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Cheng M, Shao Y, Li L, Jiang M, Song Z. Cost-effectiveness of immunotherapies for advanced squamous non-small cell lung cancer: a systematic review. BMC Cancer 2024; 24:312. [PMID: 38448878 PMCID: PMC10916025 DOI: 10.1186/s12885-024-12043-w] [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: 10/24/2023] [Accepted: 02/22/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND There are differences in the pharmacoeconomics of Immune checkpoint blocking (ICB) therapies for the treatment of lung squamous cell carcinoma (LSCC). However, no corresponding review studies have fully discussed the cost-effectiveness of ICBs in treating LSCC. The aim of this paper is to systematically review and evaluate all available pharmacoeconomic studies of ICBs for LSCC. METHOD The inclusion criteria were based on the population, intervention, comparator, outcomes, and study designs. An electronic search was conducted by June 2023, and the following databases were used: PubMed, EMBASE, Cochrane Library, and Web of Science. Search keywords included 'Carcinoma', Non-Small-Cell Lung', 'Immunotherapy', and 'Economics, Medical'. The primary outcome was the cost-effectiveness analysis of ICB therapy in LSCC patients. Drummond Checklist was used to assess quality problems and possible bias in the study design of included pharmacoeconomic studies. RESULTS This review searched 15 articles on the economic evaluation of ICB treatment for LSCC. After a qualitative review of 15 studies, we concluded that nivolumab is more cost-effective as a monotherapy than chemotherapy alone. In the combination regimen, pembrolizumab combined with chemotherapy appears to be the most cost-effective option at present, but for Chinese payers with LSCC, locally developed treatments such as sintilimab or toripalimab in combination with chemotherapy are more cost-effective. DISCUSSION The inclusion of economic evaluation has heterogeneity in research design and outcomes, which can only support qualitative synthesis. Therefore, The results of this paper need to be treated with caution. For the Chinese market, instead of imported drugs, the possible cost-effectiveness of locally developed ICB therapies should be the focus of future research.
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Affiliation(s)
- Minyu Cheng
- Department of Pharmacy, Zhejiang Hospital, 310013, Hangzhou, China
| | - Yanfei Shao
- Department of Pharmacy, Zhejiang Provincial People's Hospital, 310014, Hangzhou, China
| | - Li Li
- Department of Pharmacy, Zhejiang Hospital, 310013, Hangzhou, China
| | - Menglao Jiang
- Zhejiang Center of Drug and Cosmetics Evaluation, 310000, Hangzhou, Zhejiang, China
| | - Zhouye Song
- Department of Pharmacy, Zhejiang Hospital, 310013, Hangzhou, China.
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Wu C, Li W, Tao H, Zhang X, Xin Y, Song R, Wang K, Zuo L, Cai Y, Wu H, Hui W. Cost-effectiveness of first-line immunotherapy for advanced non-small cell lung cancer with different PD-L1 expression levels: A comprehensive overview. Crit Rev Oncol Hematol 2024; 193:104195. [PMID: 37931769 DOI: 10.1016/j.critrevonc.2023.104195] [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: 07/20/2023] [Revised: 10/15/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Immunotherapies can substantially improve treatment efficacy, despite their high cost. A comprehensive overview of the cost-effectiveness analysis (CEA) of immune checkpoint inhibitors (ICIs) in patients with non-small cell lung cancer based on different tumor proportion scores (TPSs) was conducted. METHODS PubMed, Embase, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, and NHS Economic Evaluation databases were searched from their inception until August 24, 2022. Data relevant to the CEA results were recorded, and quality assessments conducted based on the Quality of Health Economic Studies (QHES) process. FINDINGS Fifty-one original studies from seven countries were included. The mean QHES score was 77.0 (range: 53-95). Twenty-seven studies were classified as high-quality, and the rest as fair quality. Pembrolizumab, nivolumab, ipilimumab, atezolizumab, camrelizumab, cemiplimab, sintilimab, tislelizumab, and durvalumab were identified using three TPS categories. While nivolumab plus ipilimumab and pembrolizumab plus chemotherapy were unlikely to be cost-effective in China, the results for the US were uncertain. Atezolizumab combinations were not cost-effective in China or the US, and tislelizumab and sintilimab were cost-effective in China. For TPSs ≥ 50%, the pembrolizumab monotherapy could be cost-effective in some developed countries. Cemiplimab was more cost-effective than chemotherapy, pembrolizumab, and atezolizumab in the US. For TPSs ≥ 1%, the cost-effectiveness of pembrolizumab was controversial due to the different willingness-to-pay thresholds. CONCLUSIONS None of the atezolizumab combination regimens were found to be cost-effective in any perspective of evaluations. Camrelizumab, tislelizumab, and sintilimab have lower ICERs compared to atezolizumab, pembrolizumab, and nivolumab in China. Cemiplimab may be a more affordable alternative to pembrolizumab or atezolizumab. However, it remains unclear which ICIs are the best choices for each country. Future CEAs are required to select comprehensive regimens alongside randomized trials and real-world studies to help verify the economics of ICIs in specific decision-making settings.
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Affiliation(s)
- Changjin Wu
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Wentan Li
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Hongyu Tao
- Laboratory of Oncology, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiyan Zhang
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Yu Xin
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruomeng Song
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Kaige Wang
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Zuo
- Department of Pulmonary and Critical Care Medicine, West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China; Integrated Care Management Center, Outpatient Department, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuanyi Cai
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Huazhang Wu
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Wen Hui
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Dai H, Wang W, Fan X, Chen Y. Cost-effectiveness of camrelizumab plus chemotherapy vs. chemotherapy in the first-line treatment of non-squamous NSCLC: Evidence from China. Front Med (Lausanne) 2023; 10:1122731. [PMID: 36865055 PMCID: PMC9971596 DOI: 10.3389/fmed.2023.1122731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Objective We aimed to evaluate the cost-effectiveness of camrelizumab plus chemotherapy compared with chemotherapy alone as the first-line treatment for patients with metastatic or advanced non-squamous non-small cell lung cancer (NSCLC) without targetable epidermal growth factor receptor or anaplastic lymphoma kinase genetic aberrations in patients in China. Methods A partitioned survival model was constructed to estimate the cost-effectiveness of camrelizumab plus chemotherapy vs. chemotherapy in the first-line treatment of non-squamous NSCLC from a Chinese healthcare perspective. Survival analysis was performed to calculate the proportion of patients in each state using data from trial NCT03134872. The cost of drugs was obtained from Menet, and the cost of disease management was obtained from local hospitals. Health state data were obtained from published literature. Both deterministic sensitivity analyses (DSA) and probabilistic sensitivity analysis (PSA) were adopted to verify the robustness of the results. Results Compared with chemotherapy alone, camrelizumab plus chemotherapy provided 0.41 incremental quality-adjusted life years (QALYs) at an incremental cost of $10,482.12. Therefore, the incremental cost-effectiveness ratio of camrelizumab plus chemotherapy was $25,375.96/QALY from the Chinese healthcare perspective, much lower than three times the GDP per capita of China in 2021 ($35,936.09) as the willingness-to-pay threshold. The DSA indicated that the incremental cost-effectiveness ratio was most sensitive to the utility value of progression-free survival, followed by the cost of camrelizumab. The PSA illustrated that camrelizumab had 80% probability of being cost-effective at the threshold of $35,936.09 per QALY gained. Conclusion The results suggest that camrelizumab plus chemotherapy is a cost-effective choice in the first-line treatment for patients with non-squamous NSCLC in China. Although this study has limitations such as short time of use of camrelizumab, no adjustment of Kaplan-Meier curves and the median overall survival that has not been reached, the difference in results caused by these factors is relatively small.
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Affiliation(s)
| | | | - Xin Fan
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
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Huo G, Liu W, Kang S, Chen P. Toripalimab plus chemotherapy vs. chemotherapy in patients with advanced non-small-cell lung cancer: A cost-effectiveness analysis. Front Pharmacol 2023; 14:1131219. [PMID: 36865925 PMCID: PMC9971805 DOI: 10.3389/fphar.2023.1131219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023] Open
Abstract
Background: The potency and safety of toripalimab combination with chemotherapy (TC) as the first-line therapy for advanced non-small cell lung cancer (NSCLC) have been demonstrated in the CHOICE-01 study. Our research explored whether TC was cost-effective compared to chemotherapy alone from the Chinese payer perspective. Materials and methods: Clinical parameters were obtained from a randomized, multicenter, registrational, placebo-controlled, double-blind, phase III trial. Standard fee databases and previously published literature were used to determine costs and utilities. A Markov model with three mutually exclusive health statuses (progression-free survival (PFS), disease progression, and death) was used to predict the disease course. The costs and utilities were discounted at 5% per annum. The main endpoints of the model included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Univariate and probabilistic sensitivity analyses were performed to investigate the uncertainty. Subgroup analyses were performed to verify the cost-effectiveness of TC in patients with squamous and non-squamous cancer. Results: TC combination therapy yielded an incremental 0.54 QALYs with an incremental cost of $11,777, compared to chemotherapy, giving rise to ICERs of $21,811.76/QALY. Probabilistic sensitivity analysis revealed that TC was not favorable at 1 time GDP per capita. With a prespecified willingness-to-pay threshold (WTP) of three times the GDP per capita, combined treatment had a 100% probability of being cost-effective and had substantial cost-effectiveness in advanced NSCLC. Probabilistic sensitivity analyses showed that TC was more likely to be accepted with a WTP threshold higher than $22,195 in NSCLC. Univariate sensitivity analysis showed that the utility of PFS state, crossover proportions of the chemotherapy arm, cost per cycle of pemetrexed treatment, and discount rate were the dominant influencing factors. Subgroup analyses found that in patients with squamous NSCLC, the ICER was $14,966.09/QALY. In the non-squamous NSCLC, ICER raised to $23,836.27/QALY. ICERs were sensitive to the variance of the PFS state utility. TC was more likely to be accepted when WTP increases exceeded $14,908 in the squamous NSCLC subgroup and $23,409 in the non-squamous NSCLC subgroup. Conclusion: From the perspective of the Chinese healthcare system, TC may be cost-effective in individuals with previously untreated advanced NSCLC at the prespecified WTP threshold compared to chemotherapy, and more significant in individuals with squamous NSCLC, which will provide evidence for clinicians to make the best decisions in general clinical practice.
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Affiliation(s)
- Gengwei Huo
- Department of Thoracic Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy Of Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China,Department of Oncology, Jining No. 1 People’s Hospital, Jining, Shandong, China
| | - Wenjie Liu
- Department of Thoracic Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy Of Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Shuo Kang
- Medical Insurance Office, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Peng Chen
- Department of Thoracic Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy Of Tianjin, Tianjin’s Clinical Research Center for Cancer, Tianjin, China,*Correspondence: Peng Chen,
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Yang SC, Ou HT, Su WC, Wang SY. Cost-effectiveness of first-line immunotherapies for advanced non-small cell lung cancer. Cancer Med 2023; 12:8838-8850. [PMID: 36653947 PMCID: PMC10134257 DOI: 10.1002/cam4.5632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 12/25/2022] [Accepted: 01/07/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Researchers have not simultaneously compared the cost-effectiveness of six immunotherapies with chemotherapy for advanced non-small cell lung cancer. This study evaluated the cost-effectiveness across different programmed death-ligand 1 (PD-L1) levels. METHODS A Markov model with lifetime horizon was created for seven regimens: pembrolizumab plus chemotherapy (pembro-chemo), nivolumab plus ipilimumab (nivo-ipi), nivolumab, ipilimumab plus chemotherapy (nivo-ipi-chemo), atezolizumab plus chemotherapy (atezo-chemo), atezolizumab, bevacizumab plus chemotherapy (atezo-beva-chemo), single-agent pembrolizumab, and chemotherapy alone. Input parameters were derived from trial data, a network meta-analysis, and other literature. We conducted the analysis from the perspective of US health care sector. RESULTS For all patients without considering PD-L1 expression, the incremental cost-effectiveness ratio (ICER) of pembro-chemo versus chemotherapy was $183,299 per quality-adjusted life year (QALY). The preferred regimens based on ICERs differed by PD-L1 levels. For patients with PD-L1 ≥50%, pembrolizumab versus chemotherapy and pembro-chemo versus pembrolizumab resulted in ICERs of $96,189 and $198,913 per QALY, respectively. The other strategies were dominated. For patients with PD-L1 of 1%-49%, the ICER of pembro-chemo comparing to chemotherapy was $218,159 per QALY. The other regimens were dominated by pembro-chemo. For patients with PD-L1 <1%, nivo-ipi versus chemotherapy and nivo-ipi-chemo versus nivo-ipi resulted in ICERs of $161,277 and $881,975 per QALY, and the other regimens were dominated strategies. At the willingness-to-pay threshold of $150,000 per QALY, pembrolizumab had 87% and pembro-chemo had 1% probabilities being cost-effective in patients with PD-L1 ≥50% and 1%-49%, respectively. Nivo-ipi had a 34% probability being cost-effective in patients with PD-L1 <1%. CONCLUSIONS The PD-L1 level should be incorporated into treatment decision-making. Our findings suggest that first-line pembrolizumab, pembro-chemo, and nivo-ipi are the preferred strategies for patients with PD-L1 ≥50%, 1%-49%, and <1%, respectively.
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Affiliation(s)
- Szu-Chun Yang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wu-Chou Su
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut, USA
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Chen P, Teng S, Chen MG, Yao TT. Comparison of the effect of two-way evaluation model in the whole process management of PICC catheterization in patients with lung cancer. Asian J Surg 2023:S1015-9584(23)00013-1. [PMID: 36641275 DOI: 10.1016/j.asjsur.2022.12.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/29/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Peng Chen
- Department of Oncology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, Shandong, 266003, China
| | - Shan Teng
- PICC Outpatient Service, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, Shandong, 266003, China
| | - Mei-Gui Chen
- Department of Oncology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, Shandong, 266003, China
| | - Ting-Ting Yao
- Department of Oncology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, Shandong, 266003, China.
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Zhang C, Zhang J, Tan J, Tian P, Li W. Cost-Effectiveness of Pembrolizumab for the treatment of Non–Small-Cell lung cancer: A systematic review. Front Oncol 2022; 12:815587. [PMID: 36110966 PMCID: PMC9469648 DOI: 10.3389/fonc.2022.815587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 07/18/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Pembrolizumab, an immune checkpoint inhibitor for treating non-small cell lung cancer (NSCLC), can impose a high financial burden. Several studies have explored the cost-effectiveness of this expensive agent. We conducted a systematic review and pooled analysis to evaluate the quality of the existing pharmacoeconomic studies on pembrolizumab strategies for NSCLC treatment as well as to conclude the cost-effectiveness of such strategies. Methods English and Chinese databases were searched to collect health economic studies on pembrolizumab therapies (monotherapy or a combination with chemotherapy) compared with chemotherapy for the treatment of NSCLC patients. The reporting quality, modeling methods, and results of incremental cost-effectiveness analysis of the included literature were descriptively analyzed. Results A total of 24 studies, 3 in Chinese and 21 in English, were selected. All reports satisfy a median of 31 out of 40 reporting quality assessment items based on a quality checklist for pharmacoeconomic evaluations. 12 studies used the Markov model and 11 used the partitioned survival model. A common problem identified in the modeling methods was the insufficient justification of the choices of model structure and data inputs. Pembrolizumab was found to be cost-effective in the United States and Switzerland, but not in China, France, the UK, or Singapore. Conclusion The current cost-effectiveness studies on pembrolizumab for the treatment of NSCLC are of moderate quality, and the relevant decision-analytic modeling methods have much scope for improvement. The cost-effectiveness of pembrolizumab strategies for NSCLC varies across countries, warranting the need to pay more attention to the methodologies of pharmacoeconomic research in order to produce correct outcomes in terms of cost-effectiveness for different countries. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021250480
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Affiliation(s)
- Chuan Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Jiaxu Zhang
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Panwen Tian
- Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Weimin Li
- Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Weimin Li,
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Rojo F, Conde E, Torres H, Cabezón-Gutiérrez L, Bautista D, Ramos I, Carcedo D, Arrabal N, García JF, Galán R, Nadal E. Clinical and economic impact of 'ROS1-testing' strategy compared to a 'no-ROS1-testing' strategy in advanced NSCLC in Spain. BMC Cancer 2022; 22:292. [PMID: 35303812 PMCID: PMC8933896 DOI: 10.1186/s12885-022-09397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Detection of the ROS1 rearrangement is mandatory in patients with advanced or metastatic non-small cell lung cancer (NSCLC) to allow targeted therapy with specific inhibitors. However, in Spanish clinical practice ROS1 determination is not yet fully widespread. The aim of this study is to determine the clinical and economic impact of sequentially testing ROS1 in addition to EGFR and ALK in Spain. Methods A joint model (decision-tree and Markov model) was developed to determine the cost-effectiveness of testing ROS1 strategy versus a no-ROS1 testing strategy in Spain. Distribution of ROS1 techniques, rates of testing, positivity, and invalidity of biomarkers included in the analysis (EGFR, ALK, ROS1 and PD-L1) were based on expert opinion and Lungpath real-world database. Treatment allocation depending on the molecular testing results was defined by expert opinion. For each treatment, a 3-states Markov model was developed, where progression-free survival (PFS) and overall survival (OS) curves were parameterized using exponential extrapolations to model transition of patients among health states. Only medical direct costs were included (€ 2021). A lifetime horizon was considered and a discount rate of 3% was applied for both costs and effects. Both deterministic and probabilistic sensitivity analyses were performed to address uncertainty. Results A target population of 8755 patients with advanced NSCLC (non-squamous or never smokers squamous) entered the model. Over a lifetime horizon, the ROS1 testing scenario produced additional 157.5 life years and 121.3 quality-adjusted life years (QALYs) compared with no-ROS1 testing scenario. Total direct costs were increased up to € 2,244,737 for ROS1 testing scenario. The incremental cost-utility ratio (ICUR) was 18,514 €/QALY. Robustness of the base-case results were confirmed by the sensitivity analysis. Conclusions Our study shows that ROS1 testing in addition to EGFR and ALK is a cost-effective strategy compared to no-ROS1 testing, and it generates more than 120 QALYs in Spain over a lifetime horizon. Despite the low prevalence of ROS1 rearrangements in NSCLC patients, the clinical and economic consequences of ROS1 testing should encourage centers to test all advanced or metastatic NSCLC (non-squamous and never-smoker squamous) patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09397-4.
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Affiliation(s)
- Federico Rojo
- Hospital Universitario Fundación Jiménez Diaz - CIBERONC, Madrid, Spain
| | - Esther Conde
- Hospital Universiario 12 de Octubre-CIBERONC, Madrid, Spain
| | - Héctor Torres
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | - David Carcedo
- Hygeia Consulting, S.A, Madrid, Spain. .,Hygeia Consulting, Barcelona, Spain.
| | | | | | | | - Ernest Nadal
- Catalan Institute of Oncology, Hospital Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Spain
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Kongnakorn T, Sarri G, Freitag A, Marczell K, Kazmierska P, Masters E, Pawar V, Zhang X. Modeling Challenges in Cost-Effectiveness Analysis of First-Line Immuno-Oncology Therapies in Non-small Cell Lung Cancer: A Systematic Literature Review. PHARMACOECONOMICS 2022; 40:183-201. [PMID: 34595671 PMCID: PMC8795065 DOI: 10.1007/s40273-021-01089-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The introduction of immuno-oncology (IO) therapies has changed the treatment landscape of non-small cell lung cancer (NSCLC). Numerous cost-effectiveness analyses (CEAs) and technology appraisals (TAs) evaluating IO therapies have been recently published. OBJECTIVE We reviewed economic models of first-line (1L) IO therapies for previously untreated advanced or metastatic NSCLC to identify methodological challenges associated with modeling cost effectiveness from published literature and TAs and to make recommendations for future CEAs in this disease area. METHODS A systematic literature review was conducted following Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched MEDLINE, Embase, EconLit (January 2009-January 2020), and select conferences (since 2016) for CEAs of 1L IO treatments in patients with recurrent or metastatic, epidermal growth factor receptor (EGFR)/anaplastic lymphoma kinase (ALK) mutation-negative NSCLC, published in English. TAs from England, Scotland, Canada, Australia, Germany, and France were also examined. Two reviewers screened the results and extracted the data. The quality of the CEAs was described using the Drummond checklist. RESULTS In total, 46 records reporting on 38 unique models met protocol-defined criteria and were included. Five models adjusted for treatment switching or crossover in base-case analyses, and the remainder considered treatment switching or crossover to represent clinical practice and made no adjustment. Seven models used external real-world data for survival modeling or extrapolation validation. Six models that assumed long-term treatment benefit stopped at 3 or 5 years after initiation. Seven models used the observed time-on-treatment distribution from the trial, and eight used progression-free survival for treatment duration. All models compared one or more IO monotherapies or combination therapies with chemotherapy. Only one study directly compared different IO agents but did not consider the concordance issue across programmed death-ligand 1 (PD-L1) testing methods. Utilities were modeled by health state in 12 models, four applied a time-to-death approach, and ten explored both. None applied cure models. CONCLUSION Variations in methodological challenges were seen across studies. Previous models took approaches that were followed in subsequent models, such as a 2-year stopping rule of IO duration or treatment-effect waning. Challenges such as heterogeneity in PD-L1 testing and survival extrapolation and validation using real-world data should be further considered for future models in advanced or metastatic NSCLC.
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Affiliation(s)
| | | | | | | | | | | | - Vivek Pawar
- EMD Serono Research & Development Institute, Inc., 45A Middlesex Turnpike, Billerica, 01821, MA, USA
| | - Xinke Zhang
- EMD Serono Research & Development Institute, Inc., 45A Middlesex Turnpike, Billerica, 01821, MA, USA.
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Zhu Y, Hu H, Ding D, Li S, Liao M, Shi Y, Huang J. First-line pembrolizumab plus chemotherapy for extensive-stage small-cell lung cancer: a United States-based cost-effectiveness analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:77. [PMID: 34863203 PMCID: PMC8642846 DOI: 10.1186/s12962-021-00329-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/30/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The clinical trial of Keynote-604 showed that pembrolizumab plus chemotherapy could generate clinical benefits for extensive-stage small-cell lung cancer (ES-SCLC). We aim to assess the efficacy and cost of pembrolizumab combined with chemotherapy in the first-line treatment setting of ES-SCLC from the United States (US) payers' perspective. METHODS A synthetical Markov model was used to evaluate cost and effectiveness of pembrolizumab plus platinum-etoposide(EP) versus EP in first-line therapy for ES-SCLC from the data of Keynote-604. Lifetime costs life-years(LYs), quality adjusted LYs(QALYs) and incremental cost-effectiveness ratios(ICERs) were estimated. One-way and probabilistic sensitivity analyses were performed. Furthermore, we performed subgroup analysis. RESULTS Pembrolizumab plus EP resulted in additional 0.18 QALYs(0.32 LYs) and corresponding incremental costs $113,625, resulting an ICER of $647,509 per QALY versus EP. The price of pembrolizumab had a significant impact on ICER. Probabilistic sensitivity analysis indicated that pembrolizumab combined chemotherapy may become a cost-effective option with a probability of 0%. Besides, subgroup analysis suggested that all subgroups were not cost-effective. CONCLUSION From the perspective of the US payer, pembrolizumab plus EP is not a cost-effective option for first-line treatment patients with ES-SCLC at a WTP threshold of $150,000 per QALY.
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Affiliation(s)
- Youwen Zhu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Huabin Hu
- Department of Medical Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, China
| | - Dong Ding
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Shuosha Li
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Mengting Liao
- Department of Health Management Center, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Yin Shi
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Jin Huang
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China. .,Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Hunan Key Laboratory of Skin Cancer and Psoriasis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
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11
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Peng Y, Zeng X, Peng L, Liu Q, Yi L, Luo X, Li S, Wang L, Qin S, Wan X, Tan C. Cost-Effectiveness of Nivolumab Plus Ipilimumab Combined with Two Cycles of Chemotherapy as First-Line Treatment in Advanced Non-Small Cell Lung Cancer. Adv Ther 2021; 38:3962-3972. [PMID: 34100243 DOI: 10.1007/s12325-021-01788-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The effectiveness of nivolumab plus ipilimumab with two cycles of chemotherapy (NIC) for advanced non-small cell lung cancer (NSCLC) has been demonstrated. We aimed to evaluate the cost-effectiveness of NIC for advanced NSCLC from the US payer perspective. METHODS A Markov model has been established to predict the disease course of previously untreated advanced NSCLC. The clinical data were derived from the CheckMate 9LA trial. Cost and utility were obtained from the literature. Model outputs included the incremental cost-effectiveness ratios (ICERs), incremental monetary benefit (INMB), and incremental net-health benefit (INHB). A series of sensitivity analyses were performed to analyze the uncertainty of the model. RESULTS Our results showed that NIC versus chemotherapy alone cost $264,278 and yielded an additional 0.80 quality-adjusted life-years (QALYs), which led to an ICER of $202,275/QALY gained. The INHB was - 0.28 QALY, and the INMB was - $41,865 at the threshold of $150,000/QALY. The results of one-way sensitivity analysis showed that the hazard ratio of overall survival was the most sensitive parameter. CONCLUSION NIC was unlikely to be cost-effective as a first-line treatment for patients with advanced NSCLC.
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Affiliation(s)
- Ye Peng
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Xiaohui Zeng
- PET-CT Center, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Liubao Peng
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Qiao Liu
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Lidan Yi
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Xia Luo
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Sini Li
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Liting Wang
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Shuxia Qin
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China
| | - Xiaomin Wan
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China.
| | - Chongqing Tan
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, No.139 Renmin Middle Road, Changsha, 410011, Hunan, China.
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12
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Yu A, Huang E, Abe M, An K, Park SK, Park C. Cost-effectiveness analyses of targeted therapy and immunotherapy for advanced non-small cell lung cancer in the United States: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2021; 21:381-393. [PMID: 33554675 DOI: 10.1080/14737167.2021.1886928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Mutation-targeting and immuno-oncology drugs are revolutionizing the treatment of advanced non-small cell lung cancer (NSCLC). Cost-effectiveness analyses (CEA) of these drugs have been conducted using various analytical methods and cost-effectiveness thresholds. This systematic review provides a comprehensive summary of the available evidence.Area covered: PubMed, Embase, and Cochrane Library were used to select for CEA of targeted therapies for NSCLC in the United States published between 2008 and 2020. Among the 28 included studies, a majority were published from 2017 to 2020 (n = 18) and more than half targeted non-squamous NSCLC (n = 15). The most frequently evaluated therapy was pembrolizumab (n = 11), followed by bevacizumab (n = 8) and erlotinib (n = 4). After 2009, all included studies applied $100,000 or more thresholds. Thresholds of studies supported by industry (median = $150,000) were more distributed than those of studies supported by nonprofits (median = $100,000).Expert commentary: Medications of interest have changed and are individualized to particular mutations. The cost-effectiveness thresholds varied among sponsors but generally trended to increase over time. This review provides an overview of the available cost-effectiveness findings for stakeholders and contributes to evidence-based practice.
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Affiliation(s)
- Anthony Yu
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Eva Huang
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Momoka Abe
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Kang An
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Sun-Kyeong Park
- College of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Chanhyun Park
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
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13
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Insinga RP, Feliciano JL, Qiao N, Vandormael K, Zhang Y. Cost-effectiveness of pembrolizumab + chemotherapy versus chemotherapy and pembrolizumab monotherapy in first line treatment of NSCLC in the US - updated analyses with additional trial follow-up. J Med Econ 2021; 24:792-805. [PMID: 34098842 DOI: 10.1080/13696998.2021.1937188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Pembrolizumab + chemotherapy substantially extends life expectancy for metastatic non-small cell lung cancer (NSCLC) patients. Its cost-effectiveness (CE) was previously evaluated based on interim trial analyses (follow-up ∼1 year). The present analysis describes CE incorporating additional follow-up based on protocol-specified final trial analyses (1-1.5 years additional follow-up), from a US healthcare payer perspective. METHODS A partitioned survival model is used to compare pembrolizumab + chemotherapy vs chemotherapy using data from the KN189 (non-squamous patients) and KN407 (squamous patients) clinical trials. An indirect treatment comparison vs pembrolizumab monotherapy is made for patient subgroups with PD-L1 TPS ≥50% and 1-49% based on data from the KN024 and KN042 trials. Efficacy, treatment utilization, health utility, and safety data are derived from trials and projected over 20 years. Costs for drugs, non-drug disease management, and adverse events are also incorporated. RESULTS Overall, versus chemotherapy alone, pembrolizumab + chemotherapy is projected to increase life expectancy by 1.12 years (3.35 vs 2.23) and 0.67 years (3.17 vs 2.50) in non-squamous and squamous patients, respectively. Resultant ICERs ($158,030/QALY and $178,387/QALY) are below a US 3-times GDP per capita threshold ($195,000/QALY). ICERs vs chemotherapy also generally fall below the threshold within PD-L1 sub-groups (except in squamous PD-L1 < 1%, which may have differed due to small sample size) while ICERs vs pembrolizumab monotherapy in PD-L1 ≥ 50% and 1-49% sub-groups generally exceed it (except in squamous PD-L1 1-49%); largely a result of the higher drug acquisition cost of pembrolizumab + chemotherapy relative to differences in life expectancy. CONCLUSIONS Taken together, with longer-term trial follow-up and in the context of prior literature, in the US, one of the two options for pembrolizumab use (either pembrolizumab + chemotherapy or pembrolizumab monotherapy), represents a cost-effective treatment in virtually all non-squamous and squamous metastatic NSCLC patient populations and PD-L1 sub-groups evaluated.
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Affiliation(s)
- Ralph P Insinga
- Center for Observational and Real-World Evidence, Merck & Co., Inc, Kenilworth, NJ, USA
| | - Josephine L Feliciano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Nan Qiao
- Center for Observational and Real-World Evidence, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | - Ying Zhang
- Merck Sharp & Dohme, HTA Statistics Europe, Brussels, Belgium
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14
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Li N, Zheng H, Zheng B, Chen C, Cai H, Liu M. Economic Evaluations of Immune Checkpoint Inhibitors for Patients with Non-Small Cell Lung Cancer: A Systematic Review. Cancer Manag Res 2020; 12:4503-4518. [PMID: 32606944 PMCID: PMC7297344 DOI: 10.2147/cmar.s248020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 05/09/2020] [Indexed: 12/26/2022] Open
Abstract
Objective This review aimed to assess the quality of available evidence on the economic evaluations of immune checkpoint inhibitors in patients with non-small cell lung cancer (NSCLC) and provide evidence to improve the efficiency of healthcare resources. Materials and Methods Literature search was performed using some electronic databases (PubMed, Embase and Cochrane Central Register of Controlled Trials). Final search was performed in December 2019. Study characteristics and results were recorded and compared. The quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklists. We did not elaborate the restrictions on the target population. We included patients with squamous or non-squamous NSCLC and metastatic or advanced cancer. Results Of 98 papers considered, 21 were chosen for this review. Most of them are cost-effectiveness analysis. Comparative regimens consisted of either immune checkpoint inhibitor monotherapy, immune checkpoint inhibitor plus chemotherapy, or chemotherapy alone. Fourteen, four, and three studies were about pembrolizumab, nivolumab, and atezolizumab, respectively. The methods mostly used in these studies were modeling and sensitivity analysis. All studies used quality-adjusted life year (QALY) and life years (LY) as outcomes. Most studies were conducted in high-income countries. Based on the willingness to pay threshold, atezolizumab, and pembrolizumab were found to be cost-effective in one and 10 studies, respectively. None of the studies concluded that nivolumab was cost-effective. For quality assessment, all studies fulfilled more than 50% of the CHEERS checklist. Conclusion The included studies indicated that pembrolizumab regimens are cost-effective as first-line treatment for patients with NSCLC in developed countries. Nivolumab and atezolizumab are likely to be cost-effective as second-line treatment but not as first-line treatment.
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Affiliation(s)
- Na Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Huanrui Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Bin Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Chaoxin Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Hongfu Cai
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
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15
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Rahouma M, Baudo M, Kamel M, Abdel Karim N, Altorki N. Anti-PDL1 effect in squamous non-small cell lung cancer. Transl Lung Cancer Res 2020; 9:406-409. [PMID: 32420083 PMCID: PMC7225162 DOI: 10.21037/tlcr.2020.02.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/03/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Mohamed Rahouma
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- Cardiothoracic Surgery Department, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | - Massimo Baudo
- Cardiothoracic Surgery Department, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | - Mohamed Kamel
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- Cardiothoracic Surgery Department, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | - Nagla Abdel Karim
- Hematology and Oncology Department, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nasser Altorki
- Cardiothoracic Surgery Department, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
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16
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Zhang B, Liu Y, Zhou S, Jiang H, Zhu K, Wang R. Predictive effect of PD-L1 expression for immune checkpoint inhibitor (PD-1/PD-L1 inhibitors) treatment for non-small cell lung cancer: A meta-analysis. Int Immunopharmacol 2020; 80:106214. [PMID: 31982822 DOI: 10.1016/j.intimp.2020.106214] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/06/2020] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Programmed death-ligand-1 (PD-L1) is a well-known predictive biomarker in non-small cell lung cancer (NSCLC) patients, however, its accuracy remains controversial. Here, we investigated the correlation between PD-L1 expression level and efficacy of its inhibitors, and hence assessed the predictive effect of PD-L1 expression. METHODS Studies that evaluated the efficacy of programmed death-1 (PD-1)/ PD-L1 inhibitors in advanced NSCLC patients according to tumor PD-L1 expression levels were searched for on Medline, Cochrane Library, and Embase. The pooled risk ratio (RR) and 95% confidence intervals (95% CIs) were calculated for the objective response rate (ORR) with overall survival (OS) and progression-free survival (PFS) were measured in terms of hazard ratio (HR) and the corresponding 95% CIs. RESULTS 1432 NSCLC patients from six randomized controlled trials (RCTs) were included and three PD-1/PD-L1 inhibitors (atezolizumab, nivolumab, and pembrolizumab) were used to treat the patients. A significantly higher ORR was observed in the high PD-L1 expression group compared to the low expression group (0.35 [95% CI, 0.30-0.40] vs 0.11 [95% CI, 0.09-0.14]). The results of the subgroup analysis, grouped by the type of drugs and antibodies which assess immune checkpoint inhibitors were identical with the pooled result. However, our study showed that PD-L1 expression was neither prognostic nor predictive of overall survival (OS) or progression-free survival (PFS) in patients treated with PD-1/PD-L1 inhibitors compared to chemotherapy. CONCLUSIONS PD-L1 can be a predictive biomarker for ORR. Nevertheless, PD-L1 expression is not a good predictive tool for OS and PFS.
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Affiliation(s)
- Binbin Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Yi Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Sijing Zhou
- Hefei Prevention and Treatment Center for Occupational Diseases, Hefei 230022, China.
| | - Huihui Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Ke Zhu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Ran Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China.
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