How are we evaluating the cost-effectiveness of companion biomarkers for targeted cancer therapies? A systematic review

How is Value Defined in Molecular Testing in Cancer? A Scoping Review

OBJECTIVE

To identify how value is defined in studies that focus on the value of molecular testing in cancer and the extent to which broadening the conceptualisation of value in healthcare has been applied in the molecular testing literature.

METHODS

A scoping review was undertaken using Joanna Briggs Institute (JBI) guidance. Medline, Embase, EconLit and Cochrane Library were searched in August 2023. Articles were eligible if they reported costs relative to outcomes, novel costs, or novel outcomes of molecular testing in cancer. Results were synthesised and qualitative content analysis was performed with deductive and inductive frameworks.

RESULTS

Ninety-one articles were included in the review. The majority (75/91) were conventional economic analyses (comparative economic evaluations and budget impact assessments) and undertaken from a healthcare system perspective (38/91). Clinical outcomes dominate the assessment of value (61/91), with quality-adjusted life-years (QALYs) the most common outcome measure (45/91). Other definitions of value were diverse (e.g. psychological impact, access to trials), inconsistent, and largely not in keeping with evolving guidance.

CONCLUSIONS

Broader concepts of value were not commonly described in the molecular testing literature focusing on cancer. Conventional approaches to measuring the health costs and outcomes of molecular testing in cancer prevail with little focus on non-clinical elements of value. There are emerging reports of non-clinical outcomes of testing information, particularly psychological consequences. Intrinsic attributes of the testing process and preferences of those who receive testing information may determine the realised societal value of molecular testing and highlight challenges to implementing such a value framework.

Expert-based collaborative analysis of the situation and prospects of biomarker test implementation in oncology in Spain

PURPOSE

Biomarkers as screening for precision medicine is a fundamental step. The purpose of this article is twofold. First, to highlight the existing barriers in the implementation of Precision Medicine in Spain, with a special emphasis on barriers in access to the determination of biomarkers. Second, to provide a Roadmap that can help implement Precision Medicine equitably at the national level and optimize the use of biomarkers.

METHODS

A systematic review of literature (SRL) and a focus group (FG) with multidisciplinary experts has been carried out in 2023. Participants were contacted individually, and discourse analysis was processed anonymously.

RESULTS

We carried out a quantitative (SRL) and a qualitative approach (FG). The discourse analysis and roadmap were sent individually to each expert for approval.

CONCLUSIONS

The potential of Precision Medicine has not been fulfilled in Spain. While several regional initiatives are in place, a national plan or strategy around Precision Medicine and use of biomarkers is lacking. In a general context of rapid progress at a global and European level, including the 2021 Europe's Beating Cancer Plan, it is time to define and implement a National Plan to make the promise come true. While some comparable countries within Europe - such as the UK or France - are mature enough to adopt such strategies, in Spain there is still a long way to go. We consider that the different strands of work outlined in the Roadmap can be used as basis for such purpose.

Economic Evaluations of Imaging Biomarker-Driven Companion Diagnostics for Cancer: A Systematic Review

INTRODUCTION

There is a boom in imaging biomarker-driven companion and complementary diagnostics (CDx) for cancer, which brings opportunity for personalized medicine. Whether adoption of these technologies is likely to be cost-effective is a relevant question, and studies on this topic are emerging. Despite the growing number of economic evaluations, no review of the methods used, quality of reporting, and potential risk of bias has been done. We report a systematic review to identify, summarize, and critique the cost-effectiveness evidence for the use of biomarker-driven and imaging-based CDx to inform cancer treatments.

METHODS

The Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Systematic literature searches until 30 December 2022 were performed in PubMed, Web of Science, Medline, Embase, and Scopus for economic evaluations of imaging biomarker-based CDx for cancer. The inclusion and exclusion of studies were determined by pre-specified eligibility criteria informed by the 'Patient, Intervention, Comparison, Outcome' (PICO) framework. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) was used to assess the quality of reporting, and the Bias in Economic Evaluation (ECOBIAS) was used to examine the potential risk of bias of included studies.

RESULTS

A total of 12 papers were included, with eight model-based and four trial-based studies. Implementing biomarker-driven, imaging-based CDx was reported to be cost-effective, cost saving, or dominant (cost saving and more effective) in ten papers. Inconsistent methods were found in the studies, and the quality of reporting was lacking against the CHEERS reporting guideline. Several potential sources of 'risk of bias' were identified. These should be acknowledged and carefully considered by researchers planning future health economic evaluations.

CONCLUSION

Despite favorable results towards the implementation of imaging biomarker-based CDx for cancer, there is room for improvement regarding the quantity and quality of economic evaluations, and that is expected as the awareness of current study limitations increases and more clinical data become available in the future.

How are Companion Diagnostics Considered in Economic Evaluations of Oncology Treatments? A Review of Health Technology Assessments

BACKGROUND

Companion diagnostic (CDx) testing is increasingly used to identify eligible patients for targeted treatments. Guidance on how CDx testing should be incorporated into cost-effectiveness models (CEM) is limited. This review evaluated how health technology assessment bodies and research organizations considered CDx in CEMs of targeted therapies in oncology and whether this ultimately impacted their decisions or time from regulatory approval to recommendations.

METHODS

An exhaustive list of approved CDx tests in oncology was compiled. For corresponding indications and treatments, NICE appraisals published between 2016 and 2019 were identified. Then, assessments for the same treatments issued from 11 other agencies were reviewed. Data extracted included background and CDx information, CDx's role in the CEM, and recommendations.

RESULTS

Twenty-seven NICE appraisals were identified; 15 considered CDx testing in the CEM, while 12 did not, mainly because testing had already been established for the comparators within the same class or in clinical practice from a prior treatment line. Both testing costs and mutation prevalence drove CDx testing costs per patient. The cross-comparison of assessments showed that CDx test characteristics were inconsistently reported. Time from regulatory approval to recommendations was not impacted by CDx cost inclusion in CEMs.

CONCLUSION

CDx testing was included in cost-effectiveness models whenever mutation testing was required solely for patients receiving targeted treatment; cost per patient was based on test costs and mutation prevalence. It is unclear if expanded reliance on CDx testing will impact future assessments of targeted therapies. A future update is warranted to track trends over time.

The Association between Early Changes in Neutrophil-Lymphocyte Ratio and Survival in Patients Treated with Immunotherapy

Dynamic changes in the blood-based biomarkers could be used as a prognostic biomarker in patients treated with immune checkpoint inhibitors (ICIs), although the data are limited. We evaluated the association between the neutrophil−lymphocyte ratio (NLR) and early NLR changes with survival in ICI-treated patients. We retrospectively evaluated the data of 231 patients with advanced-stage cancer. We recorded baseline clinical characteristics, baseline NLR and fourth-week NLR changes, and survival data. A compound prognostic score, the NLR2-CEL score, was developed with the following parameters: baseline NLR (<5 vs. ≥5), ECOG status (0 vs. ≥1), Charlson Comorbidity Index (CCI, <9 vs. ≥9), LDH (N vs. ≥ULN), and fourth-week NLR change (10% or over NLR increase). In the multivariable analyses, higher NLR (HR: 1.743, p = 0.002), 10% or over NLR increase in the fourth week of treatment (HR: 1.807, p = 0.001), higher ECOG performance score (HR: 1.552, p = 0.006), higher LDH levels (HR: 1.454, p = 0.017), and higher CCI (HR: 1.400, p = 0.041) were associated with decreased OS. Compared to patients with the lowest scores, patients in the highest score group had significantly lower OS (HR: 7.967, 95% CI: 3.531−17.979, p < 0.001) and PFS. The composite score had moderate success for survival prediction, with an AUC of 0.702 (95% CI: 0.626−0.779, p < 0.001). We observed significantly lower survival in patients with higher baseline NLR values and increased NLR values under treatment.