van-Anh Nguyen
- Department of Dermatology, Venerology and Allergology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Johann W Bauer
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
| | - Martin Laimer
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
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10
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Mojtahed SA, Boyer NR, Rao SA, Gajewski TF, Tseng J, Turaga KK. Cost-Effectiveness Analysis of Adjuvant Therapy for BRAF-Mutant Resected Stage III Melanoma in Medicare Patients. Ann Surg Oncol 2021; 28:9039-9047. [PMID: 34129153 DOI: 10.1245/s10434-021-10288-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adjuvant therapy for stage III melanoma improves several measures of patient survival. However, decisions regarding inclusion of adjuvant therapies in the formularies of public payers necessarily consider the cost-effectiveness of those treatments. The objective of this study is to evaluate the cost-effectiveness of four recently approved adjuvant therapies for BRAF-mutant stage III melanoma in the Medicare patient population. METHODS In this cost-effectiveness analysis, a Markov microsimulation model was used to simulate the healthcare trajectory of patients randomized to receive either first-line targeted therapy (dabrafenib-trametinib) or immunotherapy (ipilimumab, nivolumab, or pembrolizumab). The base case was a 65-year-old Medicare patient with BRAF V600E-mutant resected stage III melanoma. Possible health states included recurrence-free survival, adverse events, local recurrence, distant metastases, and death. Transition probabilities were determined from published clinical trials. Costs were estimated from reimbursement rates reported by CMS and the Red Book drug price database. Primary outcomes were costs (US$), life years, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model robustness was evaluated using one-way and probabilistic sensitivity analyses. RESULTS Dabrafenib-trametinib provided 1.83 QALYs over no treatment and 0.23 QALYs over the most effective immunotherapy, pembrolizumab. Dabrafenib-trametinib was associated with an ICER of $95,758/QALY over no treatment and $285,863/QALY over pembrolizumab. Pembrolizumab yielded an ICER of $68,396/QALY over no treatment and dominated other immunotherapies. CONCLUSIONS Pembrolizumab is cost-effective at a conventional willingness-to-pay (WTP) threshold, but dabrafenib-trametinib is not. Though dabrafenib-trametinib offers incremental QALYs, optimization of drug pricing is necessary to ensure dabrafenib-trametinib is accessible at an acceptable WTP threshold.
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Affiliation(s)
- Saam A Mojtahed
- Pritzker School of Medicine, Division of Biological Sciences, University of Chicago, Chicago, IL, USA
| | - Nicole R Boyer
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Saieesh A Rao
- Pritzker School of Medicine, Division of Biological Sciences, University of Chicago, Chicago, IL, USA
| | - Thomas F Gajewski
- Department of Pathology, Division of Biological Sciences, University of Chicago, Chicago, IL, USA
| | - Jennifer Tseng
- Department of Surgery, Division of Biological Sciences, The University of Chicago, Chicago, IL, USA
| | - Kiran K Turaga
- Department of Surgery, Division of Biological Sciences, The University of Chicago, Chicago, IL, USA.
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