Cost-effectiveness analysis of adjuvant chemotherapies in patients presenting with gastric cancer after D2 gastrectomy

Cost‑effectiveness analysis of tislelizumab plus chemotherapy in Chinese patients with advanced or metastatic oesophageal squamous cell carcinoma

The RATIONALE-306 study revealed that patients with advanced or metastatic oesophageal squamous cell carcinoma (OSCC) could benefit from treatment with tislelizumab plus chemotherapy. This study aimed to evaluate the cost-effectiveness of tislelizumab plus chemotherapy for treating OSCC from the perspective of the Chinese healthcare system. Partitioned survival model estimated the cost-effectiveness of tislelizumab plus chemotherapy compared with chemotherapy alone for treating OSCC using RATIONALE-306 data. Costs and utilities were obtained from local databases and published studies. Costs, quality-adjusted life-years (QALYs), life-years, incremental cost-effectiveness ratios (ICER), incremental net health benefits (INHB), and incremental net monetary benefits (INMB) were outcomes. Price simulation were conducted at the willingness-to-pay (WTP) threshold. Sensitivity and subgroup analyses were performed to assess model robustness. Compared with chemotherapy alone, tislelizumab plus chemotherapy yielded an ICER of USD 27,896/QALY, gained an additional 0.414 QALYs and 0.751 life-years, and increased the cost by USD 11,560. Probabilistic sensitivity analysis revealed that tislelizumab plus chemotherapy was cost-effective at the WTP of USD 38,258/QALY with probability of 94.43%. When the price in China was less than USD 3.714 per mg, the price simulation results indicated that tislelizumab plus chemotherapy was cost-effective at a WTP threshold of USD 38,258. Tislelizumab plus chemotherapy yielded an INHB of 0.112 QALYs and an INMB of USD 4,279 compared with chemotherapy alone at a WTP threshold of USD 38,258. Based on the sensitivity analyses, the above results were stable. A general trend was observed for subgroups with better survival benefits related to a higher probability of cost-effectiveness. From the Chinese healthcare perspective, tislelizumab plus chemotherapy is more cost-effective than chemotherapy alone as a first-line therapy for OSCC. These findings can help clinicians make optimal clinical decisions and assist decision-makers in evaluating the cost-effectiveness of tislelizumab in clinical practice.

Cost-effectiveness analysis of pembrolizumab plus chemotherapy versus placebo plus chemotherapy for HER2-negative advanced gastric/gastroesophageal junction cancer in the Chinese healthcare system

BACKGROUND

This study compares first-line pembrolizumab plus chemotherapy with chemotherapy alone for patients with HER2-negative advanced gastric cancer (GC) and gastroesophageal junction cancer (GEJC) in China.

METHODS

A Markov state-transition model was developed based on the phase 3 randomized KEYNOTE-859 clinical trial data. The health state utility values and direct medical costs were derived from the KEYNOTE-859 clinical trial, the relevant literature, and local charges. The measured outcomes included quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER). Probabilistic and one-way sensitivity analyses (OWSA) were performed to assess the uncertainty of the model.

RESULTS

In the base analysis, the incremental effectiveness and cost of pembrolizumab plus chemotherapy versus chemotherapy alone were 0.22 QALYs and $16,627.31, respectively, resulting in an ICER of $76,936.60/QALY, which is higher than the willingness-to-pay threshold in China ($35,864.61/QALY). Subgroup analyses revealed that the ICERs of pembrolizumab plus chemotherapy versus chemotherapy alone were $72,762.68 and $34,813.70 in the populations with PD-L1 CPS of 1 or higher (CPS ≥ 1) and PD-L1 CPS ≥ 10 (CPS ≥ 10), respectively.

CONCLUSIONS

As first-line therapy for patients with locally advanced or metastatic HER2-negative GC/GEJC in China, pembrolizumab plus chemotherapy is less cost-effective than chemotherapy alone, however, in the CPS ≥ 10 subgroup is more.

Cost-effectiveness analysis of camrelizumab plus paclitaxel and carboplatin versus sintilimab plus gemcitabine and cisplatin or carboplatin for the first-line treatment of local advanced or metastatic squamous NSCLC in Chinese mainland

Objective

Both camrelizumab plus paclitaxel and carboplatin (CTC) and sintilimab plus gemcitabine and cisplatin or carboplatin (SGP) have been approved by the National Medical Products Administration of China (NMPA) for the first-line treatment of local advanced or metastatic sqNSCLC. However, the comparison of the two treatments as first-line treatments in efficacy or pharmacoeconomics has barely been studied. To deeply understand the costs and outcomes of the two treatments, this work directly compared the cost-effectiveness for the first-line treatment of local advanced or metastatic squamous NSCLC in the Chinese mainland.

Methods

A network meta-analysis was first performed based on the three clinical trials, namely, CameL-Sq, ORIENT-12, and C-TONG1002, to compare the clinical benefits of the two treatments. The Weibull approximation was applied to further calculate the life expectancy of the two treatments. The partitioned survival model (PSM) was next established, and one-way sensitivity analysis and probabilistic sensitivity analysis were also performed to evaluate the stability of the underlying parameter values and assumptions within the model.

Results

CTC treatment gained 0.68 QALYs and cost $14,764. SGP treatment gained 0.54 QALYs and cost $14,584. The CTC arm gained 0.14 additional QALYs and cost $179 more than the SGP arm, and the ICERs was $1,269/QALY, which was lower than one-fold GDP per capita in the Chinese mainland ($12,734 GDP per capita in 2022). In probabilistic sensitivity analysis, when the WTP ranged from $12,734-38,202 (1-3 folds, 2022 GDP per capita in China), the CTC group had higher probabilities than the SGP group for being cost effective, which ranged from 85.65% to 88.38%.

Conclusion

From the perspective of the payers, camrelizumab plus chemotherapy was cost-effective compared with sintilimab plus chemotherapy for the first-line treatment of local advanced or metastatic squamous NSCLC in the Chinese mainland.

First-line serplulimab plus chemotherapy versus chemotherapy in PD-L1-positive esophageal squamous-cell carcinoma: a cost-effectiveness analysis

Patients with PD-L1-positive esophageal squamous-cell carcinoma (ESCC) were significantly more likely to survive when treated with serplulimab plus cisplatin plus 5-fluorouracil (serplulimab-CF). At this point, it is unknown whether this expensive therapy is cost-effective. From the Chinese healthcare system's perspective, we aimed to evaluate serplulimab-CF versus CF alone for cost-effectiveness. A partitioned survival model was constructed based on the ASTRUM-007 trial. Quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were calculated. A further analysis of subgroups and scenarios was conducted. The willingness to pay (WTP) threshold of $38,258/QALY or $84,866/QALY is defined as three times the per capita gross domestic product value of the general region or affluent region. Compared with CF alone, in the overall (scenario 1), patients with PD-L1 expression level of 1 ≤ CPS < 10 (scenario 2), and patients with PD-L1 CPS ≥ 10 (scenario 3) populations, the ICERs were $69,025/QALY, $82,533/QALY, and $75,436/QALY for serplulimab-CF. Nevertheless, the probability of serplulimab-CF becoming cost-effective based on scenarios 1, 2, and 3 is only 2.71%, 0.94%, and 2.84%, respectively, at a WTP threshold of $38,258/QALY. When serplulimab costs < $4.84/mg, serplulimab-CF may be cost-effective at the WTP threshold of $38,258/QALY; otherwise, CF was preferred. Similar results were obtained from sensitivity analyses, suggesting the robustness of these findings. There was no cost-effectiveness in general regions of China for serplulimab-CF in PD-L1-positive ESCC compared to CF, although it is probably considered cost-effective in affluent regions. Serplulimab-CF may achieve favorable cost-effectiveness by lowering the price of serplulimab.

Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis

Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.

Cost-effectiveness analysis of tislelizumab plus chemotherapy as the first-line treatment for advanced or metastatic oesophageal squamous cell carcinoma in China

OBJECTIVE

We aimed to investigate the cost-effectiveness of tislelizumab plus chemotherapy compared to chemotherapy alone as a first-line treatment for advanced or metastatic oesophageal squamous cell carcinoma (OSCC).

METHODS

A partitioned survival model was developed to evaluate the cost-effectiveness of tislelizumab plus chemotherapy versus chemotherapy alone in patients with advanced or metastatic OSCC over a 10-year lifetime horizon from the perspective of the Chinese healthcare system. Costs and utilities were derived from the drug procurement platform and published literature. The model outcomes comprised of costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were conducted to address uncertainty and ensure the robustness of the model.

RESULTS

Tislelizumab plus chemotherapy yielded an additional 0.337 QALYs and incremental costs of $7,117.007 compared with placebo plus chemotherapy, generating an ICER of $21,116.75 per QALY, which was between 1 time ($12,674.89/QALY) and 3 times GDP ($38,024.67/QALY) per capita. In one-way sensitivity analysis, the ICER is most affected by the cost of oxaliplatin, paclitaxel and tislelizumab. In the probabilistic sensitivity analysis, when the willingness-to-pay threshold was set as 1 or 3 times GDP per capita, the probability of tislelizumab plus chemotherapy being cost-effective was 1% and 100%, respectively.

CONCLUSION

Tislelizumab plus chemotherapy was probably cost-effective compared with chemotherapy alone as the first-line treatment for advanced or metastatic OSCC in China.

The cost-effectiveness of zolbetuximab in CLDN18.2-positive gastric or gastroesophageal junction adenocarcinoma

Aim: To estimate the cost-effectiveness of zolbetuximab plus capecitabine/oxaliplatin (CAPOX) in CLDN18.2-positive, HER2-negative, mG/GEJ adenocarcinoma from the perspective of Chinese payers. Materials & methods: A partitioned survival model was developed to assess the costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICER) of zolbetuximab plus CAPOX versus placebo plus CAPOX. Sensitivity analyses were performed to test the robustness of model. Results: Zolbetuximab plus CAPOX gained an additional cost of $91,551 and an extra health benefit of 0.24 QALY over placebo plus CAPOX, producing an ICER of $388,186/QALY, which exceeded the willingness-to-pay threshold of $38,223/QALY. Sensitivity analysis shows that the model was generally robust. Conclusion: Zolbetuximab plus CAPOX would not be a cost-effective first-line treatment regimen in CLDN18.2-positive, HER2-negative, mG/GEJ adenocarcinoma in China.

Immune checkpoint inhibitors versus chemotherapy as second-line therapy for advanced oesophageal squamous cell carcinoma: a systematic review and economic evaluation

Background

Recently, several novel programmed cell death protein 1 (PD-1) inhibitors have been approved for second-line treating advanced or metastatic oesophageal squamous cell carcinoma (OSCC), including camrelizumab, nivolumab, pembrolizumab, sintilimab and tislelizumab. However, the optimal treatment regimen remained ambiguous.

Objectives

The purpose of this study was to investigate the efficacy, safety and economy of available PD-1 inhibitors to determine the optimal treatment from the Chinese healthcare system perspective.

Design

A systematic review and economic evaluation.

Data sources and methods

A systematic review was undertaken utilizing PubMed, Web of Science, Cochrane Library, Embase and Scopus databases to identify eligible studies until 31 August 2023. Primary outcomes were progression-free survival (PFS), overall survival (OS) and adverse events (AEs). We also developed a partitioned survival model at 3-week intervals based on five clinical trials to predict long-term costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios for various treatment options. Direct medical costs and utility values were obtained from public drug bidding databases, clinical trials or published literature. The parameter uncertainties within the model were determined via one-way and probabilistic sensitivity analyses.

Results

Five randomized controlled trials involving 2837 patients were included in the analysis. Compared with other treatments examined, camrelizumab provided the best PFS benefits [hazard ratio (HR): 0.69, 95% confidence interval (CI): 0.56-0.86], and pembrolizumab provided the best OS benefits (HR: 0.55, 95% CI: 0.37-0.82). Nivolumab caused a relatively lower incidence of treatment-related AEs (HR: 0.10, 95% CI: 0.05-0.20) and grade 3-5 AEs (HR: 0.13, 95% CI: 0.08-0.21) than other immunotherapy regimens. In the economic evaluation, average 10-year costs ranged from $5,433.86 (chemotherapy) to $50,617.95 (nivolumab) and mean QALYs ranged from 0.55 (chemotherapy) to 0.82 (camrelizumab). Pembrolizumab was eliminated because of dominance. Of the remaining strategies, when the willingness-to-pay thresholds were 1, 2 and 3 times GDP per capita in 2022, sintilimab, tislelizumab and camrelizumab were the most cost-effective treatment options, respectively.

Conclusion

Sintilimab might be the optimal treatment alternative for second-line therapy of advanced OSCC in China, followed by tislelizumab and camrelizumab.

Trial registration

This study has been registered on the PROSPERO database with the registration number CRD42023495204.

Cost-effectiveness analysis of nivolumab versus placebo for relapsed malignant mesothelioma

BACKGROUND

Although nivolumab has shown clinical benefits for relapsed malignant mesothelioma, its cost-effectiveness requires further investigation.

AIM

This study aimed to evaluate the cost-effectiveness of nivolumab compared to placebo for relapsed malignant mesotheliomas from the perspective of the Chinese healthcare system.

METHOD

A three-state Markov model was developed based on data from the phase 3 randomized CONFIRM clinical trial. The drug cost and utility values for the health state were obtained from the relevant literature. The measured outcomes included quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). Probabilistic and one-way sensitivity analyses (OWSA) were performed to assess the uncertainty of the model.

RESULTS

Patients receiving nivolumab gained more health benefits (0.65 QALYs vs. 0.43 QALYs). The cost was higher ($25,806.08 vs. $9,310.74) than for patients in the placebo group, resulting in an ICER of $75,805.11/QALY, which was above the willingness-to-pay (WTP) threshold of three times per capita GDP ($35,864.61) in China. The result of OWSA indicated that the cost of nivolumab, the utility of the disease progression, and the discount rate were the most significant factors. Probabilistic sensitivity analysis suggested that the probability that nivolumab was not cost-effective as was 100.00% above the specified WTP threshold.

CONCLUSION

From the perspective of the Chinese healthcare system, nivolumab was not as cost-effective as placebo for relapsed malignant mesothelioma.

Cost-effectiveness analysis of toripalimab plus chemotherapy for patients with advanced esophageal squamous cell carcinoma in China

BACKGROUND

The aim of the current analysis was to evaluate the cost-effectiveness of toripalimab plus chemotherapy compared with chemotherapy alone as the first-line option for patients with advanced esophageal squamous cell carcinoma (ESCC) from the perspective of Chinese health-care system.

METHODS

A partitioned survival model was conducted to track 3-week patients' transition and evaluate the health and economic outcomes in 10-year horizon of the two competing first-line treatment among toripalimab plus chemotherapy and chemotherapy alone. The survival data were gathered from the JUPITER-06 trial, and cost and utility values were obtained from the local charges and published studies. Total costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were the model outcomes. Sensitivity and subgroup analyses were conducted.

RESULTS

Treatment with toripalimab plus chemotherapy yields marginal cost of $8,639.74 and additional 0.65 QALYs, resulting in an ICER of $13,280.97 per additional QALY gained, which was lower than the willingness-to-pay (WTP) threshold of $38,224 in China. Sensitivity and subgroup analyses confirmed the robustness of the model outcomes.

CONCLUSIONS

Toripalimab plus chemotherapy was likely to be the cost-effective first-line option for patients with advanced ESCC compared with chemotherapy alone with the WTP threshold of $38,224 per additional QALY gained from the perspective of the Chinese health-care system.

Economic evaluation of serplulimab plus chemotherapy as the first-line treatment of oesophageal squamous cell carcinoma in China

OBJECTIVE

The ASTRUM-007 study confirmed the significant efficacy and safety of serplulimab plus chemotherapy for patients with locally advanced/metastatic, programmed cell death-ligand 1 positive oesophageal squamous cell carcinoma (OSCC). The economics of this regimen, however, is unclear. Therefore, this study aimed to evaluate the cost-effectiveness of adding serplulimab to chemotherapy for the treatment of advanced OSCC from the perspective of the Chinese healthcare system.

DESIGN

A partitioned survival model was established to simulate the costs and outcomes of chemotherapy versus serplulimab plus chemotherapy. The survival data came from the ASTRUM-007 study. Only direct medical costs were considered, and utility values were referred to the literature. Sensitivity analysis was performed to assess the effect of parameter uncertainty on the model.

OUTCOME MEASURES

Total costs, incremental costs, life years, quality-adjusted life years (QALYs), incremental QALYs and incremental cost-effectiveness ratio (ICER).

RESULTS

The base case analysis showed that the cost of serplulimab plus chemotherapy (US$69 356) was US$41 607 higher than that of chemotherapy (US$27 749), but it also gained 0.38 QALYs more (1.38 vs 1 QALYs), with an ICER of US$110 744.36/QALY, which was higher than the willingness to pay. The factors that most influenced the ICER were the price of serplulimab, weight and utility value of the progression-free survival stage. The subgroup analysis and scenario analysis also demonstrated that serplulimab plus chemotherapy was not economical.

CONCLUSIONS

Compared with chemotherapy, serplulimab coupled with chemotherapy was not cost-effective for the treatment of advanced OSCC in China.

An international multi-institution real-world study of the optimal surveillance frequency for stage II/III gastric cancer: the more, the better?

BACKGROUND

Due to lacking evidence on surveillance for gastric cancer (GC), this study aimed to determine the optimal postsurgical surveillance strategy for pathological stage (pStage) II/III GC patients and compare its cost-effectiveness with traditional surveillance strategies.

METHODS

Prospectively collected data from stage II/III GC patients ( n =1661) who underwent upfront surgery at a large-volume tertiary cancer center in China (FJMUUH cohort) between January 2010 and October 2015. For external validation, two independent cohorts were included, which were composed of 380 stage II/III GC patients at an tertiary cancer center in U.S.A (Mayo cohort) between July 1991 and July 2012 and 270 stage II/III GC patients at another tertiary cancer center in China (QUAH cohort) between May 2010 and October 2014. Random forest models were used to predict dynamic recurrence hazards and to construct individual surveillance strategies for stage II/III GC. Cost-effectiveness was assessed by the Markov model.

RESULTS

The median follow-up period of the FJMUUH, the Mayo, and QUAH cohorts were 55, 158, and 70 months, respectively. In the FJMUUH cohort, the 5-year recurrence risk was higher in pStage III compared with pStage II GC patients ( P <0.001). Our novel individual surveillance strategy achieved optimal cost-effectiveness for pStage II GC patients (ICER =$490/QALY). The most intensive NCCN surveillance guideline was more cost-effective (ICER =$983/QALY) for pStage III GC patients. The external validations confirmed our results.

CONCLUSION

For patients with pStage II GC, individualized risk-based surveillance outperformed the JGCTG and NCCN surveillance guidelines. However, the NCCN surveillance guideline may be more suitable for patients with pStage III GC. Even though our results are limited by the retrospective study design, the authors believe that our findings should be considered when recommending postoperative surveillance for stage II/III GC with upfront surgery in the absence of a randomized clinical trial.

Optimal postoperative surveillance strategies for cancer survivors with gastric neuroendocrine carcinoma based on individual risk: a multicenter real-world cohort study

BACKGROUND

The best follow-up strategy for cancer survivors after treatment should balance the effectiveness and cost of disease detection while detecting recurrence as early as possible. Due to the low incidence of gastric neuroendocrine carcinoma and mixed adenoneuroendocrine carcinoma [G-(MA)NEC], high-level evidence-based follow-up strategies is limited. Currently, there is a lack of consensus among clinical practice guidelines regarding the appropriate follow-up strategies for patients with resectable G-(MA)NEC.

MATERIALS AND METHODS

The study included patients diagnosed with G-(MA)NEC from 21 centers in China. The random forest survival model simulated the monthly probability of recurrence to establish an optimal surveillance schedule maximizing the power of detecting recurrence at each follow-up. The power and cost-effectiveness were compared with the National Comprehensive Cancer Network, European Neuroendocrine Tumor Society, and European Society for Medical Oncology Guidelines.

RESULTS

A total of 801 patients with G-(MA)NEC were included. The patients were stratified into four distinct risk groups utilizing the modified TNM staging system. The study cohort comprised 106 (13.2%), 120 (15.0%), 379 (47.3%), and 196 cases (24.5%) for modified groups IIA, IIB, IIIA, and IIIB, respectively. Based on the monthly probability of disease recurrence, the authors established four distinct follow-up strategies for each risk group. The total number of follow-ups 5 years after surgery in the four groups was 12, 12, 13, and 13 times, respectively. The risk-based follow-up strategies demonstrated improved detection efficiency compared to existing clinical guidelines. Further Markov decision-analytic models verified that the risk-based follow-up strategies were better and more cost-effective than the control strategy recommended by the guidelines.

CONCLUSIONS

This study developed four different monitoring strategies based on individualized risks for patients with G-(MA)NEC, which may improve the detection power at each visit and were more economical, effective. Even though our results are limited by the biases related to the retrospective study design, we believe that, in the absence of a randomized clinical trial, our findings should be considered when recommending follow-up strategies for G-(MA)NEC.

Cost-effectiveness analysis of atezolizumab plus chemotherapy as first-line treatment for patients with advanced nonsquamous non-small-cell lung cancer in China

OBJECTIVE

The aim of the study was to evaluate the cost-effectiveness of adding atezolizumab to first-line chemotherapy for advanced nonsquamous non-small-cell lung cancer (NSCLC) from Chinese healthcare system.

METHODS

A partitioned survival model (PSM) was established to simulate 3-week patients transition in a 20-year time horizon to estimate the health and economic outcomes of adding atezolizumab to first-line chemotherapy for advanced nonsquamous NSCLC. Costs and utility values were obtained from the local charges and published studies. Sensitivity analyses were conducted to confirm the robustness of the model results.

RESULTS

Atezolizumab plus chemotherapy yielded additional 0.36 life years (LYs) and 0.23 quality-adjusted life-years (QALYs), and the marginal cost was $60,154.48, resulting in an ICER of atezolizumab plus chemotherapy versus chemotherapy was $267,264.85/QALY. One-way sensitivity analyses revealed that the cost of atezolizumab was the main driver of the model outcomes, and the probabilistic sensitivity analyses suggested that atezolizumab plus chemotherapy had 0% probability of being cost-effective first-line option at the willingness-to-pay (WTP) threshold of $37,652/QALY in China.

CONCLUSIONS

Atezolizumab plus chemotherapy could not be considered cost-effective compared with chemotherapy alone as the first-line strategy for patients with advanced nonsquamous NSCLC in China. And appropriately reduce the price of atezolizumab is necessary.

Serplulimab Plus Chemotherapy vs Chemotherapy for Treatment of US and Chinese Patients with Extensive-Stage Small-Cell Lung Cancer: A Cost-Effectiveness Analysis to Inform Drug Pricing

BACKGROUND

Serplulimab is a potential valuable therapy, while patients, physicians, and decision-makers are uncertain about the cost-effectiveness of this novel drug and its corresponding reasonable price. This study aimed to simulate the price at which serplulimab was cost-effective as first-line therapy for United States (US) and Chinese extensive-stage small-cell lung cancer (ES-SCLC) patients.

METHODS

In this economic evaluation, a partitioned survival model was constructed from the perspective of US and Chinese payers. Baseline characteristics of patients and critical clinical data were obtained from ASTRUM-005. Costs and utilities were collected from open-access databases and published literature. Cumulative costs (in US dollars), life years, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were measured and compared. Price simulation was conducted to inform the pricing strategy at the given willingness-to-pay (WTP) threshold. The robustness of the model was assessed via sensitivity analyses and scenario analyses; subgroup analyses were also included.

RESULTS

Base-case analysis indicated that serplulimab ($818.16/100 mg) would be cost-effective in the US at the WTP threshold of $150,000, with improved effectiveness of 0.61 QALYs and an additional cost of $64,918 (ICER $106,757). Serplulimab ($818.16/100 mg, patient assistance program considered) was cost-effective in China, with improved effectiveness of 0.58 QALYs and an increased overall cost of $19,369 (ICER $33,392). The price simulation results indicated that serplulimab was favored in the US when the price was less than $762.11/100 mg and $1261.57/100 mg at the WTP threshold of $100,000 and $150,000, respectively; it was cost-effective at the WTP threshold of $38,184 when the price was less than $373.37/100 mg in China. Sensitivity analyses revealed that the above results were stable. Subgroup analysis results indicated an overall trend for subgroups with better survival advantages to have a higher probability of cost-effectiveness, despite serplulimab not being cost-effective in some subgroups.

CONCLUSIONS

Serplulimab might be a valuable and cost-effective therapy in both the US and China. The evidence-based pricing strategy provided by this study could benefit decision-makers in making optimal decisions and clinicians in general clinical practice. More evidence about the budget impact and affordability for patients is needed.

Cost-effectiveness of toripalimab plus chemotherapy for advanced esophageal squamous cell carcinoma

BACKGROUND

Toripalimab is an immune checkpoint inhibitor (ICI) against programmed death ligand 1 (PD-L1). It has been approved for advanced esophageal squamous cell carcinoma (ESCC) as the first-line treatment due to significantly improved progression-free survival (PFS) and overall survival (OS) in the JUPITER-06 trial.

AIM

This study aimed to compare the cost-effectiveness between toripalimab plus chemotherapy and placebo plus chemotherapy from the perspective of the Chinese health system.

METHOD

The study developed a 3-year partitioned survival model to assess costs and outcomes in two treatment groups with or without toripalimab. The critical indicator was the incremental cost-effectiveness ratio (ICER). Scenario and sensitivity analyses were performed to evaluate the robustness of the findings and identify the parameters with the greatest impact on cost-effectiveness.

RESULTS

In the base case analysis, the incremental effectiveness and cost of toripalimab plus chemotherapy versus placebo plus chemotherapy were 0.26 quality-adjusted life year (QALYs) and $11,254.84, respectively, resulting in an ICER of $43,405.09/QALY, higher than the 2021 willingness-to-pay threshold in China ($37,658.70/QALY). The results were sensitive to the utility of PFS, the incidence of neutropenia in the toripalimab group, and the cost of toripalimab. The toripalimab plus chemotherapy group was cost-effective only if the price of toripalimab decreased by more than 40%.

CONCLUSION

Adding toripalimab to chemotherapy was not cost-effective in patients with advanced ESCC in China.

Economic evaluation of first-line sugemalimab plus chemotherapy for metastatic non-small cell lung cancer in China

Objective

To evaluate the economics of sugemalimab plus chemotherapy in the first-line treatment of metastatic non-small cell lung cancer, and to provide a reference for the formulation of relevant medical insurance policies and rational drug use.

Methods

From the perspective of the Chinese health system, a three-state partitioned survival model was constructed based on data from a phase III randomized clinical trial (GEMSTONE 302) to evaluate the cost-utility of sugemalimab plus chemotherapy compared with chemotherapy in first-line treatment of metastatic non-small cell lung cancer. Model results were expressed as total cost, life years, quality-adjusted life years, and incremental cost-effectiveness ratio. The robustness of the underlying analysis results was verified using one-way sensitivity analysis and probabilistic sensitivity analysis.

Results

The results of the base-case analysis showed that sugemalimab plus chemotherapy yielded 1.63 QALYs at a total cost of 130,667.70 USD, chemotherapy yielded 1.04 QALYs at a total cost of 64,001.02 USD, and the ICER was 113,155.52 USD/QALY, which was well above the current willingness-to-pay threshold in China (3 times 2021 per capita GDP) (36,203.88 USD).

Conclusion

This study suggests that sugemalimab in combination with a chemotherapy regimen is more effective but not economical for patients with metastatic non-small cell lung cancer receiving first-line therapy in China and that a reasonable reduction in drug prices could improve the probability of it being economical.

Cost-effectiveness analysis of sintilimab plus chemotherapy for advanced or metastatic esophageal squamous cell carcinoma

Background

Sintilimab plus chemotherapy (SIDCHM) is more effective than placebo plus chemotherapy (PLCHM) for advanced or metastatic esophageal squamous cell carcinoma (ESCC). However, considering the high cost of sintilimab, this study evaluated the cost-effectiveness of SIDCHM in comparison with PLCHM for advanced or metastatic ESCC from the Chinese healthcare system perspective.

Methods

Polymorphic Markov models were constructed to simulate the course and cost of SIDCHM. Treatment drug costs were calculated at national list prices and clinical data, other costs, and utility values were extracted from the reference literature. Primary outcomes included quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). The robustness of the model was verified by one-way sensitivity analysis and probabilistic sensitivity analysis (PSA).

Results

SIDCHM obtained 1.03 QALYs at $24,044.49, whereas the effectiveness and cost of PLCHM were 0.67 QALYs and $14,166.24, respectively. The ICER for SIDCHM versus PLCHM was $23,458.08/QALY. The utility of the PFS state was the parameter that had the greatest effect on the ICER. The PSA showed that SIDCHM had an 86% probability of being cost-effective at the willingness-to-pay threshold of 3* Chinese gross domestic product per capita ($37,653/QALY).

Conclusion

From the Chinese healthcare system perspective, SIDCHM is considered a cost-effective treatment option compared with PLCHM as first-line therapy for advanced or metastatic ESCC.

Economic evaluation of FLOT and ECF/ECX perioperative chemotherapy in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma

OBJECTIVE

The perioperative chemotherapy with fluorouracil, leucovorin, oxaliplatin plus docetaxel (FLOT) was recommended by the Chinese Society of Clinical Oncology Guidelines for gastric cancer (2018 edition) for patients with resectable gastric or gastro-oesophageal junction adenocarcinoma (class IIA). However, the economic impact of FLOT chemotherapy in China remains unclear. The analysis aimed to compare the cost-effectiveness of FLOT versus epirubicin, cisplatin plus fluorouracil or capecitabine (ECF/ECX) in patients with locally advanced resectable tumours.

DESIGN

We developed a Markov model to compare the healthcare and economic outcomes of FLOT and ECF/ECX in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma. Costs were estimated from the perspective of Chinese healthcare system. Clinical and utility inputs were derived from the FLOT4 phase II/III clinical trial and published literature. Sensitivity analyses were employed to assess the robustness of our result. The annual discount rate for costs and health outcomes was set at 5%.

OUTCOME MEASURES

The primary outcome of incremental cost-effectiveness ratios (ICERs) was calculated as the cost per quality-adjusted life years (QALYs).

RESULTS

The base-case analysis found that compared with ECF/ECX, the use of FLOT chemotherapy was associated with an additional 1.08 QALYs, resulting in an ICER of US$851/QALY. One-way sensitivity analysis results suggested that the HR of overall survival and progression-free survival had the greatest impact on the ICER. Probabilistic sensitivity analysis demonstrated that FLOT was more likely to be cost-effective compared with ECF/ECX at a willingness-to-pay threshold of US$31 513/QALY.

CONCLUSIONS

For patients with locally advanced resectable tumours, the FLOT chemotherapy is a cost-effective treatment option compared with ECF/ECX in China.

TRIAL REGISTRATION NUMBER

NCT01216644.

Cost-effectiveness analysis of adjuvant therapy with atezolizumab in Chinese patients with stage IB-IIIA resectable NSCLC after adjuvant chemotherapy

Background

Atezolizumab was first shown to significantly improve progression-free survival (PFS) after platinum-based chemotherapy in early-stage non-small cell lung cancer (NSCLC) in the IMpower010 Phase 3 trial. However, the cost-effectiveness and potential economic impact of atezolizumab treatment in Chinese patients are unknown.

Methods

Markov models were constructed based on follow-up data from the IMpower010 trial and assessed separately in the programmed cell death receptor ligand-1 (PD-L1) tumor cells (TC) ≥ 1% stage II – IIIA group, all stage II – IIIA groups, and the intention-to-treat (ITT) group (stage IB–IIIA). Efficacy and safety data were obtained from the IMpower010 trial, and costs and utility values were derived from the literature and local surveys to estimate their incremental cost-effectiveness ratios (ICERs) compared with willingness-to-pay (WTP) thresholds in scenarios implementing patient assistance programs (PAP) or drug price negotiations. Univariate sensitivity analysis and probabilistic sensitivity analysis (PSA) were performed to investigate the stability of the model results.

Results

Compared with best supportive care (BSC), atezolizumab produced an additional 0.45 quality-adjusted life-years (QALYs), 0.04 QALYs, and -0.0028 QALYs in the PD-L1 TC ≥ 1% stage II – IIIA group, all stage II – IIIA groups, and the ITT group, and the ICERs were 108,825.37/QALY, 1,028,538.22/QALY, and -14,381,171.55/QALY, respectively. The ICERs all exceeded the WTP threshold of $27,354 per QALY (three times the per capita gross domestic product of China in 2022), and univariate sensitivity analysis showed that the price of atezolizumab played a crucial role in the model results. PSA showed that the probability of cost-effectiveness of atezolizumab in the PD-L1 TC ≥ 1% stage II – IIIA group, all stage II – IIIA groups, and the ITT group increased with the increasing WTP threshold.

Conclusion

From the perspective of China’s health care system, in the PD-L1 TC ≥ 1% stage II – IIIA group, all stage II – IIIA groups, and the ITT group, the use of atezolizumab in the adjuvant treatment of patients with early-stage NSCLC after platinum-based chemotherapy is unlikely to be cost-effective. The implementation of PAP or price reduction negotiations for atezolizumab might be among the most effective measures to improve its cost-effectiveness.

Atezolizumab with chemotherapy in first-line treatment for metastatic urothelial cancer: a cost-effectiveness analysis

Purpose: To evaluate the cost-effectiveness of atezolizumab plus chemotherapy as first-line treatment for metastatic urothelial cancer (mUC). Materials & methods: A Markov model was established for the analysis. Parametric survival models were used to fit to progression-free survival and overall survival data in the IMvigor130 study. A series of one-way and probabilistic sensitivity analyses were performed to test the robustness of the model. Results: The incremental cost-effectiveness ratios for atezolizumab plus chemotherapy versus chemotherapy alone were US$475,633.17 and $207,488.17 per quality-adjusted life-year in the USA and China, respectively. Utility for the progression-free survival and progressive disease states, the cost of atezolizumab had the most significant impact on the incremental cost-effectiveness ratio. Conclusion: Atezolizumab plus chemotherapy is not a cost-effective treatment option as a first-line treatment for metastatic urothelial cancer.

Cost-effectiveness analysis of nivolumab combination therapy in the first-line treatment for advanced esophageal squamous-cell carcinoma

Objective

We aimed to investigate the cost-effectiveness of nivolumab plus chemotherapy and nivolumab plus ipilimumab versus chemotherapy in the first-line treatment for advanced esophageal squamous-cell carcinoma (ESCC) patients from a healthcare system perspective in China.

Methods

On the basis of the CheckMate 648 trial, a partitioned survival model was constructed to estimate economic costs and health outcomes among overall and PD-L1-positive advanced ESCC patients over a 10-year lifetime horizon. The health-related costs and utilities were obtained from the local charges and published literature. The lifetime costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were measured. One-way and probabilistic sensitivity analyses (PSA) were performed to assess the robustness of the model.

Results

In the base-case analysis, in overall and PD-L1-positive advanced ESCC patients, the ICERs were $415,163.81/QALY and $216,628.00/QALY for nivolumab plus chemotherapy, and$430,704.11/QALY and $185,483.94/QALY for nivolumab plus ipilimumab, respectively, compared with chemotherapy. One-way sensitivity analyses revealed that patients’ weight was the most influential parameter on ICER. The PSA demonstrated that the probability of nivolumab combination therapy being cost-effective was 0% over chemotherapy at the current price and willingness-to-pay threshold ($38,351.20/QALY). When the price of nivolumab and ipilimumab decreased 80%, the cost-effective probability of nivolumab plus ipilimumab increased to 40.44% and 86.38% in overall and PD-L1-positive advanced ESCC patients, respectively.

Conclusion

Nivolumab combination therapy could improve survival time and health benefits over chemotherapy for advanced ESCC patients, but it is unlikely to be a cost-effective treatment option in China.

Cost-Effectiveness Analysis of Capecitabine Plus Oxaliplatin Versus Gemcitabine Plus Oxaliplatin as First-Line Therapy for Advanced Biliary Tract Cancers

Background: In the first-line treatment of biliary tract cancers (BTCs), XELOX (capecitabine plus oxaliplatin) showed comparable clinical efficacy and safety to gemcitabine and oxaliplatin (GEMOX), with fewer visits and better treatment management. Our study aims to investigate the cost-effectiveness of XELOX and GEMOX as the first-line therapy for BTCs from the perspective of the Chinese healthcare systems and to provide valuable suggestions for clinical decision-making.

Methods: A Markov model was developed using the phase 3 randomized clinical trial (ClinicalTrials.gov number, NCT01470443) to evaluate the cost-effectiveness of XELOX and GEMOX. Quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) were used as the primary outcomes of the model. Uncertainty was assessed using univariate and probabilistic sensitivity analysis.

Results: The QALYs for the XELOX and GEMOX groups were 0.66 and 0.54, respectively. In China, the total cost of XELOX treatment is US $12,275.51, which is lower than that of the GEMOX regimen. In addition, XELOX is more effective than GEMOX, making it the preferred regimen. A sensitivity analysis determined that XELOX therapy has a stable economic advantage in China.

Conclusion: Compared to GEMOX, XELOX is a more cost-effective treatment as a first-line treatment for advanced BTC from the perspective of the Chinese health service system.

Cost-Effectiveness Analysis of Pembrolizumab Plus Chemotherapy vs. Chemotherapy Alone as First-Line Treatment in Patients With Esophageal Squamous Cell Carcinoma and PD-L1 CPS of 10 or More

BACKGROUND

This study aimed to analyze the economics of pembrolizumab plus chemotherapy as first-line treatment in patients with esophageal squamous cell carcinoma (ESCC) and programmed cell death-Ligand 1 (PD-L1) combined positive score (CPS) of 10 or more in China.

METHODS

Based on the advanced ESCC of the KEYNOTE-590 clinical trial data, a Markov model was performed to simulate the clinical course and evaluate the patient's total lifetime, total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) for pembrolizumab plus chemotherapy (cisplatin and 5-fluorouracil) vs. chemotherapy alone in first-line treatment of ESCC and PD-L1 CPS of 10 or more. Utility values and direct costs related to the treatments were gathered from the published literature data. One-way and probabilistic sensitivity analyses were conducted to check the stability of the model.

RESULTS

The baseline analysis indicated that the incremental effectiveness and cost of pembrolizumab plus chemotherapy vs. chemotherapy alone added 1.23 QALYs and resulted in an incremental cost of $51,320.22, which had an ICER of $41,805.12/QALY, higher than the willingness-to-pay (WTP) threshold of China ($37,663.26/QALY). The sensitivity analysis demonstrated that the ICERs were most sensitive to the cycle of pembrolizumab used and the cost of pembrolizumab.

CONCLUSION

The result of our present analysis suggests that the addition of pembrolizumab plus chemotherapy as first-line treatment might not be cost-effective for patients with ESCC and PD-L1 CPS of 10 or more in China.

Cost-effectiveness analysis of donafenib versus lenvatinib for first-line treatment of unresectable or metastatic hepatocellular carcinoma

BACKGROUND

Donafenib and lenvatinib are approved by China National Medical Products Administration and recommended as first-line treatment of Metastatic Hepatocellular Carcinoma (HCC). The aim of this study was to assess the cost-effectiveness of donafenib compared with lenvatinib for first-line treatment of advanced HCC in China.

METHODS

A partitioned survival model consisting with three health states was developed to simulate lifetime development of advanced HCC from China healthcare payer's perspective. The lifetime costs, quality-adjusted life-years (QALYs), life-years (LYs), and incremental cost-effectiveness ratio (ICER) were calculated. The efficacy data were obtained from ZGDH3 and REFLECT trials. The cost and health outcomes were discounted at a rate of 5%. Sensitivity and scenario analyses were carried out to explore the variation of model results.

RESULTS

Compared with lenvatinib, donafenib incurred more costs of $1500.86 and had 0.139 QALYs gained, resulting in an ICER of $10,790.18/QALY. The probability of being cost-effective was 84.9% at a willingness-to-pay threshold of gross domestic product per capita in 2020 in China ($31,499.2/QALY). Sensitive and scenario analysis results were in line with base-case analysis.

CONCLUSIONS

Donafenib appears to be a cost-effective strategy compared with lenvatinib for the first-line treatment of patients with unresectable or metastatic HCC in China.

Cost-Effectiveness of Nivolumab Plus Chemotherapy vs. Chemotherapy as First-Line Treatment for Advanced Gastric Cancer/Gastroesophageal Junction Cancer/Esophagel Adenocarcinoma in China

Objective

The purpose of this study was to evaluate the cost-effectiveness of nivolumab plus chemotherapy vs. chemotherapy as first-line therapy in patients with advanced gastric cancer/gastroesophageal junction cancer/esophageal adenocarcinoma from the perspective of the Chinese healthcare system.

Methods

This economic evaluation used a state-transition Markov model to assess the cost and effectiveness of nivolumab plus chemotherapy vs. chemotherapy as first-line treatment for advanced gastric cancer/gastroesophageal junction cancer/esophageal adenocarcinoma. The characteristics of patients in the model came from a phase 3 open-label randomized clinical trial (CheckMate 649). Key clinical data were based on the CheckMate 649 trial conducted from March 2017 to April 2019, and costs and utilities were collected from the published literature. The total cost of treatment per patient, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated for the two treatment strategies. Deterministic sensitivity analysis and probabilistic sensitivity analysis were performed.

Results

In the baseline analysis, the incremental effectiveness and cost of nivolumab plus chemotherapy vs. chemotherapy were 0.28 QALYs and $78,626.53, resulting in an ICER of $278,658.71/QALY, higher than the willingness-to-pay (WTP) threshold of China ($31,498.70/QALY). The model was sensitive to the duration of progression-free survival (PFS) for the nivolumab plus chemotherapy group, the cost of nivolumab per 100 mg, and the utility of PFS.

Conclusion

Nivolumab plus chemotherapy was clearly not a cost-effective treatment strategy compared with chemotherapy as first-line therapy for patients with advanced gastric cancer/gastroesophageal junction cancer/esophageal adenocarcinoma in China. Reducing the price of nivolumab may improve its cost-effectiveness.

Cost-Effectiveness Analysis of Gefitinib Alone and Combined with Chemotherapy as First-Line Treatment for Patients with Advanced Non-Small-Cell Lung Cancer

Background

The rational choice of drugs for treating patients with advanced non-small-cell lung cancer (NSCLC) is significantly impacted by changes in modern drug policy, health insurance negotiation, and budget impact analyses. Here, we provide a basis for rational drug use decisions in clinical practice and promote the widespread use of pharmacoeconomic methods in clinical decision-making based on current drug policies in China and real-world data.

Methods

A Markov model was developed to evaluate the health and economic outcomes in patients with advanced NSCLC treated with first-line chemotherapy with gefitinib and gefitinib plus chemotherapy. Clinical data, cost, and utility data were extracted from published literature or real-world data; sensitivity analysis was performed to assess the uncertainty in the results. The results were summarized as QALYs and the ICER.

Results

The average cost and QALYs associated with gefitinib and gefitinib plus chemotherapy strategies were $62,882.83 and 1.70 and $84,509.30 and 1.93, respectively. The ICER for gefitinib plus chemotherapy versus gefitinib alone was $95,135.50. The one-way sensitivity analysis showed that the utility value of progressive disease (PD) had the greatest impact on the treatment outcome. Probabilistic sensitivity analysis showed that if China’s willingness to pay threshold was $33,300/QALY, the probability of superiority of the gefitinib plus chemotherapy regimen was 0.

Conclusion

The study suggests that, from the perspective of the Chinese health system, gefitinib plus chemotherapy is not a cost-effective option for NSCLC patients with EGFR mutations. These findings may help clinicians make the best treatment decisions for patients with NSCLC.

Quality of Health Economic Evaluations in Mainland China: A Comparison of Peer-Reviewed Articles in Chinese and in English

OBJECTIVE

Our objective was to assess the incidence and quality of reporting of published health economic evaluations in mainland China and compare the quality of peer-reviewed articles in Chinese and English.

METHODS

A comprehensive search was conducted for economic evaluations pertaining to China published from 2006 to 2015 using the PubMed, CBM, CMCC, CNKI, VIP, and Wanfang databases. All studies in English that met the inclusion criteria were included. For studies in Chinese, 200 sampled studies were included according to the random seeds method, and the same number of the most-cited studies in Chinese as those in English were included according to the number of citations and journal grades. Researchers independently assessed the quality of the studies using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

After literature search and screening, a total of 310 studies were identified. The majority of these studies were cost-effectiveness studies (82.26%). Scores among different CHEERS items varied greatly. There was a gap between the average quality scores of the studies published in Chinese and those published in English (49.78 ± 9.31 vs. 82.48 ± 17.69) and between the average quality scores of the included most-cited studies in Chinese and English, which was slightly smaller (54.08 ± 10.27 vs. 82.48 ± 17.69). The methods, results, and discussion sections of studies published in Chinese were of low quality.

CONCLUSION

The quality of reporting of health economic evaluations in mainland China has developed slowly. Most of the included studies were incomplete in the presentation of content, making the results less reliable. It is important to standardize and improve the quality of Chinese health economic research.

Cost-Effectiveness Analysis of Camrelizumab vs. Placebo Added to Chemotherapy as First-Line Therapy for Advanced or Metastatic Esophageal Squamous Cell Carcinoma in China

Objective

The purpose of this cost-effectiveness analysis was to estimate the effects of adding camrelizumab to standard chemotherapy as the first-line treatment in patients with advanced or metastatic esophageal squamous cell carcinoma (ESCC) on health and economic outcomes in China.

Methods

A Markov model was developed to simulate the clinical course of typical patients with advanced or metastatic ESCC in the ESCORT-1st trial. Weibull survival model was employed to fit the Kaplan-Meier progression-free survival and overall survival probabilities of the camrelizumab-chemotherapy and placebo-chemotherapy strategy, respectively. Quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER) were estimated over a 5-year lifetime horizon. Meanwhile, one-way and probabilistic sensitivity analyses were conducted to test the uncertainty in the model.

Results

On baseline analysis, the incremental effectiveness and cost of camrelizumab-chemotherapy versus placebo-chemotherapy were 0.15 QALYs and $7,110.56, resulting in an ICER of $46,671.10/QALY, higher than the willingness-to-pay (WTP) threshold of China ($31,498.70/QALY). The results were sensitive to the utility of PFS and cost of camrelizumab.

Conclusion

The findings from the present analysis suggest that the addition of camrelizumab to chemotherapy might not be cost-effective in patients with advanced or metastatic ESCC in China.

PD-L1 Test-Based Strategy With Nivolumab as the Second-Line Treatment in Advanced NSCLC： A Cost-Effectiveness Analysis in China

OBJECTIVE

Our previous economic assessment found that nivolumab was not cost-effective for Chinese patients with advanced non-small cell lung cancer (NSCLC) and without EGFR mutations or ALK translocations, when compared with the standard second-line drug docetaxel. However, a greater survival benefit with nivolumab was observed for patients with 1% or greater tumor programmed death ligand 1 (PD-L1) expression. In view of this, we designed the present analysis to explore whether it is cost-effective to use the PD-L1 test to guide second-line nivolumab treatment in China.

MATERIAL AND METHODS

A Markov model was established to project the lifetime costs and quality-adjusted life-years (QALYs) of three second-line treatment strategies: nivolumab and docetaxel (strategies without a PD-L1 test) and PD-L1 test-based strategy. Deterministic and probabilistic sensitivity analyses were performed to examine the robustness of our results. Additional price reduction and willingness-to-pay (WTP) threshold scenario analyses were performed to explore the impact of economic and health policies with Chinese characteristics on our results.

RESULTS

The PD-L1 test-based strategy costs approximately CNY 194,607 (USD 28,210) or more and yielded an additional 0.27 QALYs compared to the docetaxel strategy without a PD-L1 test, equating an incremental cost-effectiveness ratio (ICER) of CNY 731,089 (USD 105,978)/QALY. Deterministic sensitivity analyses showed that the price of nivolumab was the strongest source of variation in the ICERs. Probability sensitivity analysis showed that the probability for the PD-L1 test-based strategy being cost-effective increases with the increase of WTP thresholds.

CONCLUSION

From the perspective of the Chinese healthcare system, using a PD-L1 test to guide second-line nivolumab treatment was not cost-effective. The National Healthcare Security Administration negotiation on the price reduction of nivolumab was found to be the most effective action to improve its cost-effectiveness in China.

Cost-effectiveness analysis of camrelizumab in the second-line treatment for advanced or metastatic esophageal squamous cell carcinoma in China

Background

This study aimed to evaluate the cost-effectiveness of camrelizumab versus chemotherapy as second-line treatment for patients with advanced/metastatic esophageal squamous cell carcinoma (ESCC) from the perspective of the Chinese healthcare system.

Methods

A trial-based Markov model was constructed using Excel to integrate clinical and economic data in a hypothetical cohort of advanced/metastatic ESCC patients with a 5-year time horizon. Clinical inputs were derived directly from the ESCORT trial (NCT03099382). Weibull distribution was used to fit transition probabilities extracted from the Kaplan-Meier curves. Cost inputs were estimated from the Beijing Medicine Sunshine Purchasing official website, local charges, publications and expert opinions. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model results.

Results

At 5 years, camrelizumab had higher quality-adjusted life years (QALYs) (0.782 vs. 0.499) and higher cost (US$31,537 vs. US$6,998) than chemotherapy. The incremental cost-effectiveness ratio (ICER) was estimated to be US$86,745 per QALY gained. The two primary parameters upon which this result was most sensitive were median overall survival of camrelizumab and camrelizumab cost. At a willingness-to-pay threshold of three times per capita gross domestic product (US$30,094 per QALY gained), the probability of camrelizumab being cost-effective was 33.7%.

Conclusions

Camrelizumab was not cost-effective as a second-line treatment for advanced/metastatic ESCC patients in China compared with chemotherapy.

Determining the optimal PD-1/PD-L1 inhibitors for the first-line treatment of non-small-cell lung cancer with high-level PD-L1 expression in China

Background and Objective

The programmed death 1 and ligand (PD‐1/PD‐L1) inhibitors have significantly altered therapeutic perspectives on non‐small‐cell lung cancer (NSCLC). However, their efficacy and safety are unknown since direct clinical trials have not yet been performed on them. It is also necessary to determine the economics of PD‐1/PD‐L1 inhibitors due to their high cost. The aim was to evaluate the efficacy, safety, and cost‐effectiveness of PD‐1/PD‐L1 inhibitor monotherapy for advanced NSCLC patients in China with high PD‐L1 expression as first‐line treatment.

Methods

From the PubMed, Cochrane, and Web of Science databases, we retrieved survival, progression, and safety data on PD‐1/PD‐L1 inhibitor monotherapy for advanced NSCLC patients. A network meta‐analysis (NMA) was performed to consider PD‐1/PD‐L1 inhibitors in efficacy and safety. A Markov model with a full‐lifetime horizon was adopted. Clinical and utility data were collected through the trial. The cost per quality‐adjusted life year (QALY) was as incremental cost‐effectiveness ratio (ICER). Sensitivity analyses were performed.

Results

This study included five phase III clinical trials using four drugs: nivolumab, pembrolizumab, atezolizumab, and durvalumab. The NMA demonstrated that the four drugs had similar efficacy and safety, while pembrolizumab and atezolizumab were better for than for nivolumab (hazard ratio (HR) = 0.66, 95% confidence intervals (CIs): 0.46–0.95 and HR = 0.59, 95%CI: 0.37–0.94) in progression‐free survival (PFS), and the risk of a severe adverse event was higher for atezolizumab than for nivolumab and pembrolizumab. Compared with nivolumab, durvalumab, pembrolizumab, and atezolizumab had QALY of 0.19, 0.38, and 0.53, respectively, which induced ICERs of $ 197,028.8/QALY, $ 111,859.0/QALY, and $ 76,182.3/QALY, respectively.

Conclusion

The efficacy and safety are similar among types of PD‐1/PD‐L1‐inhibitor monotherapy. The cost‐effectiveness of nivolumab appears optimal, but the other PD‐1/PD‐L1 inhibitors are not as cost‐effective for the first‐line treatment of advanced NSCLC in China.

Cost-Effectiveness Analysis of Olaparib Maintenance Treatment for Germline BRCA-Mutated Metastatic Pancreatic Cancer

Background: The PARP inhibitor olaparib has been shown to have clinical efficacy in patients with a germline BRCA mutation and ovarian or breast cancer. However, the high treatment cost associated with this drug limits its viability as a clinical treatment option. This work aims to evaluate the cost-effectiveness of olaparib as a maintenance treatment for metastatic pancreatic cancer from the perspective of the United States and China healthcare systems and provides valuable suggestions for clinical decision making.

Method: A three-state Markov model (progression-free, progressed disease, death) was constructed using TreeAge Pro 2020 software to evaluate the economic value of olaparib vs. placebo maintenance treatment for metastatic pancreatic cancer based on the clinical data derived from phase III randomized controlled trial (POLO, ClinicalTrials.gov number, NCT02184195). Total costs, quality-adjusted life years and incremental cost-effectiveness ratio were used as economic indicators for this analysis. A 5-years horizon and 5%/year discount rates were used. One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) were performed to assess the model uncertainty.

Results: The incremental cost-effectiveness ratios (ICERs) of the use of olaparib vs. placebo in China and the United States were $6,694/QALY and $13327/QALY, respectively. All ICERs were far below the thresholds of $30829 in China and $50000 in the United States. Sensitivity analysis confirmed a stable economic advantage in the use of olaparib vs. placebo as maintenance therapy in China and the United States.

Conclusion: Olaparib was estimated to be more cost effective than placebo for the maintenance therapy of patients with a germline BRCA mutation and pancreatic cancer in China and the United States at thresholds of $30829 and $50000 per QALY, respectively.

Adding Enzalutamide to First-Line Treatment for Metastatic Hormone-Sensitive Prostate Cancer: A Cost-Effectiveness Analysis

Background: The aim of this study is to evaluate the pharmacoeconomic profile of adding enzalutamide to first-line treatment for metastatic, hormone-sensitive prostate cancer (mHSPC) from the US and Chinese payers' perspectives.

Materials and Methods: A Markov model with three health states: progression-free survival (PFS), progressive disease (PD), and death, was constructed. All patients were assumed to enter the model in the PFS state and transit according to the transition structure. Efficacy data were derived from the ENZAMET trial and Weibull distribution curves were modeled to fit the survival curves. Costs in the model included cost of drugs, best-supportive care (BSC), follow-up, tests, and adverse events (AEs)-related treatments. The primary endpoint of the study was incremental cost-effectiveness ratio (ICER). In addition, the impact of several key parameters on the results of the cost-effectiveness analysis was tested with one-way sensitivity analyses and probabilistic sensitivity analyses.

Results: Overall, ICERs were $430,933.95/QALY and $225,444.74/QALY of addition of enzalutamide to androgen deprivation therapy (ADT) vs. ADT from the US and Chinese payers' perspective, respectively. The most influential factors were the utility for the PFS state and the cost of enzalutamide. At the willingness-to-pay (WTP) thresholds of $100,000.00/QALY in the US and $28,988.40/QALY in China, the probability of adding enzalutamide to first-line treatment being a cost-effective option for mHSPC was 0%.

Conclusions: Based on the data from the ENZAMET trial and the current price of enzalutamide, adding enzalutamide to first-line treatment is not cost-effective for patients with mHSPC from the US and Chinse payers' perspectives.

Cost-effectiveness analysis of adding ramucirumab to the first-line erlotinib treatment for untreated EGFR-mutated metastatic non-small cell lung cancer in China

OBJECTIVE

To investigate the cost-effectiveness of ramucirumab plus erlotinib compared with placebo plus erlotinib in the first-line setting for patients with EGFR-mutated metastatic non-small cell lung cancer (mNSCLC) from the Chinese healthcare system perspective.

DESIGN

A Markov model consisting of three health states using clinical survival data from the RELAY phase III randomised clinical trial, a lifetime horizon for costs and quality-adjusted life-years (QALYs) was constructed to analyse the cost-effectiveness of ramucirumab plus erlotinib. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the model. Additional price reduction scenario analyses were performed.

SETTING

The Chinese healthcare system perspective.

PARTICIPANTS

A hypothetical Chinese cohort of patients with confirmed previously documented ex19del or Leu858Arg mutation stage IV NSCLC, and without known epidermal growth factor receptor (EGFR) Thr790Met mutation and central nervous system metastases.

INTERVENTIONS

Ramucirumab plus erlotinib versus placebo plus erlotinib.

PRIMARY OUTCOME MEASURE

Costs, QALYs, incremental cost-effectiveness ratio (ICER).

RESULTS

In base-case analysis, ramucirumab plus erlotinib yield an additional 4.21 QALYs at a cost of $540 590, resulting in an ICER of $128 302/QALY. In price reduction scenario analysis, the ICER ($65 227/QALY) was decreased significantly when the National Reimbursement Drug List (NRDL) negotiation was available for ramucirumab, and the ICER ($131 554/QALY) was increased slightly when the NRDL negotiation was unavailable for erlotinib. Sensitivity analyses demonstrated our results to be most sensitive to the unit cost of ramucirumab (10 mg/kg), and more than 52.1% reduction in the price of ramucirumab resulted in the ICER under the willingness-to-pay threshold set for affluent regions ($70 353/QALY).

CONCLUSIONS

Ramucirumab plus erlotinib is unlikely to be cost-effective for patients with untreated EGFR-mutated mNSCLC in China. Reducing the price of ramucirumab through the National Healthcare Security Administration negotiation was found to be the most realistic action to improve cost-effectiveness.

Lenalidomide plus rituximab Vs rituximab alone in relapsed or refractory indolent lymphoma: A cost-effectiveness analysis

Background

The aim of the study was to evaluate the cost‐effectiveness of lenalidomide plus rituximab vs rituximab alone in patients with relapsed or refractory indolent lymphoma.

Methods

A Markov decision model was established to carry out the cost‐effectiveness analysis. Three discrete health states, progression‐free survival (PFS), progressive disease (PD), and death, were included. Cycle length was set at 1 month, and utility scores were derived from previously published literature. The incremental cost‐effectiveness ratio (ICER) was defined as the primary endpoint, and the willingness‐to‐pay (WTP) threshold was set at $29,306.43 per quality‐adjusted life year (QALY). Both cost and effectiveness were determined using a 3% annual discount rate. Furthermore, one‐way and probabilistic sensitivity analyses were performed to check the robustness of the model.

Results

Lenalidomide plus rituximab gained 6.08 QALYs at a cost of $120,979.62 while rituximab alone gained 4.84 QALYs at a cost of $48,052.11. The ICER of lenalidomide plus rituximab vs rituximab alone was $58,812.51/QALY. The parameters most significantly influenced the model were the utility values for the PFS state, the duration of the PFS state in the lenalidomide plus rituximab group, and the cost of lenalidomide. The probability of lenalidomide plus rituximab or rituximab alone being the most cost‐effective option was 0% and 100%, respectively, at a WTP threshold of $29,306.43/QALY.

Conclusions

Lenalidomide plus rituximab is not a cost‐effective strategy compared with rituximab monotherapy for relapsed or refractory indolent lymphoma from a Chinese societal perspective.

Health economic analysis of curative-intent gastrectomy for gastric carcinoma and the costs related to post-operative complications

BACKGROUND

The management of post-gastrectomy complications requires considerable resources and is likely associated with a substantial economic burden. The objectives of this study were to perform a cost analysis of admissions following gastrectomy for gastric carcinoma and then to quantify the financial impact of post-operative complications.

METHODS

A retrospective analysis was conducted in patients that underwent a gastrectomy from 2008 to 2019. Demographic data, operative information, post-operative complications and facility costs were compared.

RESULTS

A total of 74 patients underwent a curative-intent gastrectomy during the study period. The 36 (48.6%) patients that had no complications had a median total admission cost of AU$29 228. A total of 21 (28.4%) patients had a minor complication and 17 (23.0%) patients had a major complication, with a median total admission cost of AU$36 592 and AU$71 808, respectively. The difference across all three groups was statistically significant. In patients who had major complications compared to those without complications, there was a significant increase in the cost of intensive care services, theatre resources and nursing care. Across the whole cohort, the principal cost centres accounting for the largest proportion of total cost were theatre equipment and resources (33.9%), nursing care on the ward (23.0%) and staffing time of the surgical team (16.7%).

CONCLUSION

The surgical management of gastric cancer carries a substantial cost burden. The presence and severity of post-operative complications is strongly associated with increasing cost. Minimizing complications, in addition to obvious clinical benefits, enables a large reduction in costs of care.

Cost-effectiveness analysis of nivolumab in the second-line treatment for advanced esophageal squamous cell carcinoma

Background: To investigate the cost-effectiveness of nivolumab versus chemotherapy in the second-line treatment for advanced esophageal squamous cell carcinoma. Materials & methods: A Markov model reflecting the patients in the ATTRACTION-3 trial was established. Weibull survival model was employed to fit the Kaplan-Meier progression-free survival and overall survival probabilities of the nivolumab and chemotherapy strategy, respectively. Meanwhile, one-way and PSA were performed to test the uncertainty in the model. Results: Overall, the incremental effectiveness and cost of nivolumab versus chemotherapy were 0.107 quality-adjusted life-years and $14,627.90, resulting in an incremental cost-effectiveness ratio of $136,709.35/quality-adjusted life-year. Conclusion: Nivolumab is not a cost-effective treatment option compared with chemotherapy from the perspective of Chinese society.

Cost-effectiveness analysis of the first-line EGFR-TKIs in patients with non-small cell lung cancer harbouring EGFR mutations

OBJECTIVES

To compare the cost-effectiveness of first-line gefitinib, erlotinib, afatinib, and osimertinib in patients with non-small cell lung cancer (NSCLC) harbouring epidermal growth factor receptor (EGFR) mutations.

METHODS

A systematic review and network meta-analysis (NMA) were conducted to compare the relative efficacy of gefitinib, erlotinib, afatinib, and osimertinib in EGFR-mutated NSCLC. To assess the cost-effectiveness of these treatments, a Markov model was developed from Dutch societal perspective. The model was based on the clinical studies included in the NMA. Incremental costs per life-year (LY) and per quality-adjusted life-year (QALY) gained were estimated. Deterministic and probabilistic sensitivity analyses (PSA) were conducted.

RESULTS

Total discounted per patient costs for gefitinib, erlotinib, afatinib, and osimertinib were €65,889, €64,035, €69,418, and €131,997, and mean QALYs were 1.36, 1.39, 1.52, and 2.01 per patient, respectively. Erlotinib dominated gefitinib. Afatinib versus erlotinib yielded incremental costs of €27,058/LY and €41,504/QALY gained. Osimertinib resulted in €91,726/LY and €128,343/QALY gained compared to afatinib. PSA showed that gefitinib, erlotinib, afatinib, and osimertinib had 13%, 19%, 43%, and 26% probability to be cost-effective at a threshold of €80,000/QALY. A price reduction of osimertinib of 30% is required for osimertinib to be cost-effective at a threshold of €80,000/QALY.

CONCLUSIONS

Osimertinib has a better effectiveness compared to all other TKIs. However, at a Dutch threshold of €80,000/QALY, osimertinib appears not to be cost-effective.

Nivolumab Versus Docetaxel for Previously Treated Advanced Non-Small Cell Lung Cancer in China: A Cost-Effectiveness Analysis

BACKGROUND AND OBJECTIVE

The economic assessment of immuno-oncology agents in Chinese patients is limited despite a need for new therapies. Nivolumab is the first immune checkpoint inhibitor approved for the second-line treatment of non-small cell lung cancer (NSCLC) in China, and it significantly prolongs overall survival. However, considering the high cost of nivolumab, it is urgent to assess its value in China in terms of both efficacy and cost. The objective of this study was to investigate the cost-effectiveness of nivolumab vs docetaxel in the second-line setting for NSCLC patients from the Chinese healthcare system perspective.

METHODS

A Markov model consisting of three health states, was designed to evaluate the lifetime cost and effectiveness of nivolumab vs docetaxel in the second-line treatment of NSCLC patients. Clinical data was derived from the CheckMate 078 phase III clinical trial, which included 504 patients predominantly from China. Parametric survival models to fit and extrapolate survival data were chosen based on clinical rationality, visual fit and statistical goodness-of-fit. Lifetime costs and health outcomes were calculated, and US$28,899 and $63,564 per quality-adjusted life-year (QALY) were selected as the willingness-to-pay (WTP) threshold values for general regions and affluent regions, respectively. One-way and probabilistic sensitivity analyses were undertaken to explore the robustness of the model. Additional subgroup analyses were performed.

RESULTS

In base case analysis, Nivolumab yielded an additional 0.24 QALYs, at a cost of $93,307 per QALY. Sensitivity analyses suggested that the results to be most sensitive to the price of nivolumab per kg (mean $60.00; range $26.00-$60.00) and the mean patient weight (65 kg, range 52-78 kg). Utility values in progression-free survival state (mean 0.804; range 0.643-0.965) and overall survival hazard ratio (0.68; 97.7% CI 0.52-0.90) had moderate impact on the model results. Subgroup analyses indicated that nivolumab was most cost-effective for patients who were 65 years of age or older ($85,171/QALY), followed by female patients ($85,273/QALY) and patients with tumor PD-L1 expression at least 1% ($90,309/QALY).

CONCLUSIONS

Nivolumab is unlikely to be cost-effective compared with docetaxel for patients with previously treated advanced NSCLC in China. Ensuring that nivolumab is included in the National Reimbursement Drug List (NRDL) may be a valid mean of meeting extensive treatment demands in China.

Adjuvant Chemoradiotherapy for Gastric Cancer: Efficacy and Cost-Effectiveness Analysis

Purpose: The benefit of adjuvant chemotherapy (CT) for localized gastric cancer (GC) after D2-gastrectomy has been clearly demonstrated. However, adjuvant chemoradiotherapy (CRT) remains controversial. This study aimed to assess the efficacy and cost-effectiveness of treatment for GC after D2-gastrectomy. Materials and methods: Stage IB-IIICGC patients who had received adjuvant CRT or CT, or who had just been observed after D2-gastrectomy were retrospectively selected. Therapeutic strategy after surgery, disease-free survival (DFS), overall survival (OS), adverse events and costs were recorded retrospectively. A Markov model was developed to simulate the process of GC after D2-gastrectomy. Health outcomes were measured using quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratio (ICER) was regarded as the primary outcome. Results: A total of 254 patients were selected. Three year OS and DFS were 83.02 and 64.15% in the adjuvant CRT group, 74.19 and 63.54% in the adjuvant CT group, and 45.45 and 43.35% in the observation group. Total grade 3 or 4 toxicity was higher in the CRT group than in the CT group (54.72% vs. 37.10%, p < 0.05). The ICER of the CT and CRT groups vs. the observation group were $10,571.55 and $11,467.41/QALY, respectively. The probability of CT, CRT and observation being cost-effective were 28.9, 37.9, and 33.2%, respectively, when a willingness-to-pay threshold (WTP) of $25,648.45/QALY was used. Conclusions: Adjuvant CRT was associated with improved OS and DFS compared with adjuvant CT and postoperative observation. Both adjuvant CRT and CT are likely to be cost effective compared with postoperative observation. However, adjuvant CRT was the optimal choice for a WTP threshold of $25,648.45/QALY.

Cost-effectiveness of afatinib, gefitinib, erlotinib and pemetrexed-based chemotherapy as first-line treatments for advanced non-small cell lung cancer in China

PURPOSE

Tyrosine kinase inhibitors (TKI) of the epidermal growth factor receptor (EGFR) are becoming the standard treatments for Chinese patients with advanced non-small cell lung cancer (NSCLC) harboring an EGFR mutation. However, the economic impact is unclear yet in China.

MATERIALS AND METHODS

A decision-analytic model was developed to simulate 1-month patient transitions in a 10-year time horizon from Chinese heath care system perspective. The health and economic outcomes of four first-line strategies (pemetrexed plus cisplatin [PC], gefitinib, erlotinib, and afatinib) among NSCLC patients harboring EGFR mutations were estimated and assessed via indirect comparisons. Costs in the Chinese setting were estimated by using local hospital data and literatures. A 5% annual discount rate was applied to both costs and outcomes. The primary outcome was the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed.

RESULTS

Afatinib achieved additional 0.382, 0.216 and 0.174 quality-adjusted life-years (QALYs) with marginal $7930, $3680 and $2818 costs in comparison with PC, gefitinib and erlotinib, which resulted in the ICERs of $20,758, $17,693 and $16,197 per QALY gained, respectively. The hazard ratios (HR) of overall survival (OS) of afatinib against gefitinib, erlotinib and PC strategy had substantial influential parameters.

CONCLUSIONS

First-line afatinib is cost-effective compared with gefitinib, erlotinib and PC treatment for Chinese patients with EGFR mutation-positive NSCLC.

Cutting-edge evidence of adjuvant treatments for gastric cancer

In recent decades, adjuvant therapy has secured a firm position in the treatment of gastric cancer by improving patient prognosis. Currently, standard therapy varies between East Asia, Europe and North America due to heterogeneities of the tumor, race, medical environment and/or surgical procedure. Although adjuvant strategies, proved effective in each region and implemented to clinical practice, certain patient populations with advanced gastric cancer show recurrence and a fatal prognosis. The development of a universal adjuvant therapy with a high efficacy and acceptable adverse events or with less toxicity and non-inferiority seems to have become urgent and imperative. Areas covered: In this review, we aimed to summarize the current knowledge regarding adjuvant therapies for gastric cancer, including chemotherapy, chemoradiotherapy and molecular targeted therapy, based on clinical trials and to introduce the pivotal ongoing phase III trials. Expert commentary: The efficacy of adjuvant therapy to prevent recurrence remains insufficient although several trials have shown a significant benefit in patients with localized advanced gastric cancer. The development of more effective and universal multimodal adjuvant therapy is required.

Cost-effectiveness of ALK testing and first-line crizotinib therapy for non-small-cell lung cancer in China

INTRODUCTION

Anaplastic lymphoma kinase (ALK) rearrangement gene testing is used increasingly to identify patients with advanced non-small-cell lung cancer (NSCLC) who are most likely to benefit from crizotinib. This study was to evaluate the cost-effectiveness of the ALK tests followed by crizotinib compared to the standard chemotherapy in advanced NSCLC from the Chinese healthcare system perspective.

METHODS

A 10-year Markov model was constructed to compare the costs and quality-adjusted life-years (QALYs) of crizotinib with standard chemotherapy, guided by the ALK rearrangement tests: next-generation sequencing (NGS) panel tests and multiplex polymerase chain reaction (PCR) testing. The health states included progression-free survival (PFS), progressed survival, and death. The costs examined included cost of drugs (pemetrexed, standard chemotherapy, salvage chemotherapy, and crizotinib), follow-up, palliative care, supportive care, severe adverse events, and ALK rearrangement testing.

RESULTS

Under Patient Assistance Program (PAP), the model demonstrated that the patients using NGS panel tests spent US $31,388 and gained 0.780 QALYs, whereas patients using multiplex PCR spent US $31,362 and gained 0.780 QALYs, respectively. The incremental cost-effectiveness ratios of crizotinib with PAP compared to the control strategy were projected at $14,384 (NGS) and $13,740 (multiplex PCR) per QALY gained, respectively. Sensitivity analyses showed the utility of PFS and the costs of crizotinib and pemetrexed were the most impactful factors on the model outcomes. The results were robust to changes in all parameters.

CONCLUSION

ALK-rearrangement test positive followed by crizotinib may be cost-effective compared to standard chemotherapy from the Chinese healthcare system perspective when PAP was available.

Cost-effectiveness analysis of capecitabine monotherapy versus capecitabine plus oxaliplatin in elderly patients with advanced gastric cancer

BACKGROUND

There is no single standard chemotherapy regimen for elderly patients with advanced gastric cancer (AGC). A phase III trial has confirmed that both capecitabine monotherapy and capecitabine plus oxaliplatin are well tolerated for elderly patients with AGC, but their economic influence in China is unknown.

OBJECTIVE

The purpose of this cost-effectiveness analysis was to estimate the effects of capecitabine monotherapy and capecitabine plus oxaliplatin in elderly patients with AGC on health and economic outcomes in China.

METHODS

We created a Markov model based on data from a Korean clinical phase III trial to analyze the cost-effectiveness of the treatment of elderly patients in the capecitabine monotherapy (X) group and capecitabine plus oxaliplatin (XELOX) group. The costs were obtained from published reports and the local health system. The utilities were assumed on the basis of the published literature. Costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICER) were estimated. One-way and probabilistic sensitivity analyses (Monte Carlo simulations) were performed.

RESULTS

In the cost-effectiveness analysis, X had a lower total cost ($45,731.68) and cost-effectiveness ratio ($65,918.93/QALY). The one-way sensitivity analysis suggested that the most influential parameter was the risk of requiring second-line chemotherapy in XELOX group. The probabilistic sensitivity analysis predicted that the X regimen was cost-effective 100% of the time, given a willingness-to-pay threshold of $26,598.

CONCLUSIONS

Our findings show that the XELOX regimen is less cost-effective compared to the X regimen for elderly patients with AGC in China from a Chinese healthcare perspective.

Cost-effectiveness of gefitinib, icotinib, and pemetrexed-based chemotherapy as first-line treatments for advanced non-small cell lung cancer in China

Tyrosine kinase inhibitors of the epidermal growth factor receptor (EGFR) are becoming the standard treatment option for patients with advanced non-small cell lung cancer (NSCLC) harboring an EGFR mutation, but the economic impact of this practice is unclear, especially in a health resource-limited setting. A decision-analytic model was developed to simulate 21-day patient transitions in a 10-year time horizon. The health and economic outcomes of four first-line strategies (pemetrexed plus cisplatin [PC] alone, PC followed by maintenance with pemetrexed, or initial treatment with gefitinib or icotinib) among patients harboring EGFR mutations were estimated and assessed via indirect comparisons. Costs in the Chinese setting were estimated. The primary outcome was the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed. The icotinib strategy resulted in greater health benefits than the other three strategies in NSCLC patients harboring EGFR mutations. Relative to PC alone, PC followed by pemetrexed maintenance, gefitinib and icotinib resulted in ICERs of $104,657, $28,485 and $19,809 per quality-adjusted life-year gained, respectively. The cost of pemetrexed, the EGFR mutation prevalence and the utility of progression-free survival were factors that had a considerable impact on the model outcomes. When the icotinib Patient Assistance Program was available, the economic outcome of icotinib was more favorable. These results indicate that gene-guided therapy with icotinib might be a more cost-effective treatment option than traditional chemotherapy.

Estimation of population-based utility weights for gastric cancer-related health states

BACKGROUND

This study aimed to generate utility weights of gastric cancer-related health states from the perspective of the Korean general population.

METHODS

The Korean adults (age ≥19 years) included in the study were sampled using multistage quota sampling methods stratified by sex, age, and education level. Nine scenarios for hypothetical gastric cancer-related health states were developed and reviewed. After consenting to participate, the subjects were surveyed by trained interviewers using a computer-assisted personal interview method. Participants were asked to perform standard gamble tasks to measure the utility weights of 5 randomly assigned health states (from among nine scenarios). The mean utility weight was calculated for each health state.

RESULTS

Three hundred twenty-six of the 407 adults who completed this study were included in the analysis. The mean utility weights from the standard gamble were 0.857 (no gastric cancer with Helicobacter pylori infection), 0.773 (early gastric cancer [EGC] with endoscopic surgery), 0.779 (EGC with subtotal gastrectomy), 0.767 (EGC with total gastrectomy), 0.602 (advanced gastric cancer with subtotal gastrectomy and adjuvant chemotherapy), 0.643 (advanced gastric cancer with total gastrectomy and adjuvant chemotherapy), 0.522 (advanced gastric cancer with extended gastrectomy and adjuvant chemotherapy), 0.404 (metastatic gastric cancer with palliative chemotherapy), and 0.399 (recurrent gastric cancer with palliative chemotherapy).

CONCLUSION

This study was the first to comprehensively estimate the utility weights of gastric cancer-related health states in a general population. The utility weights derived from this study could be useful for future economic evaluations related to gastric cancer interventions.

A review of capecitabine-based adjuvant therapy for gastric cancer in the Chinese population

In China, the treatment of locally advanced gastric cancer (AGC) faces unique challenges. Chinese patients may harbor more unfavorable prognostic factors than western populations and, in comparison with other Asian populations such as Japan and South Korea, a higher proportion of Chinese patients are diagnosed with AGC due to inadequate early diagnosis of the malignancy. This review summarizes the use of combination chemotherapy regimens with capecitabine as adjuvant therapy in the Chinese AGC population. Based on the available domestic data in China, the review concludes that capecitabine-based chemotherapy regimens, especially XELOX, offer good efficacy following radical gastrectomy in patients with AGC, with a low incidence of adverse events, acceptable tolerance, greater patient convenience and a lower overall cost than other regimens.

RAS testing and cetuximab treatment for metastatic colorectal cancer: a cost-effectiveness analysis in a setting with limited health resources

PURPOSE

To test the cost-effectiveness of cetuximab plus irinotecan, fluorouracil, and leucovorin (FOLFIRI) as first-line treatment in patients with metastatic colorectal cancer (mCRC) from a Chinese medical insurance perspective.

RESULTS

Baseline analysis showed that the addition of cetuximab increased quality-adjusted life-years (QALYs) by 0.63, an increase of $17,086 relative to FOLFIRI chemotherapy, resulting in an incremental cost-effectiveness ratio (ICER) of $27,145/QALY. When the patient assistance program (PAP) was available, the ICER decreased to $14,049/QALY, which indicated that the cetuximab is cost-effective at a willingness-to-pay threshold of China ($22,200/QALY). One-way sensitivity analyses showed that the median overall survival time for the cetuximab was the most influential parameter.

METHODS

A Markov model by incorporating clinical, utility and cost data was developed to evaluate the economic outcome of cetuximab in mCRC. The lifetime horizon was used, and sensitivity analyses were carried out to test the robustness of the model results. The impact of PAP was also evaluated in scenario analyses.

CONCLUSIONS

RAS testing with cetuximab treatment is likely to be cost-effective for patients with mCRC when PAP is available in China.

Cost-Effectiveness Analysis of Second-Line Chemotherapy Agents for Advanced Gastric Cancer

STUDY OBJECTIVE

Gastric cancer is the fifth most common malignancy and second leading cause of cancer-related mortality. Chemotherapy options for patients who fail first-line treatment are limited. Thus the objective of this study was to assess the cost-effectiveness of second-line treatment options for patients with advanced or metastatic gastric cancer.

DESIGN

Cost-effectiveness analysis using a Markov model to compare the cost-effectiveness of six possible second-line treatment options for patients with advanced gastric cancer who have failed previous chemotherapy: irinotecan, docetaxel, paclitaxel, ramucirumab, paclitaxel plus ramucirumab, and palliative care.

MEASUREMENTS AND MAIN RESULTS

The model was performed from a third-party payer's perspective to compare lifetime costs and health benefits associated with studied second-line therapies. Costs included only relevant direct medical costs. The model assumed chemotherapy cycle lengths of 30 days and a maximum number of 24 cycles. Systematic review of literature was performed to identify clinical data sources and utility and cost data. Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were calculated. The primary outcome measure for this analysis was the ICER between different therapies, where the incremental cost was divided by the number of QALYs saved. The ICER was compared with a willingness-to-pay (WTP) threshold that was set at $50,000/QALY gained, and an exploratory analysis using $160,000/QALY gained was also used. The model's robustness was tested by using 1-way sensitivity analyses and a 10,000 Monte Carlo simulation probabilistic sensitivity analysis (PSA). Irinotecan had the lowest lifetime cost and was associated with a QALY gain of 0.35 year. Docetaxel, ramucirumab alone, and palliative care were dominated strategies. Paclitaxel and the combination of paclitaxel plus ramucirumab led to higher QALYs gained, at an incremental cost of $86,815 and $1,056,125 per QALY gained, respectively. Based on our prespecified WTP threshold, our base case analysis demonstrated that irinotecan alone is the most cost-effective regimen, and both paclitaxel alone and the combination of paclitaxel and ramucirumab were not cost-effective (ICER more than $50,000). Both 1-way sensitivity analyses and PSA demonstrated the model's robustness. PSA illustrated that paclitaxel plus ramucirumab was extremely unlikely to be cost-effective at a WTP threshold less than $400,000/QALY gained.

CONCLUSION

Irinotecan alone appears to be the most cost-effective second-line regimen for patients with gastric cancer. Paclitaxel may be cost-effective if the WTP threshold was set at $160,000/QALY gained.