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

The Characteristics of Immunoncology Drugs Appraised by NICE and SMC: A Retrospective Analysis 2012-2023

INTRODUCTION

Immunoncology has revolutionized cancer treatment by offering improved survival and quality of life. This study aimed to explore the characteristics of NICE and SMC's decisions for the reimbursement of immunoncology drugs, within the healthcare systems of the UK & Wales and Scotland respectively.

METHODS

The classification of the Cancer Research Institute was used, to identify immunoncology drugs. A systematic search of publicly available HTA decisions on immunoncology drugs was performed, taking into account technology appraisals conducted from 2012 to 2023. Data on drug-indication pairs, recommendation status and ICER for both NICE and SMC appraisals, were extracted in standardized tables. A retrospective analysis of the reviewed decisions was conducted.

RESULTS

A total of 58 NICE and 57 SMC appraisals were analyzed, revealing that most decisions were positive or optimised/restricted (91.4% and 87.7%, respectively). Lung cancer and melanoma were the most frequently appraised indications. More than half of the appraisals (53.4% for NICE and 61.4% for SMC) reported ICERs above £30,000 per QALY. Patient group submissions were included in 89.7% of NICE and all SMC decisions, reflecting the agencies' commitment to incorporating patient perspectives. Policy summary: The number of immunoncology drugs assessed by NICE and SMC has increased significantly in the latest years, reflecting their expanding use across a broad range of cancer indications. This study highlights the high acceptance rates of immunoncology therapies appraised by both agencies, as well as the link between high ESMO-MCBS score (for both curative and non-curative and non-curative settings) and positive or optimised/restricted coverage recommendations. By exploring the characteristics of immunoncology drugs appraisals, the analysis provides insights into the evolving landscape of this therapeutic area.

Financial burden of high-cost immunotherapy among cancer survivors in Medicare

PURPOSE

Cancer survivors often experience significant financial hardship, which is exacerbated by the rising costs of novel immunotherapies. This study examined the association between financial hardship and receipt of high-cost immunotherapy among cancer survivors.

METHODS

We used data from the 2010-2020 Health and Retirement Study linked to Medicare Part B and D claims to examine cancer survivors aged 65 and older who received infusion and oral immunotherapy. Adjusted linear probability models assessed the relationship between high-cost treatment and key outcomes, including reported debt, inability to afford medical care, reduced medication use due to cost, and high out-of-pocket expenses.

RESULTS

Among all cancer survivors, we found that high-cost immunotherapy significantly increased the likelihood of financial hardship, including a 7.2 percentage point (pp) increase in the inability to afford medical care (95% confidence intervals (CI), - 0.011 to 0.156; P = 0.089). Blood cancer survivors experienced greater financial hardship than those with solid tumor cancers. Specifically, blood cancer survivors experienced a 23.8 pp (CI, 0.013 to 0.463; P = 0.038) increase in the inability to afford medical care and a 42.7 pp (CI, 0.148 to 0.706; P = 0.003) increase in taking fewer medications than prescribed.

CONCLUSIONS

High-cost immunotherapy increased the risk of cancer survivors reporting an inability to afford care and taking fewer medications due to cost. Blood cancer survivors were more likely to report financial hardship compared to those diagnosed with solid tumors.

IMPLICATIONS FOR CANCER SURVIVORS

These results underscore the need for interventions to alleviate economic burdens and improve access for patients receiving high-cost cancer treatments.

Exploring molecular imaging to investigate immune checkpoint inhibitor-related toxicity

Immune checkpoint inhibitors (ICI) boost the endogenous anticancer immunity, evoking long-lasting anticancer responses in a subset of patients with solid tumors. Simultaneously, ICI are also associated with serious toxicities, impacting treatment duration and the quality of life. The proposed processes underlying ICI-related toxicity include T-cell activation and recruitment to non-tumor tissues, involvement of other immune cells and fibroblasts and the host' microbiome composition. However, the exact mechanisms of these processes remain incompletely understood, hindering clinicians' ability to predict and identify ICI-related toxicity in the early stages of treatment. Molecular imaging may play a role as a non-invasive biomarker, providing a tool to study ICI-related toxicity. This review discusses the applications of molecular imaging to answer questions regarding the mechanisms, detection, and prediction of ICI-related toxicity. Potential targets and the current state of development of suitable imaging techniques are discussed.

Cost of Neoadjuvant Immunotherapy vs Up-Front Surgery in Cutaneous Squamous Cell Carcinoma: A Post Hoc Analysis of a Nonrandomized Clinical Trial

Importance

There is increasing interest in use of neoadjuvant immunotherapy (NAT) in advanced cutaneous squamous cell carcinoma (cSCC) to reduce surgical morbidity and forego adjuvant therapy, while potentially improving survival outcomes.

Objective

To assess the cost to Medicare of NAT compared with up-front surgery.

Design, Setting, and Participants

This cohort study was a post hoc analysis of a phase 2 clinical trial evaluating the feasibility of neoadjuvant atezolizumab. The study was conducted from June 2021 to December 2023 at a tertiary-level academic institution among 20 patients with advanced stage II-IV cSCC.

Interventions

Up to 3 doses of neoadjuvant atezolizumab, followed by surgical resection with or without adjuvant radiation therapy.

Main Outcomes and Measures

Direct medical costs in US dollars of care received on trial were compared with baseline treatment plans of up-front surgery developed a priori from a Medicare payer perspective.

Results

Of 20 patients with advanced cSCC enrolled (median [range] age, 71.5 [53-88] years; 17 male [85.0%]), most individuals had stage III (12 patients [60.0%]) or IV (5 patients [25.0%]) disease. The median (range) follow-up was 14.2 (3.5-28.7) months. Compared with $26 602.67 for up-front surgery, NAT was associated with mean overall costs of $51 561.02, or a 93.8% increase, equivalent to $24 958.36 (95% CI, $22 057.95 to $24 692.43) per patient, which was primarily associated with the drug acquisition costs of atezolizumab ($30 603.96). NAT was associated with mean cost reductions from $12 707.07 to $10 543.71 (17.0%) in surgery and $11 711.97 to $7157.32 (38.9%) in radiation across all patients compared with up-front surgery. Adjuvant radiation therapy was obviated in 5 of 17 patients not previously irradiated (29.4%), reducing costs of radiation. Mean (SD) surgical complexity was reduced from 63.81 (30.55) to 44.71 (32.49) work relative value units (wRVUs; difference, 19.10 wRVU; 95% CI, 5.00 to 33.20 wRVU). NAT was associated with 5 fewer free flaps, 4 fewer neck dissections, 5 more organ-preserving resections, and 3 conversions from inpatient to outpatient surgery.

Conclusions and Relevance

This study found that treatment with 3 doses of NAT was associated with an overall cost increase compared with up-front surgery, driven by drug acquisition costs, and cost reductions from less extensive surgical resections and obviated adjuvant radiation. Predictive markers for response to NAT could optimize patient selection and improve cost-effectiveness.

Trial Registration

ClinicalTrials.gov Identifier: NCT04710498.

Reporting Quality in Health Economic Evaluation Studies of Immune Checkpoint Inhibitors: A Systematic Review

BACKGROUND AND OBJECTIVE

The introduction of immune checkpoint inhibitors (ICIs) in oncology presents a critical healthcare policy challenge for resource allocation due to their substantial financial burden. This study assessed the reporting quality of health economic evaluation (HEE) studies of ICIs.

METHODS

This study conducted a systematic literature search of four databases (PubMed, EMBASE, Cochrane CENTRAL, and the International HTA Database) for studies published between January 1, 2014 and December 31, 2022. All ICIs approved up to December 31, 2022, in the USA, EU, China, and Japan were included. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards published in 2013 (CHEERS 2013), which is the most widely recognised and implemented reporting guideline for HEE studies. Subgroup analyses were also performed based on the risk of sponsorship bias or citation of CHEERS 2013.

RESULTS

A total of 5368 records were identified, 252 of which were included after full-text review. The study design, setting, and ICIs most frequently observed were cost-effectiveness and cost-utility analyses (63.5%), the USA (46.0%), and pembrolizumab (38.1%), respectively. Of the 24 items of CHEERS 2013, fully reported items were limited, particularly in the Methods section. Setting and location were not reported in 94.4% of the records. Subgroup analyses also revealed insufficient reporting of items in the Methods section, particularly "Setting and location".

CONCLUSION

Health economic evaluation studies on ICIs between 2014 and 2022 had limited reporting across the 24 items of CHEERS 2013, regardless of sponsorship bias risk or citations. The items on setting and location in the Methods section were particularly underreported, emphasising the need for transparent reporting in HEE studies of ICIs.

Trends in NICE technology appraisals of non-small cell lung cancer drugs over the last decade

OBJECTIVES

The aim of this study is to analyse the trends in technology appraisals for non-small cell lung cancer (NSCLC) treatments performed by the National Institute for Health and Care Excellence (NICE) over the last ten years.

METHODS

A systematic search was conducted for single technology appraisals of NSCLC drugs in the online NICE database from 2012 to 2022. Search terms used were 'non small cell lung cancer', and 'NSCLC'. Appraisals that were under development or terminated as well as multiple technology appraisals were considered out of scope.

RESULTS

In the 30 included appraisals for targeted therapies and immunotherapies within NSCLC, a total of 53 different comparators were included by NICE for 41 assorted indications or subgroups. Partitioned survival models were most frequently used, often including three health states and time horizons of up to 30 years. Throughout the decade the use of indirect comparisons was high and became more established and complex over time. Of all appraisals, 90% positively recommended the treatment for use in the UK.

CONCLUSION

Technology appraisals became more complex over time due to the emergence of targeted therapies and immunotherapies, leading to multiple different indications, subpopulations and comparators that needed to be included in appraisals. Partitioned Survival Analysis (PartSA) models became the cornerstone within NSCLC, with time horizons up to 30 years and over time methods for indirect treatment comparisons became more established. The majority of the appraisals resulted in a positive recommendation for reimbursement.

Novel immune drug combination induces tumour microenvironment remodelling and reduces the dosage of anti-PD-1 antibody

Immune checkpoint inhibitors (ICIs) are effective in clinical settings; however, they present immune-related adverse effects and financial burden. Although dose reduction of ICIs may mitigate these limitations, it could compromise therapeutic efficacy. Using two adjuvants (poly(I:C) and LAG-3-Ig) combined with three neoantigen peptides (Comb), we examined whether Comb could enhance the efficacy of reduced dose of αPD-1 monoclonal antibody (RD-αPD-1 mAb), which has limited efficacy. In a murine colorectal cancer model using an MC38 cell line, Comb addition to RD-αPD-1 mAb enhanced treatment efficacy. Analysis of the tumour microenvironment (TME) in mice treated with Comb using flow cytometry and single-cell RNA sequencing revealed decreased macrophages with highly expressing immunosuppressive genes and increased plasmacytoid dendritic cells with highly expressing antigen-presenting genes. A potent infiltration of CD8+ tumour-infiltrating lymphocytes (TILs) with an effector profile was only observed in RD-αPD-1 mAb with Comb. Additionally, single-cell T cell receptor repertoire analysis underscored an oligoclonal expansion of CD8+ TILs following treatment with RD-αPD-1 mAb with Comb. This novel immune drug combination may be a promising strategy for reducing αPD-1 mAb dosage while preserving antitumour efficacy through modulating the TME.

Cost-effectiveness of atezolizumab plus bevacizumab versus sorafenib as first-line therapy in unresectable hepatocellular carcinoma in the US and Chinese setting: a modelling comparison study

OBJECTIVE

Atezolizumab plus bevacizumab demonstrates a significant improvement in overall survival and progression-free survival compared with sorafenib in patients with unresectable hepatocellular carcinoma (HCC). The combined usage of these two medications could result in substantial consumption of resources, primarily due to their exceptionally high costs. The current study aims to evaluate the cost-effectiveness of atezolizumab plus bevacizumab as a first-line treatment for advanced HCC from the perspective of payers in developed and developing countries.

DESIGN

A partitioned survival model was constructed to evaluate the cost-effectiveness of atezolizumab plus bevacizumab versus sorafenib as a first-line treatment for advanced HCC. The efficacy and safety data incorporated within the model were derived from the IMbrave150 trial. Costs and utilities were extracted from published sources.

INTERVENTIONS

Atezolizumab plus bevacizumab versus sorafenib.

OUTCOME MEASURES

Estimates were calculated for costs, life-years, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER) for both treatment strategies. One-way sensitivity, probabilistic sensitivity, expected value of perfect information (EVPI), subgroup and scenario analyses were conducted.

RESULTS

The combination therapy of atezolizumab and bevacizumab results in an additional 0.72 life-years/0.57 QALYs in the USA and 0.64 life-years/0.47 QALYs in China compared with standard sorafenib treatment, although with a significant increase in costs, yielding an average ICER of US$253 247.07/QALY in the USA and US$181 552.71/QALY in China. The probability sensitivity analysis indicated that atezolizumab plus bevacizumab demonstrated a 13.60% likelihood of cost-effectiveness in the USA, whereas this likelihood is negligible (0%) in China. The expected value of uncertainty, as quantified by the EVPI, was estimated at approximately US$3658.41/patient in the USA and US$0/patient in China. The ICER was most sensitive to the cost of subsequent treatment in the USA, and most sensitive to the cost of atezolizumab in China. In scenario analyses, the atezolizumab plus bevacizumab treatment becomes favourable when the cost of atezolizumab decreases to 67.85% and 18.45% of its original price in the USA and China, respectively.

CONCLUSIONS

The atezolizumab plus bevacizumab is unlikely to be cost-effective compared with sorafenib for patients with unresectable HCC in the context of the USA and China. The implementation of significant reductions in drug prices may render the treatment economically viable.

Cost-Effectiveness of Pembrolizumab With Chemoradiotherapy for Locally Advanced Cervical Cancer

Importance

The KEYNOTE-A18 trial demonstrated that adding concurrent and adjuvant pembrolizumab to chemoradiotherapy and brachytherapy significantly improved survival in patients with newly diagnosed, locally advanced cervical cancer. However, considering the annual global incidence of 660 000 cases of cervical cancer, including 13 820 in the US in 2024, incorporating this regimen into the standard of care could have substantial health care economic implications for both patients and the health care system.

Objective

To determine the cost-effectiveness of adding pembrolizumab to the first-line treatment of newly diagnosed, locally advanced cervical cancer.

Design, Setting, and Participants

This economic evaluation created a Markov model simulating 50-year outcomes to evaluate cost-effectiveness from the payer perspective for patients receiving either pembrolizumab or placebo in addition to chemoradiotherapy plus brachytherapy. Probabilities, including disease progression, survival, and treatment-related toxic effects, were derived from KEYNOTE-A18 clinical trial data in patients with newly diagnosed, locally advanced cervical cancer. Costs and health utilities were obtained from published literature; 1-way, 3-way, and probabilistic sensitivity analyses were used to assess model uncertainty. Data analyses were conducted from April to November 2024.

Exposure

Pembrolizumab.

Main Outcomes and Measures

Costs, measured in 2024 US dollars, and effectiveness, measured in quality-adjusted life-years (QALYs) were used to calculate an incremental cost-effectiveness ratio (ICER). A willingness-to-pay threshold of $100 000 per QALY was chosen, below which pembrolizumab would be considered cost-effective.

Results

KEYNOTE-A18 enrolled 1060 patients (529 in pembrolizumab group, 531 in placebo group). The median age was 50 years. Pembrolizumab increased costs by $257 000 and effectiveness by 1.40 QALYs, yielding an incremental cost-effectiveness ratio of $183 400 per QALY. The addition of pembrolizumab became cost-effective if its monthly cost was decreased from $16 990 to $9190 (a 45.6% reduction) or its maximum duration of 24 months was decreased to 10 months. The model was insensitive to assumptions about treatment-related toxic effects, progression-free survival, and overall survival. Probabilistic sensitivity analysis indicated that at a willingness-to-pay threshold of $100 000 per QALY, the addition of pembrolizumab was cost-effective 37.3% of the time.

Conclusions and Relevance

In this economic evaluation of adding concurrent and adjuvant pembrolizumab to first-line treatment of newly diagnosed, locally advanced cervical cancer, this regimen was not cost-effective at current prices despite data demonstrating improved survival with this regimen.

Association of baseline neutrophil-to-lymphocyte ratio and prognosis in melanoma patients treated with PD-1/PD-L1 blockade: a systematic review and meta-analysis

Immunotherapy treatments that target programmed cell death receptor-1 (PD-1) or its ligand (PD-L1) have revolutionized the treatment of metastatic melanoma and currently represent the standard first-line treatment for this type of cancer. However, it is still not entirely clear which biomarkers are cost-effective, simple, and highly reliable. This systematic review and meta-analysis aims to analyze the predictive value of the baseline neutrophil-lymphocyte ratio (NLR) regarding disease progression and overall survival of patients with metastatic melanoma undergoing treatment with PD-1/PD-L1 blockade. PubMed, Scopus, and Web of Science were searched for studies comparing high versus low NLR. We performed the meta-analysis using RStudio v4.4.2 software. A total of 20 studies and 2691 patients were included, all with diagnoses of melanoma. The majority of the individuals were male 2278 (84, 65%). The median overall survival (OS) and progression-free survival (PFS) ranged from 5.0 to 44.4 and from 1.8 to 15.0 months, respectively. Compared with the high NLR ratio, the low exposure group achieved better rates of OS [hazard ratio (HR), 2.07; 95% CI, 1.73-2.48; P  < 0.00001; I ² = 47%]. Regarding PFS, there was a statistically significant difference between groups with tendencies toward the low NLR exposure group (HR, 1.59; 95% CI, 1.39-1.81; P  < 0.00001; I²=31%]. This systematic review and meta-analysis revealed significant lower OS in melanoma patients treated with PD-1/PD-L1 blockade who had elevated baseline NLR values. Furthermore, an increased PFS was observed in patients with a lower baseline NLR value. This study highlights NLR as an important prognostic biomarker for patients with metastatic melanoma who are candidates for treatment with PD-1 and PD-L1.

Deep learning on CT scans to predict checkpoint inhibitor treatment outcomes in advanced melanoma

Immune checkpoint inhibitor (ICI) treatment has proven successful for advanced melanoma, but is associated with potentially severe toxicity and high costs. Accurate biomarkers for response are lacking. The present work is the first to investigate the value of deep learning on CT imaging of metastatic lesions for predicting ICI treatment outcomes in advanced melanoma. Adult patients that were treated with ICI for advanced melanoma were retrospectively identified from ten participating centers. A deep learning model (DLM) was trained on volumes of lesions on baseline CT to predict clinical benefit. The DLM was compared to and combined with a model of known clinical predictors (presence of liver and brain metastasis, level of lactate dehydrogenase, performance status and number of affected organs). A total of 730 eligible patients with 2722 lesions were included. The DLM reached an area under the receiver operating characteristic (AUROC) of 0.607 [95%CI 0.565-0.648]. In comparison, a model of clinical predictors reached an AUROC of 0.635 [95%CI 0.59 -0.678]. The combination model reached an AUROC of 0.635 [95% CI 0.595-0.676]. Differences in AUROC were not statistically significant. The output of the DLM was significantly correlated with four of the five input variables of the clinical model. The DLM reached a statistically significant discriminative value, but was unable to improve over known clinical predictors. The present work shows that the assessment over known clinical predictors is an essential step for imaging-based prediction and brings important nuance to the almost exclusively positive findings in this field.

Cost-effectiveness analysis of pembrolizumab with chemotherapy for metastatic nonsquamous non-small cell lung cancer in Taiwan

This study was aimed to evaluate the cost-effectiveness of pembrolizumab with chemotherapy (pembrolizumab combination therapy) and compare it with standard-of-care platinum-based chemotherapy (chemotherapy alone) as a first-line treatment for metastatic nonsquamous NSCLC from the perspective of Taiwan's third-party-payer public health-care system. We used a partitioned survival model with an estimated time horizon of 10 years. The partitioned survival model uses Kaplan-Meier estimates of progression-free and overall survival from the KEYNOTE-189 clinical trial. The quality-adjusted life-year (QALY) values were based on utility values by progression status calculated from the KEYNOTE-189 trial. This study examined costs related to treatment regimens, disease management, second-line therapy, end-of-life care, and adverse event management. Cost and utility were discounted at 3% per year. Probabilistic and deterministic sensitivity analyses were performed to test the robustness of the results. The willingness-to-pay threshold was set at 3 × Taiwan's gross domestic product (GDP), equivalent to NT$2,788,290. In the base-case scenario, pembrolizumab combination therapy resulted in an expected gain of 0.89 QALYs and an incremental cost of NT$2,201,203 relative to chemotherapy alone. The ICER was NT$2,478,601/QALY. In the analysis of the PD-L1 tumor proportion score (TPS) ≥ 50% subgroup, the patients who received pembrolizumab combination therapy gained 1.12 QALYs more than those who received chemotherapy alone, and the incremental cost was NT$2,522,528. Therefore, the ICER for this subset of patients was NT$2,258,358/QALY. In conclusion, pembrolizumab combination therapy is a cost-effective option for first-line treatment of metastatic nonsquamous NSCLC. The relative cost-effectiveness of pembrolizumab combination therapy is greatest for patients with PD-L1 TPS ≥50%.

Marginal health care expenditures for melanoma care in the United States

BACKGROUND

The incidence of melanoma has increased significantly in the past few decades, posing a significant public health challenge. However, there is an evidence gap regarding the marginal costs of treating melanoma.

OBJECTIVE

To examine the marginal health care expenditures for melanoma compared with other nonskin cancers among US adults.

METHODS

This study examined individuals aged 18 years or older with melanoma, nonmelanoma skin cancer (NMSC), and other cancers from the 2011-2020 Medical Expenditure Panel Survey datasets. Direct health care expenditures involving hospital inpatient, outpatient, prescription medications, dental, vision, home health care, and other medical services for melanoma were analyzed using generalized linear models, and comparisons were made with expenditures for other types of cancers while adjusting for other patient characteristics.

RESULTS

There were 0.70 million individuals (95% CI = 0.61-0.78) diagnosed with melanoma annually. Total health care expenditures among individuals with melanoma, NMSC, and other cancers were $19,427, $13,744, and $23,741, respectively. A generally increasing trend of expenditure was observed over the years. Notably, office-based care (30.46%), inpatient services (28.78%), and prescription (18.27%) costs primarily accounted for the health care burden of patients with melanoma. Adjusted marginal total health care expenditures for melanoma were found to be lower ($-3,369.01 [95% CI = -$5,934.15 to -$803.85]) than other cancers but higher ($2,844.75 [95% CI = $2,204.77-$3,484.72]) compared with NMSC. Prescription expenditures were similar across the 3 cancer study groups.

CONCLUSIONS

This study found that adjusted marginal expenditures for melanoma were higher than those with NMSC but lower than other nonskin cancers, with office-based care and inpatient expenditures contributing to most of the expenditures. The findings suggest that concerted efforts are needed to control the primary cost drivers to reduce the associated burden of potentially preventable skin cancer like melanoma.

Pan-Cancer Survival Impact of Immune Checkpoint Inhibitors in a National Healthcare System

BACKGROUND

The cumulative, health system-wide survival benefit of immune checkpoint inhibitors (ICIs) is unclear, particularly among real-world patients with limited life expectancies and among subgroups poorly represented on clinical trials. We sought to determine the health system-wide survival impact of ICIs.

METHODS

We identified all patients receiving PD-1/PD-L1 or CTLA-4 inhibitors from 2010 to 2023 in the national Veterans Health Administration (VHA) system (ICI cohort) and all patients who received non-ICI systemic therapy in the years before ICI approval (historical control). ICI and historical control cohorts were matched on multiple cancer-related prognostic factors, comorbidities, and demographics. The effect of ICI on overall survival was quantified with Cox regression incorporating matching weights. Cumulative life-years gained system-wide were calculated from the difference in adjusted 5-year restricted mean survival times.

RESULTS

There were 27,322 patients in the ICI cohort and 69,801 patients in the historical control cohort. Among ICI patients, the most common cancer types were NSCLC (46%) and melanoma (10%). ICI demonstrated a large OS benefit in most cancer types with heterogeneity across cancer types (NSCLC: adjusted HR [aHR] 0.56, 95% confidence interval [CI] 0.54-0.58, p < 0.001; urothelial: aHR 0.91, 95% CI 0.83-1.01, p = 0.066). The relative benefit of ICI was stable across patient age, comorbidity, and self-reported race subgroups. Across VHA, 15,859 life-years gained were attributable to ICI within 5-years of treatment, with NSCLC contributing the most life-years gained.

CONCLUSION

We demonstrated substantial increase in survival due to ICIs across a national health system, including in patient subgroups poorly represented on clinical trials.

Predictive markers of response to immune checkpoint inhibitor rechallenge in metastatic non-small cell lung cancer

Aim

The present study aims to evaluate the efficacy of rechallenge with immune checkpoint inhibitors (ICIs) compared to chemotherapy and the predictive role of clinical parameters in non-small cell lung cancer (NSCLC) patients who were rechallenged.

Methods

The study included 113 metastatic NSCLC patients who had initially responded to ICIs and platinum-based chemotherapy, either in combination in the first line or sequentially in the first and second line, but later experienced disease progression. Of those patients, 52 later received ICI rechallenge and 61 were exposed to chemotherapy.

Results

In the rechallenge cohort, the median age was 67 years, 38 patients were men (73.1%), 26 (50.0%) had squamous cell carcinoma. Patients who underwent ICI rechallenge had longer overall survival (OS) compared to those who received chemotherapy (12.9 months vs. 9.6 months, P = 0.008). Multivariate analysis for progression-free survival (PFS) and OS revealed that poor Eastern Cooperative Oncology Group Performance Status (ECOG PS; PFS: P = 0.013 and OS: P = 0.037), absence of objective response during initial ICI therapy (PFS: P = 0.014 and OS: P = 0.028), and baseline neutrophil-to-lymphocyte ratio (NLR) ≥ 3.8 (PFS: P = 0.001 and OS: P = 0.003) were negative predictive factors of ICI rechallenge. The three parameters were included in a risk model named as the NEO score, which stratified patients who received ICI rechallenge into two predictive groups. Patients with ECOG PS 0-1, objective response during initial ICI treatment, and NLR < 3.8 (favorable group) had longer PFS (8.6 months vs. 3.0 months, P < 0.001) and OS (16.6 months vs. 5.5 months, P < 0.001) compared to those with absence of all three markers (poor group). There was no association between the NEO score and survival outcomes in patients who did not undergo rechallenge.

Conclusions

ICI rechallenge showed a survival benefit, particularly in NSCLC patients with NLR < 3.8, good ECOG PS, and objective response.

Differences in Health Care Expenditures by Cancer Patients During Their Last Year of Life: A Registry-Based Study

BACKGROUND

During the last year of life, persons with cancer should probably have similar care needs and costs, but studies suggest otherwise.

METHODS

A study of direct medical costs (excluding costs for expensive prescription drugs) was performed based on registry data in Stockholm County, which covers 2.4 million inhabitants, for all deceased persons with cancer during 2015-2021. The data were mainly analyzed with the aid of multiple regression models, including Generalized Linear Models (GLMs).

RESULTS

In a population of 20,431 deceased persons with cancer, the costs increased month by month (p < 0.0001). Higher costs were mainly associated with lower age (p < 0.0001), higher risk of frailty, as measured by the Hospital Frailty Risk Scale (p < 0.0001), and having a hematological malignancy. In a separate model, where those 5% with the highest costs were identified, these variables were strengthened. Sex and socio-economic groups on an area level had little or no significance. Systemic cancer treatments during the last month of life and acute hospitals as place of death had only a moderate impact on costs in adjusted models.

CONCLUSIONS

Higher costs are mainly related to lower age, higher frailty risk and having a hematological malignancy, and the effects are both statistically and clinically significant despite the fact that expensive drugs were not included. On the other hand, the costs were mainly comparable in regard to sex or socio-economic factors, indicating equal care.

Strongly quenched activatable theranostic nanogel for precision imaging-guided photodynamic therapy and enhanced immunotherapy

Immune checkpoint inhibitors (ICIs) are innovative immunotherapeutic agents for cancer. However, their low therapeutic efficacy in patients with large or rapidly growing tumors, along with their high cost, represents a notable limitation in their clinical applications. Therefore, new and safe strategies must be developed to enhance the therapeutic efficacy of ICIs in clinical settings. In this study, we developed a near-infrared (NIR) fluorescent dye-loaded activatable theranostic nanogel (NATNgel) for precision imaging-guided photodynamic therapy (PDT) and combined immunotherapy for rapidly growing tumors. Although NIR fluorescence and phototoxicity of NATNgel are strongly quenched, these can be selectively activated inside target tumor cells. A high tumor-to-background ratio (7.31 ± 1.40) in NIR fluorescence imaging could be achieved in NATNgel-treated mice, enabling real-time image-guided PDT. The combination of PDT and anti-PD-1 antibody therapy resulted in complete tumor regression. Histopathological evaluation of major organs and blood chemistry analysis revealed no side effects of the combined treatment regimen. In addition, the combination treatment completely suppressed the growth of rechallenged tumors. Overall, NATNgel is a safe and promising theranostic material for precision imaging-guided PDT and enhanced immunotherapy.

Uniform block copolymer nanofibers for the delivery of paclitaxel in 2D and 3D glioblastoma tumor models

Cancer treatment has transformed in recent years, with the introduction of immunotherapy providing substantial improvements in prognoses for certain cancers. However, traditional small molecule chemotherapeutics remain the major frontline of defence, and improving their delivery to solid tumors is of utmost importance for improving potency and reducing side effects. Here, length-controlled one-dimensional seed nanofibers (ca. 25 nm, ĐL = 1.05) were generated from poly(fluorenetrimethylenecarbonate)-block-poly(dimethylaminoethylmethacrylate) via living crystallization-driven self-assembly. Paclitaxel, with an encapsulation content ranging from 1 to 100 wt%, was loaded onto the preformed nanoparticles by solvent addition and evaporation. Drug loading was quantified by dynamic light scattering and transmission electron microscopy. Drug-loaded vectors were then incubated with U87 MG glioblastoma cells in a 2D cell assay for up to 72 h, and their anticancer properties were determined. It was observed that seed nanofibers loaded with 20 wt% paclitaxel were the most advantageous combination (IC50 = 0.48 μg mL-1), while pure seed nanofibers with no loaded drug displayed much lower cytotoxicity (IC50 = 11.52 μg mL-1). The IC50 of the loaded seed nanofibers rivaled that of the commercially approved Abraxane® (IC50 = 0.46 μg mL-1). 3D tumor spheroids were then cultured and subjected to the same stresses. Live/dead cell staining revealed that once more, seed nanofibers with 20 wt% paclitaxel, Abraxane®, and paclitaxel all exhibited similar levels of potency (55% viability), whereas control samples exhibited much higher cell viability (70%) after 3 days. These results demonstrate that nanofibers contain great potential as biocompatible drug delivery vehicles for cancer treatment as they exert a similar anticancer effect to the commercially available Abraxane®.

Five latent factors underlie response to immunotherapy

Only a subset of patients treated with immune checkpoint inhibitors (CPIs) respond to the treatment, and distinguishing responders from non-responders is a major challenge. Many proposed biomarkers of CPI response and survival probably represent alternative measurements of the same aspects of the tumor, its microenvironment or the host. Thus, we currently ignore how many truly independent biomarkers there are. With an unbiased analysis of genomics, transcriptomics and clinical data of a cohort of patients with metastatic tumors (n = 479), we discovered five orthogonal latent factors: tumor mutation burden, T cell effective infiltration, transforming growth factor-beta activity in the microenvironment, prior treatment and tumor proliferative potential. Their association with CPI response and survival was observed across all tumor types and validated across six independent cohorts (n = 1,491). These five latent factors constitute a frame of reference to organize current and future knowledge on biomarkers of CPI response and survival.

Toward a Wireless Image Sensor for Real-Time Fluorescence Microscopy in Cancer Therapy

We present a mm-sized, ultrasonically powered lensless CMOS image sensor as a progress towards wireless fluorescence microscopy. Access to biological information within the tissue has the potential to provide insights guiding diagnosis and treatment across numerous medical conditions including cancer therapy. This information, in conjunction with current clinical imaging techniques that have limitations in obtaining images continuously and lack wireless compatibility, can improve continual detection of multicell clusters deep within tissue. The proposed platform incorporates a 2.4 × 4.7 mm2 integrated circuit (IC) fabricated in TSMC 0.18 µm, a micro laser diode (µLD), a single piezoceramic and off-chip storage capacitors. The IC consists of a 36 × 40 array of capacitive trans-impedance amplifier-based pixels, wireless power management and communication via ultrasound and a laser driver all controlled by a Finite State Machine. The piezoceramic harvests energy from the acoustic waves at a depth of 2 cm to power up the IC and transfer 11.5 kbits/frame via backscattering. During Charge-Up, the off-chip capacitor stores charge to later supply a high-power 78 mW µLD during Imaging. Proof of concept of the imaging front end is shown by imaging distributions of CD8 T-cells, an indicator of the immune response to cancer, ex vivo, in the lymph nodes of a functional immune system (BL6 mice) against colorectal cancer consistent with the results of a fluorescence microscope. The overall system performance is verified by detecting 140 µm features on a USAF resolution target with 32 ms exposure time and 389 ms ultrasound backscattering.

Cost-effectiveness of nivolumab plus gemcitabine-cisplatin as first-line treatment for advanced urothelial carcinoma in China and the United States

Objective

Nivolumab, recently proven in a phase 3 clinical trial (CheckMate 901) to enhance survival when combined with gemcitabine-cisplatin for advanced urothelial carcinoma. This study aimed to assess its cost-effectiveness against gemcitabine-cisplatin alone, from US and Chinese payers' perspectives.

Methods

A partitioned survival model was established to assess the life-years, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs) of nivolumab plus gemcitabine-cisplatin versus gemcitabine-cisplatin alone as first-line treatment for advanced urothelial carcinoma. Univariate, two-way, and probabilistic sensitivity analyses were conducted to assess the model's robustness. Additionally, subgroup analyses were performed.

Results

Nivolumab plus gemcitabine-cisplatin and gemcitabine-cisplatin achieved survival benefits of 4.238 life-years and 2.979 life-years for patients with advanced urothelial carcinoma, respectively. Compared with gemcitabine-cisplatin, nivolumab plus gemcitabine-cisplatin resulted in ICERs of $116,856/QALY in the US and $51,997/QALY in China. The probabilities of achieving cost-effectiveness at the current willingness-to-pay thresholds were 77.5% in the US and 16.5% in China. Cost-effectiveness could be reached if the price of nivolumab were reduced to $920.87/100mg in China. Subgroup analyses indicated that the combination had the highest probability of cost-effectiveness in patients under 65 or with an Eastern Cooperative Oncology Group (ECOG) performance-status score of 0 in the US and China.

Conclusion

Nivolumab plus gemcitabine-cisplatin first-line treatment for advanced urothelial carcinoma results in longer life expectancy than gemcitabine-cisplatin, but is not cost-effective in China at current price. However, cost-effectiveness is likely to be achieved in most patient subgroups in the US.

Unravelling the success of transferosomes against skin cancer: Journey so far and road ahead

Skin cancer remains one of the most prominent types of cancer. Melanoma and non-melanoma skin cancer are commonly found together, with melanoma being the more deadly type. Skin cancer can be effectively treated with chemotherapy, which mostly uses small molecular medicines, phytoceuticals, and biomacromolecules. Topical delivery of these therapeutics is a non-invasive way that might be useful in effectively managing skin cancer. Different skin barriers, however, presented a major obstacle to topical cargo administration. Transferosomes have demonstrated significant potential in topical delivery by improving cargo penetration through the circumvention of diverse skin barriers. Additionally, the transferosome-based gel can prolong the residence of drug on the skin, lowering the frequency of doses and their associated side effects. However, the choice of appropriate transferosome compositions, such as phospholipids and edge activators, and fabrication technique are crucial for achieving improved entrapment efficiency, penetration, and regulated particle size. The present review discusses skin cancer overview, current treatment strategies for skin cancer and their drawbacks. Topical drug delivery against skin cancer is also covered, along with the difficulties associated with it and the importance of transferosomes in avoiding these difficulties. Additionally, a summary of transferosome compositions and fabrication methods is provided. Furthermore, topical delivery of small molecular drugs, phytoceuticals, and biomacromolecules using transferosomes and transferosomes-based gel in treating skin cancer is discussed. Thus, transferosomes can be a significant option in the topical delivery of drugs to manage skin cancer efficiently.

Current status and quality of prognosis prediction models of non-small cell lung cancer constructed using computed tomography (CT)-based radiomics: a systematic review and radiomics quality score 2.0 assessment

Background

Radiomics extracts specific quantitative data from medical images and explores the characteristics of tumors by analyzing these representations and making predictions. The purpose of this paper is to review computed tomography (CT)-based radiomics articles related to prognostic outcomes in non-small cell lung cancer (NSCLC), assess their scientificity and quality by the latest radiomics quality score (RQS) 2.0 scoring criteria, and provide references for subsequent related studies.

Methods

CT-based radiomics studies on NSCLC prognosis published from 1 November 2012 to 30 November 2022 in English were screened through the databases of the Cochrane Library, Embase, and PubMed. By excluding criteria such as non-original studies, small sample sizes studies, positron emission tomography (PET)/CT only, and methodological studies only, 17 studies in English were included. The RQS proposed in 2017 is a quality evaluation index specific to radiomics following the PRISMA guidelines, and the latest update of RQS 2.0 has improved the scientificity and completeness of the score. Each checkpoint either belongs to handcrafted radiomics (HCR), deep learning, or both.

Results

The 17 included studies covered most treatments for NSCLC, including radiotherapy, chemotherapy, surgery, radiofrequency ablation, immunotherapy, and targeted therapy, and predicted outcomes such as overall survival (OS), progression-free survival (PFS), distant metastases, and disease-free survival (DFS). The median score rate for the included studies was 28%, with a range of 12% to 44%. The quality of studies in HCR is not high, and only 4 studies have been validated with independent cohorts.

Conclusions

The value of radiomics studies needs to be increased, such that clinical application will be possible, and the field of radiomics still has much room for growth. To make prediction models more reliable and stable in forecasting the prognosis of NSCLC and advancing the individualized treatment of NSCLC patients, more clinicians must participate in their development and clinical testing.

Tumor-associated tertiary lymphoid structures in cancer: implications for immunotherapy

INTRODUCTION

Tertiary lymphoid structures (TLS) arise at chronic inflammatory sites where they function as miniature lymph nodes to generate immune responses, which can be beneficial or detrimental, in diseases as diverse as autoimmunity, chronic infections and cancer. A growing number of studies show that a TLS presence in tumors from cancer patients treated with immune checkpoint inhibitors is closely linked with improved clinical outcomes. TLS may foster the generation of specific anti-tumor immune responses and immunological memory that recognizes a patient's own tumor. Due to repeated rounds of chronic inflammation, some tumor-associated TLS may be immunologically inactive, with immune checkpoint inhibitors functioning to revitalize them through pathway activation.

AREAS COVERED

This review summarizes work on TLS and how they mediate immune responses in human tumors. We also explore TLS as potential prognostic and predictive biomarkers for immunotherapy.

EXPERT OPINION

The presence of TLS in human tumors has been linked with a better clinical prognosis, response to treatment(s) and overall survival. TLS provide a structured microenvironment for the activation, expansion and maturation of immune cells at the tumor site. These activities can enhance the efficacy of immunotherapeutic treatments such as checkpoint inhibitors and cancer vaccines by revitalizing local anti-tumor immunity.

A digital microfluidic device integrated with electrochemical sensor and 3D matrix for detecting soluble PD-L1

PD1/PD-L1 checkpoint inhibitors are at the forefront of cancer immunotherapies. However, the overall response rate remains only 10-30%. Even among initial responders, drug resistance often occurs, which can lead to prolonged use of a futile therapy in the race with the fatal disease. It would be ideal to closely monitor key indicators of patients' immune responsiveness, such as circulating PD-L1 levels. Traditional PD-L1 detection methods, such as ELISA, are limited in sensitivity and rely on core lab facilities, preventing their use for the regular monitoring. Electrochemical sensors exist as an attractive candidate for point-of-care tool, yet, streamlining multiple processes in a single platform remains a challenge. To overcome this challenge, this work integrated electrochemical sensor arrays into a digital microfluidic device to combine their distinct merits, so that soluble PD-L1 (sPD-L1) molecules can be rapidly detected in a programmed and automated manner. This new platform featured microscale electrochemical sensor arrays modified with electrically conductive 3D matrix, and can detect as low as 1 pg/mL sPD-L1 with high specificity. The sensors also have desired repeatability and can obtain reproducible results on different days. To demonstrate the functionality of the device to process more complex biofluids, we used the device to detect sPD-L1 molecules secreted by human breast cancer cell line in culture media directly and observed 2X increase in signal compared with control experiment. This novel platform holds promise for the close monitoring of sPD-L1 level in human physiological fluids to evaluate the efficacy of PD-1/PD-L1 immunotherapy.

Prevalence of and Factors Associated with Financial Toxicity After Pancreatectomy and Gastrectomy

BACKGROUND

Financial toxicity (FT) refers to the adverse impact of cancer treatment costs on patients' experiences, potentially leading to poor adherence to treatment and outcomes. However, the prevalence of FT among patients undergoing major upper gastrointestinal cancer operations, as well as factors associated with FT, remain unclear.

METHODS

We conducted a cross-sectional study by sending the Comprehensive Score for financial Toxicity (COST) survey and Surgery-Q (a survey specifically developed for this study) to patients who underwent gastrectomy or pancreatectomy for malignant disease at our institution in 2019-2021.

RESULTS

We sent the surveys to 627 patients and received responses from 101 (16%) patients. The FT prevalence (COST score <26) was 48 (48%). Patients likely to experience FT were younger than 50 years of age, of non-White race, earned an annual income <$75,000, and had credit scores <740 (all p < 0.05). Additionally, longer hospital stay (p = 0.041), extended time off work for surgery (p = 0.011), and extended time off work for caregivers (p = 0.005) were associated with FT. Procedure type was not associated with FT; however, patients who underwent minimally invasive surgery (MIS) had a lower FT probability (p = 0.042). In a multivariable analysis, age <50 years (p = 0.031) and credit score <740 (p < 0.001) were associated with high FT risk, while MIS was associated with low FT risk (p = 0.024).

CONCLUSIONS

Patients with upper gastrointestinal cancer have a major risk of FT. In addition to predicting the FT risk before surgery, facilitating quicker functional recovery with the appropriate use of MIS is considered important to reducing the FT risk.

A Wireless, Multicolor Fluorescence Image Sensor Implant for Real-Time Monitoring in Cancer Therapy

Real-time monitoring of dynamic biological processes in the body is critical to understanding disease progression and treatment response. This data, for instance, can help address the lower than 50% response rates to cancer immunotherapy. However, current clinical imaging modalities lack the molecular contrast, resolution, and chronic usability for rapid and accurate response assessments. Here, we present a fully wireless image sensor featuring a 2.5×5 mm2 CMOS integrated circuit for multicolor fluorescence imaging deep in tissue. The sensor operates wirelessly via ultrasound (US) at 5 cm depth in oil, harvesting energy with 221 mW/cm2 incident US power density (31% of FDA limits) and backscattering data at 13 kbps with a bit error rate <10-6. In-situ fluorescence excitation is provided by micro-laser diodes controlled with a programmable on-chip driver. An optical frontend combining a multi-bandpass interference filter and a fiber optic plate provides >6 OD excitation blocking and enables three-color imaging for detecting multiple cell types. A 36×40-pixel array captures images with <125 μm resolution. We demonstrate wireless, dual-color fluorescence imaging of both effector and suppressor immune cells in ex vivo mouse tumor samples with and without immunotherapy. These results show promise for providing rapid insight into therapeutic response and resistance, guiding personalized medicine.

Heterogeneity of cancer-associated fibroblasts and tumor-promoting roles in head and neck squamous cell carcinoma

Tumor microenvironment (TME) in head and neck squamous cell carcinoma (HNSCC) has a major influence on disease progression and therapy response. One of the predominant stromal cell types in the TME of HNSCC is cancer-associated fibroblasts (CAF). CAF constitute a diverse cell population and we are only at the beginning of characterizing and understanding the functions of various CAF subsets. CAF have been shown to interact with tumor cells and other components of the TME to shape mainly a favourable microenvironment for HNSCC progression, although some studies report existence of tumor-restraining CAF subtypes. The numerous pathways used by CAF to promote tumorigenesis may represent potential therapeutic targets. This review summarizes current knowledge on the origins, subtypes and mechanisms employed by CAF in HNSCC. The aim is to contribute to the understanding on how CAF actively influence the TME and modulate different immune cell types, as well as cancer cells, to establish a conducive setting for cancer growth. Although CAF are currently a promising therapeutic target for the treatment of other types of cancer, there is no significant therapeutic advancement in HNSCC.

Immunomodulatory Precision: A Narrative Review Exploring the Critical Role of Immune Checkpoint Inhibitors in Cancer Treatment

An immune checkpoint is a signaling pathway that regulates the recognition of antigens by T-cell receptors (TCRs) during an immune response. These checkpoints play a pivotal role in suppressing excessive immune responses and maintaining immune homeostasis against viral or microbial infections. There are several FDA-approved immune checkpoint inhibitors (ICIs), including ipilimumab, pembrolizumab, and avelumab. These ICIs target cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed death ligand 1 (PD-L1). Furthermore, ongoing efforts are focused on developing new ICIs with emerging potential. In comparison to conventional treatments, ICIs offer the advantages of reduced side effects and durable responses. There is growing interest in the potential of combining different ICIs with chemotherapy, radiation therapy, or targeted therapies. This article comprehensively reviews the classification, mechanism of action, application, and combination strategies of ICIs in various cancers and discusses their current limitations. Our objective is to contribute to the future development of more effective anticancer drugs targeting immune checkpoints.

Cost-effectiveness analysis of durvalumab, tremelimumab, and etoposide-platinum in first-line treatment of extensive-stage small cell lung cancer

BACKGROUND

Durvalumab plus etoposide-platinum (DEP) showed sustained overall survival improvements in patients with extensive-stage small-cell lung cancer (ES-SCLC) compared to etoposide-platinum (EP), but adding tremelimumab to DEP (DTEP) did not significantly improve outcomes. A third-party payer perspective is taken here to evaluate the cost-effectiveness of DTEP, DEP, and EP for ES-SCLC.

METHODS

The cost-effectiveness was evaluated by partitioning survival models into 3 mutually exclusive health states. In this model, clinical characteristics and outcomes were obtained from the CASPIAN. Model robustness was evaluated through 1-way deterministic and probabilistic sensitivity analyses. Outcome measurements included costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio, life-years, incremental net health benefit, and incremental net monetary benefit. The analysis was conducted with a 10-year lifetime horizon in a United States setting.

RESULTS

Compared with EP, DEP, and DTEP were associated with an increment of 0.480 and 0.313 life-years, and an increment of 0.247 and 0.165 QALYs, as well as a $139,788 and $170,331 increase in cost per patient. The corresponding ICERs were $565,807/QALY and $1033,456/QALY, respectively. The incremental net health benefit and incremental net monetary benefit of DEP or DTEP were -0.685 QALYs and -$102,729, or -0.971 QALYs and -$145,608 at a willingness to pay threshold of $150,000/QALY, respectively. Compared with DTEP, DEP was dominated. DTEP and DEP were 100% unlikely to be cost-effective if the willingness to pay threshold was $150,000/QALY. DEP was cost-effective compared to EP when durvalumab was priced below $0.994/mg. Compared with EP, DEP, and DTEP were unlikely to be considered cost-effective across all subgroups.

CONCLUSION

DEP and DTEP were not cost-effective options in the first-line treatment for ES-SCLC compared with EP, from the third-party payer perspective in the United States. Compared with DTEP, DEP was dominated.

Cost-Effectiveness of Reduced-Intensity Allogeneic Hematopoietic Cell Transplantation for Older Patients With High-Risk Myelodysplastic Syndrome: Analysis of BMT CTN 1102

PURPOSE

BMT CTN 1102 was a phase III trial comparing reduced-intensity allogeneic hematopoietic cell transplantation (RIC alloHCT) to standard of care for persons with intermediate- or high-risk myelodysplastic syndrome (MDS). We report results of a cost-effectiveness analysis conducted alongside the clinical trial.

METHODS

Three hundred eighty-four patients received HCT (n = 260) or standard of care (n = 124) according to availability of a human leukocyte antigen-matched donor. Cost-effectiveness was calculated from US commercial and Medicare perspectives over a 20-year time horizon. Health care utilization and costs were estimated using propensity score-matched cohorts of HCT recipients in the OptumLabs Data Warehouse (age 50-64 years) and Medicare (age 65 years and older). EuroQol 5 Dimension (EQ-5D) surveys of trial participants were used to derive health state utilities.

RESULTS

Extrapolated 20-year overall survival for those age 50-64 years was 29% for HCT (n = 105) versus 13% for usual care (n = 44) and 31% for HCT (n = 155) versus 12% for non-HCT (n = 80) for those age 65 years and older. HCT was more effective (+2.36 quality-adjusted life-years [QALYs] for age 50-64 years and +2.92 QALYs for age 65 years and older) and more costly (+$452,242 in US dollars (USD) for age 50-64 years and +$233,214 USD for age 65 years and older) than usual care, with incremental cost-effectiveness ratios of $191,487 (USD)/QALY and $79,834 (USD)/QALY, respectively. For persons age 50-64 years, there was a 29% chance that HCT was cost-effective using a willingness-to-pay (WTP) threshold of $150K (USD)/QALY and 51% at a $200K (USD)/QALY. For persons age 65 years and older, the probability was 100% at a WTP >$150K (USD)/QALY.

CONCLUSION

Among patients age 65 years and older with high-risk MDS, RIC HCT is a high-value strategy. For those age 50-64 years, HCT is a lower-value strategy but has similar cost-effectiveness to other therapies commonly used in oncology.

How many Italian cancer patients are eligible for, and may respond to, Italian Medicines Agency-approved immune checkpoint inhibitors?

INTRODUCTION

This cross-sectional study was aimed at estimating the number of Italian incident cancer patients in 2020 eligible for, and respondent to, immune checkpoint inhibitors (ICI).

METHODS

The study is based on publicly available data: the ICI approved until August 2022 by the Italian Medicines Agency (AIFA) with their specific indications and overall observed responses, rther details can be found in the Online Supplementary Materi cancer incidence estimates at 2020 and observed cancer deaths, and published papers with estimates on the frequency of different cancer stage/histology/markers etc. corresponding to AIFA authorizations.

RESULTS

In the analyzed period, a total of seven ICI were authorized in Italy for 20 cancer types. The estimated number of ICI-eligible patients in 2020 was 48,400, 14.3% of those tumors (including skin epitheliomas) that may fit AIFA-indications, and 10.5% of all the incident malignant tumors, including skin epitheliomas. The number of patients who may benefit from ICI therapy was 24,052, 49.7% of the ICI-eligible ones, or 5.2% of the overall estimated incident cancers in 2020.

CONCLUSIONS

In conclusion, although the number of ICI-eligible patients is a relatively small proportion of the yearly burden of cancers, about half of them may respond to ICI-treatment.

Nivolumab plus ipilimumab versus the EXTREME regimen in recurrent/metastatic squamous cell carcinoma of the head and neck: a cost-effectiveness analysis

In the CheckMate 651 study, nivolumab plus ipilimumab versus EXTREME (cisplatin/carboplatin + cetuximab + fluorouracil) regimen was compared for effectiveness. It is not known whether these immunotherapy agents are cost-effective for recurrent or metastatic squamous cell carcinomas of the head and neck (R/M SCCHN). The purpose of this study was to compare the cost-effectiveness of nivolumab plus ipilimumab with EXTREME in the first-line setting from the standpoint of third-party payers in the United States. The projecting of costs and outcomes over 15 years was done using a three-state partitioned survival model discounted by 3% per year. Long-term extrapolation of CheckMate 651 was used to model progression-free survival and overall survival (OS). The incremental net health benefit (INHB), incremental net monetary benefit (INMB), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated. The uncertainty and stability of the model were accounted for via one-way and probabilistic sensitivity analyses. As compared with nivolumab plus ipilimumab, EXTREME was associated with an increase of 0.154 life-years and 0.076 QALYs, as well as a cost increase of $572 per patient. The corresponding ICERs were $7545/QALY along with the values of INMB and INHB were $113,267 and 0.076 QALYs, respectively, at a willingness to pay (WTP) threshold of $150,000/QALY. The probability of nivolumab plus ipilimumab being cost-effective was > 99% in patients with combined positive score (CPS) ≥ 1, CPS 1-19, or CPS ≥ 20. Moreover, hazard ratio for OS and body weight were the most sensitive parameters for the model. According to sensitivity analyses, these results were generally robust. In overall populations with R/M SCCHN, the EXTREME regimen is cost-effective compared with nivolumab plus ipilimumab. Given a WTP threshold of $150,000 per QALY, the probability of the EXTREME regiment being cost-effective compared with nivolumab and ipilimumab, was 64%. Importantly, there was heterogeneity in the cost-effectiveness probabilities, based on primary sites and expression levels of PD-L1. Therefore, tailored treatment based on individual patient and clinical characteristics, remains important, and may impact the cost-effectiveness of the regimens under study.

Unveiling the Biosimilar Paradox of Oncologists' Perceptions and Hesitations in South Korea: A Web-Based Survey Study

INTRODUCTION

Biosimilars offer a cost-effective alternative to original biopharmaceuticals with comparable efficacy and safety. The perception and familiarity of prescribers toward biosimilars play a critical role in their market penetration. Yet, few studies have explored the perception of oncologists toward biosimilars, much less in Asia.

OBJECTIVES

The objective of this study is to understand barriers of adopting biosimilars among oncologists and explore strategies to promote their use in clinical practice settings.

METHODS

A web-based survey was conducted among Korean oncologists from September to October 2022, assessing their perception of biosimilars and prescribing practices.

RESULTS

Among the 118 surveyed oncologists, 75.4% (89 out of 118) had previously prescribed biosimilars. When asked about their preference, 48.3% (57 out of 118) of the respondents preferred originators to biosimilars, whereas 16.1% (19 out of 118) favored biosimilars over the originators. The primary reason for preferring the originators was trust in safety and efficacy (94.7%, 54 out of 57). Still, a paradox was noted as 87.0% (47 out of 54) and 85.2% (46 out of 54) of these also acknowledged the comparable efficacy and safety of biosimilars. A relatively small number of the respondents (16.1%, 19 out of 118) did not consider prescribing biosimilars to biologic-naïve patients at all, and up to 56.8% (67 out of 118) expressed reluctance to switch prescriptions from originators to biosimilars. However, 90.7% (107 out of 118) of respondents considered changing their prescription to biosimilars if patients faced financial stress. Concerns regarding the efficacy when switching to biosimilars were expressed by 42.7% (38 out of 89) of oncologists with biosimilar prescribing experience, increasing to 69.0% (20 out of 29) among those without such experience.

CONCLUSION

Korean oncologists perceived biosimilars to be as safe and effective as originators. However, there is a notable mismatch between this perception and their prescribing practices, particularly among those who have not prescribed biosimilars before. The financial burden of patients served as a significant driver for prescribing biosimilars, yet marginal price differences between originators and biosimilars may be associated with the low adoption rate of biosimilars in Korea. Active price competition may enhance market penetration of biosimilars.

Cost-Effectiveness of Treatment Optimisation with Biomarkers for Immunotherapy in Solid Tumours: A Systematic Review

This study investigated the health economic evaluations of predictive biomarker testing in solid tumours treated with immune checkpoint inhibitors (ICIs). Searching PubMed, EMBASE, and Web of Science from June 2010 to February 2022, 58 relevant articles were reviewed out of the 730 screened. The focus was predominantly on non-small cell lung cancer (NSCLC) (65%) and other solid tumours (40%). Among the NSCLC studies, 21 out of 35 demonstrated cost-effectiveness, notably for pembrolizumab as first-line treatment when preceded by PD-L1 assessment, cost-effective at a threshold of $100,000/QALY compared to the standard of care. However, for bladder, cervical, and triple-negative breast cancers (TNBCs), no economic evaluations met the affordability threshold of $100,000/QALY. Overall, the review highlights a certain degree of uncertainty about the cost-effectiveness of ICI. In particular, we found PD-L1 expression associated with ICI treatment to be a cost-effective strategy, particularly in NSCLC, urothelial, and renal cell carcinoma. The findings suggest the potential value of predictive biomarker testing, specifically with pembrolizumab in NSCLC, while indicating challenges in achieving cost-effectiveness for certain other solid tumours.

Immunotherapy for advanced non-small cell lung cancer with negative programmed death-ligand 1 expression: a literature review

BACKGROUND AND OBJECTIVE

Lung cancer, mainly non-small cell lung cancer (NSCLC), is a serious threat to human life. In particular, the prognosis for advanced patients is poor, with the 5-year survival rate being exceedingly low. In recent years, immune checkpoint inhibition has changed the pattern of the treatment of a variety of cancers, including lung cancer; however, not all patients can benefit from immunotherapy, and thus finding the right biomarkers is particularly important for guiding precise treatment. Programmed death-ligand 1 (PD-L1) expression is one of the most valuable biomarkers for predicting the efficacy of lung cancer immunotherapy. Several studies have confirmed that patients with high PD-L1 expression are more likely to benefit from immunotherapy, but there is a high proportion of people with negative PD-L1 expression constituting a patient population that cannot be ignored. This article reviews the distribution of PD-L1 expression, the methods for evaluating PD-L1, and the effectiveness of immunotherapy for advanced NSCLC with negative PD-L1 expression.

METHODS

We performed a literature review to identify relevant data published until September 2022. In order to organize related information, we searched for literature in PubMed; abstracts and reports published in the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO), the World Conference on Lung Cancer (WCLC), and other congresses; and clinical trial information registered on ClinicalTrials.gov. Information on the distribution of PD-L1 expression, detection of PD-L1, and immunotherapy efficacy for NSCLC with negative PD-L1 expression was collated and reviewed.

KEY CONTENT AND FINDINGS

The incidence of PD-L1 expression in patients with stage IIIB/IV NSCLC is similar in all regions of the world, but PD-L1 expression level is associated with certain clinicopathological features. The expression of PD-L1 can be evaluated by various detecting methods. Some immunotherapy regimens have better efficacy than traditional chemotherapy in patients with negative PD-L1 expression.

CONCLUSIONS

Patients with NSCLC and negative PD-L1 expression can receive better survival benefits under some immunotherapy types, and these may represent a better treatment option for this relatively small patient population.

Human Papilloma Virus Positive Oropharyngeal Squamous Cell Carcinoma and the Immune System: Pathogenesis, Immunotherapy and Future Perspectives

Oropharyngeal squamous cell carcinoma (OPSCC), a subset of head and neck squamous cell carcinoma (HNSCC), involves the palatine tonsils, soft palate, base of tongue, and uvula, with the ability to spread to adjacent subsites. Personalized treatment strategies for Human Papillomavirus-associated squamous cell carcinoma of the oropharynx (HPV+OPSCC) are yet to be established. In this article, we summarise our current understanding of the pathogenesis of HPV+OPSCC, the intrinsic role of the immune system, current ICI clinical trials, and the potential role of small molecule immunotherapy in HPV+OPSCC.

Healthcare Costs and Resource Utilisation of Italian Metastatic Non-Small Cell Lung Cancer Patients

This study evaluated the economic burden of metastatic non-small cell lung cancer patients before and after the availability of an immuno-oncology (IO) regimen as a first-line (1L) treatment. Patients from 2014 to 2020 were categorized according to mutational status into mutation-positive and negative/unknown groups, which were further divided into pre-1L IO and post-1L IO sub-groups depending on the availability of pembrolizumab monotherapy in 1L. Healthcare costs and HCRU for a 1L treatment and overall follow-up were reported as the mean total and per-month cost per patient by groups. Of 644 patients, 125were mutation-positive and 519 negative/unknown (229 and 290 in pre- and post-1L IO, respectively). The mean total per-patient cost in 1L was lower in pre- (EUR 7804) and post-1L IO (EUR 19,301) than the mutation-positive group (EUR 45,247), persisting throughout overall disease follow-up. However, this difference was less when analyzing monthly costs. Therapy costs were the primary driver in 1L, while hospitalization costs rose during follow-up. In both mutation-positive and post-IO 1L groups, the 1L costs represented a significant portion (70.1% and 66.3%, respectively) of the total costs in the overall follow-up. Pembrolizumab introduction increased expenses but improved survival. Higher hospitalisation and emergency room occupation rates during follow-up reflected worsening clinical conditions of the negative/unknown group than the mutation-positive population.

Cost-effectiveness of first-line immunotherapy for advanced non-small cell lung cancer with different PD-L1 expression levels: A comprehensive overview

BACKGROUND

Immunotherapies can substantially improve treatment efficacy, despite their high cost. A comprehensive overview of the cost-effectiveness analysis (CEA) of immune checkpoint inhibitors (ICIs) in patients with non-small cell lung cancer based on different tumor proportion scores (TPSs) was conducted.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, and NHS Economic Evaluation databases were searched from their inception until August 24, 2022. Data relevant to the CEA results were recorded, and quality assessments conducted based on the Quality of Health Economic Studies (QHES) process.

FINDINGS

Fifty-one original studies from seven countries were included. The mean QHES score was 77.0 (range: 53-95). Twenty-seven studies were classified as high-quality, and the rest as fair quality. Pembrolizumab, nivolumab, ipilimumab, atezolizumab, camrelizumab, cemiplimab, sintilimab, tislelizumab, and durvalumab were identified using three TPS categories. While nivolumab plus ipilimumab and pembrolizumab plus chemotherapy were unlikely to be cost-effective in China, the results for the US were uncertain. Atezolizumab combinations were not cost-effective in China or the US, and tislelizumab and sintilimab were cost-effective in China. For TPSs ≥ 50%, the pembrolizumab monotherapy could be cost-effective in some developed countries. Cemiplimab was more cost-effective than chemotherapy, pembrolizumab, and atezolizumab in the US. For TPSs ≥ 1%, the cost-effectiveness of pembrolizumab was controversial due to the different willingness-to-pay thresholds.

CONCLUSIONS

None of the atezolizumab combination regimens were found to be cost-effective in any perspective of evaluations. Camrelizumab, tislelizumab, and sintilimab have lower ICERs compared to atezolizumab, pembrolizumab, and nivolumab in China. Cemiplimab may be a more affordable alternative to pembrolizumab or atezolizumab. However, it remains unclear which ICIs are the best choices for each country. Future CEAs are required to select comprehensive regimens alongside randomized trials and real-world studies to help verify the economics of ICIs in specific decision-making settings.

First-line treatment with durvalumab plus chemotherapy versus chemotherapy alone for metastatic non-small-cell lung cancer in the USA: a cost-effectiveness analysis

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness of durvalumab in combination with chemotherapy compared with chemotherapy alone as first-line therapy for metastatic non-small-cell lung cancer (NSCLC) from the perspective of the US payer.

METHODS

Based on the POSEIDON clinical trial, a partition survival model was developed to compare the cost-effectiveness of durvalumab in combination with chemotherapy versus chemotherapy alone for the first-line treatment of metastatic NSCLC. The model's primary outcomes were costs, life years (LYs), quality-adjusted LYs (QALYs) and the incremental cost-effectiveness ratio (ICER). The analysis only considered direct medical costs, and health utility value was determined using published literature. The robustness of the model was tested by probabilistic sensitivity analyses.

RESULTS

The combination therapy of durvalumab and chemotherapy improved survival by 0.713 QALYs at an incremental cost of $64 104.638 compared with chemotherapy alone, resulting in an ICER of $89 908.328 per QALY gained from the US payer perspective. The combination therapy had a 92.3% probability of being cost-effective at a willingness-to-pay threshold of $150 000 per QALY based on incremental net health benefits. Sensitivity analyses confirmed the model's consistency, and none of the parameters significantly influenced the findings.

CONCLUSION

Durvalumab in combination with chemotherapy represents a more cost-effective strategy for first-line therapy in patients with metastatic NSCLC in the USA compared with chemotherapy alone.

Development of PD-1 blockade peptide-cell conjugates to enhance cellular therapies for T-cell acute lymphoblastic leukemia

Blockade of the interaction of the immune checkpoint receptor programmed cell death protein (PD)-1 and its ligand PD-L1 has been found to be a promising cancer treatment. Our previous studies identified that nABPD1 competed with PD-L1 to bind PD-1. The aim of this study was to evaluate the efficacy and safety of anti-tumor immunotherapy of ICIK cells conjugated with peptides in vivo and in vitro. Here, we synthesized the nABPD1 derivatives SBP1 and SBP2 and showed that their binding efficiency to PD-1-positive improving cytokine-induced killer (ICIK) cells was 98 and 82%, respectively. The cytotoxicity of ICIK cells to T-cell acute lymphoblastic leukemia (T-ALL) cells was increased by conjugating with SBP1 or SBP2, which was 2 times higher than that of ICIK cells alone. Furthermore, mice experiments showed that the fluorescence intensity of leukemia cells in T-ALL xenograft models was reduced by more than 95%, indicating that the peptides enhanced the therapeutic effect in vivo, while morphological evaluations showed that the peptides had no toxicity to important organs. Therefore, peptide-cell conjugates (PCCs) may be a novel method to improve the efficacy of cancer immunotherapy by blocking PD-1 in T-ALL patients.

Towards A Wireless Image Sensor for Real-Time Fluorescence Microscopy in Cancer Therapy

We present a mm-sized, ultrasonically powered lensless CMOS image sensor as a progress towards wireless fluorescence microscopy. Access to biological information within the tissue has the potential to provide insights guiding diagnosis and treatment across numerous medical conditions including cancer therapy. This information, in conjunction with current clinical imaging techniques that have limitations in obtaining images continuously and lack wireless compatibility, can improve continual detection of multicell clusters deep within tissue. The proposed platform incorporates a 2.4×4.7 mm2 integrated circuit (IC) fabricated in TSMC 0.18 μm, a micro laser diode (μLD), a single piezoceramic and off-chip storage capacitors. The IC consists of a 36×40 array of capacitive trans-impedance amplifier-based pixels, wireless power management and communication via ultrasound and a laser driver all controlled by a Finite State Machine. The piezoceramic harvests energy from the acoustic waves at a depth of 2 cm to power up the IC and transfer 11.5 kbits/frame via backscattering. During Charge-Up, the off-chip capacitor stores charge to later supply a high-power 78 mW μLD during Imaging. Proof of concept of the imaging front end is shown by imaging distributions of CD8 T-cells, an indicator of the immune response to cancer, ex vivo, in the lymph nodes of a functional immune system (BL6 mice) against colorectal cancer consistent with the results of a fluorescence microscope. The overall system performance is verified by detecting 140 μm features on a USAF resolution target with 32 ms exposure time and 389 ms ultrasound backscattering.

Changes in Health Care Costs, Survival, and Time Toxicity in the Era of Immunotherapy and Targeted Systemic Therapy for Melanoma

Importance

Melanoma treatment has evolved during the past decade with the adoption of adjuvant and palliative immunotherapy and targeted therapies, with an unclear impact on health care costs and outcomes in routine practice.

Objective

To examine changes in health care costs, overall survival (OS), and time toxicity associated with primary treatment of melanoma.

Design, Setting, and Participants

This cohort study assessed a longitudinal, propensity score (PS)-matched, retrospective cohort of residents of Ontario, Canada, aged 20 years or older with stages II to IV cutaneous melanoma identified from the Ontario Cancer Registry from January 1, 2018, to March 31, 2019. A historical comparison cohort was identified from a population-based sample of invasive melanoma cases diagnosed from the Ontario Cancer Registry from January 1, 2007, to December 31, 2012. Data analysis was performed from October 17, 2022, to March 13, 2023.

Exposures

Era of melanoma diagnosis (2007-2012 vs 2018-2019).

Main Outcomes and Measures

The primary outcomes were mean per-capita health care and systemic therapy costs (Canadian dollars) during the first year after melanoma diagnosis, time toxicity (days with physical health care contact) within 1 year of initial treatment, and OS. Standardized differences were used to compare costs and time toxicity. Kaplan-Meier methods and Cox proportional hazards regression were used to compare OS among PS-matched cohorts.

Results

A PS-matched cohort of 731 patients (mean [SD] age, 67.9 [14.8] years; 437 [59.8%] male) with melanoma from 2018 to 2019 and 731 patients (mean [SD] age, 67.9 [14.4] years; 440 [60.2%] male) from 2007 to 2012 were evaluated. The 2018 to 2019 patients had greater mean (SD) health care (including systemic therapy) costs compared with the 2007 to 2012 patients ($47 886 [$55 176] vs $33 347 [$31 576]), specifically for stage III ($67 108 [$57 226] vs $46 511 [$30 622]) and stage IV disease ($117 450 [$79 272] vs $47 739 [$37 652]). Mean (SD) systemic therapy costs were greater among 2018 to 2019 patients: stage II ($40 823 [$40 621] vs $10 309 [$12 176]), III ($55 699 [$41 181] vs $9764 [$12 771]), and IV disease ($79 358 [$50 442] vs $9318 [$14 986]). Overall survival was greater for the 2018 to 2019 cohort compared with the 2007 to 2012 cohort (3-year OS: 74.2% [95% CI, 70.8%-77.2%] vs 65.8% [95% CI, 62.2%-69.1%], hazard ratio, 0.72 [95% CI, 0.61-0.85]; P < .001). Time toxicity was similar between eras. Patients with stage IV disease spent more than 1 day per week (>52 days) with physical contact with the health care system by 2018 to 2019 (mean [SD], 58.7 [43.8] vs 44.2 [26.5] days; standardized difference, 0.40; P = .20).

Conclusions and Relevance

This cohort study found greater health care costs in the treatment of stages II to IV melanoma and substantial time toxicity for patients with stage IV disease, with improvements in OS associated with the adoption of immunotherapy and targeted therapies. These health system-wide data highlight the trade-off with adoption of new therapies, for which there is a greater economic burden to the health care system and time burden to patients but an associated improvement in survival.

Real-world outcomes of 18,186 metastatic solid tumor outpatients: Baseline blood cell counts correlate with survival after immune checkpoint inhibitor therapy

BACKGROUND

Patient survival in advanced/metastatic melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC) has improved with immune checkpoint inhibitors (ICI). Biomarkers' role in prognosis and treatment has been limited by conflicting trial results.

METHODS

This retrospective, observational study analyzed baseline demographic, clinical, laboratory, and treatment data versus outcomes of The US Oncology Network adult outpatients. Patients with advanced/metastatic melanoma, NSCLC, or RCC treated between January 1, 2015 and November 30, 2020 were given ICI monotherapy or combination therapy with ipilimumab, pembrolizumab, nivolumab, or atezolizumab. Treatment outcomes (overall survival [OS], time to treatment discontinuation, time to next treatment) were followed longitudinally until May 31, 2021, last patient record, or date of death. Baseline blood cell counts, including absolute monocyte count (AMC), absolute lymphocyte count (ALC), monocyte-to-lymphocyte ratio (MLR), absolute neutrophil count (ANC), and eosinophil count, were subdivided into quintiles for univariate and multivariable Cox regression analyses.

RESULTS

Data from 18,186 patients with advanced/metastatic melanoma (n = 3314), NSCLC (n = 12,416), and RCC (n = 2456) were analyzed. Better OS correlated with increased baseline serum albumin concentration, increased eosinophil and lymphocyte counts, and Western United States physician practice location. Decreased OS correlated with increased AMC, MLR, ANC, age, and worse Eastern Cooperative Oncology Group performance status.

CONCLUSIONS

To our knowledge, this study is the largest to date to associate baseline survival indicators and outcomes in outpatients with advanced/metastatic melanoma, NSCLC, or RCC and receiving ICIs. Results may inform disease-specific prognostic models and help providers identify patients most likely to benefit from ICI therapy.

The next horizon now that everyone has a donor: Precision allogeneic transplantation

Post-transplant cyclophosphamide (PTCy) allows safe and effective partially matched donor allogeneic blood or marrow transplantation (alloBMT), so that almost everyone in need of the procedure now has a donor. Moreover, PTCy and other recent advances have lowered alloBMT mortality rates to less than half of that seen before the turn of the century, at costs that are substantially less than most newly approved anticancer agents. These advances also make tailoring BMT based on patients' unique diseases and characteristics now feasible for further improving outcomes. Personalizing every aspect of alloBMT, including conditioning, donor, graft type, and post-transplant maintenance is now possible. For example, alloBMT's antitumor activity historically was restricted to the allogeneic graft-versus-tumor effect directed against histocompatibility antigens. However, replacing exhausted immune systems with healthy non-exhausted, non-tolerant ones likely can enhance the activity of novel targeted therapies. The impressive results seen with tyrosine kinase inhibitors after alloBMT for patients with both Ph+ acute lymphoblastic leukemia and FLT/ITD+ acute myeloid leukemia herald the potential of precision BMT.

Cost-effectiveness analysis of first-line tislelizumab plus chemotherapy for recurrent or metastatic nasopharyngeal cancer

Introduction: The RATIONALE-309 trial confirmed the significant efficacy and safety of tislelizumab plus chemotherapy in patients with recurrent or metastatic nasopharyngeal carcinoma (R/M NPC). However, the economic benefits of this regimen are unclear. Therefore, this study aimed to evaluate the cost-effectiveness of adding tislelizumab to chemotherapy for R/M NPC from the perspective of the Chinese healthcare system. Methods: A Markov model was established to simulate the costs and outcomes of tislelizumab plus chemotherapy versus chemotherapy. The survival data came from the RATIONALE-309 trial. Only direct medical costs were considered, and utility values were referred to the literature. The incremental cost-effectiveness ratio (ICER) was used as the main outcome measure. Sensitivity analysis was performed to assess the effect of parameter uncertainty on the model. Additionally, subgroup analyses were performed. Results: The basic analysis showed that the cost of tislelizumab plus chemotherapy ($33,693) was $17,711 higher than that of chemotherapy ($15,982), but it also gained 1.05 QALYs more (2.72 QALYs vs. 1.67 QALYs), with an ICER of $16,859/QALY, which was lower than the willing-to-pay (WTP) of $36,289/QALY. The factors that most influenced the model were the utility of PD, the cost of tislelizumab, and the risk of platelet count decreased in tislelizumab plus chemotherapy group. The subgroup analysis also demonstrated that tislelizumab plus chemotherapy was cost-effective in the whole population regardless of EBV DNA level and PD-L1 expression level. Conclusion: Compared with chemotherapy alone, tislelizumab plus chemotherapy was cost-effective for the treatment of R/M NPC in China.

Cost effectiveness of immune checkpoint inhibitors for treatment of Hepatocellular Carcinoma: A systematic review and Meta-analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have recently been introduced into the treatment algorithm of patients with hepatocellular carcinoma (HCC). However, the cost effectiveness of ICIs compared with pre-existing therapies for HCC has not been assessed. We performed a meta-analysis to understand the incremental cost effectiveness of ICIs compared with sorafenib.

METHODS

PubMed, Embase, Medline, Scopus, and CINAHL databases were searched (2000-2022). The incremental cost, incremental effectiveness, incremental cost effectiveness ratio (ICER) of ICI compared with sorafenib and willingness to pay (WTP) were extracted from each study. The variables were used to derive the incremental net benefit (INB). Random-effect meta-analysis was then conducted to derive the pooled INB of ICI compared with sorafenib.

RESULTS

Five studies (3265 patients, 82.1 % male) met inclusion criteria. All studies assessed the cost effectiveness of ICIs compared with sorafenib. Studies used Quality adjusted life years to assess incremental effectiveness and reported ICER values ranging from $21,000 to $221,000 for ICIs and sorafenib. Four out of five studies reported that ICI had a higher ICER compared with sorafenib at WTP $150,000. The overall pooled INB was US$-42,000 (95 % CIUS$-96,000, US$11,528) suggesting that ICI was not cost effective compared with sorafenib.

CONCLUSION

When compared with sorafenib, ICIs were not a cost-effective option for systemic therapy for patients with HCC. More work focusing on cost effective options for patients with HCC is warranted.

Nanotechnology-empowered strategies in treatment of skin cancer

In current scenario skin cancer is a serious condition that has a significant impact on world health. Skin cancer is divided into two categories: melanoma skin cancer (MSC) and non-melanoma skin cancer (NMSC). Because of its significant psychosocial effects and need for significant investment in new technology and therapies, skin cancer is an illness of global health relevance. From the patient's perspective chemotherapy considered to be the most acceptable form of treatment. However, significant negatives of chemotherapy such as severe toxicities and drug resistance pose serious challenges to the treatment. The field of nanomedicine holds significant promise for enhancing the specificity of targeting neoplastic cells through the facilitation of targeted drug delivery to tumour cells. The integration of multiple therapeutic modalities to selectively address cancer-promoting or cell-maintaining pathways constitutes a fundamental aspect of cancer treatment. The use of mono-therapy remains prevalent in the treatment of various types of cancer, it is widely acknowledged in the academic community that this conventional approach is generally considered to be less efficacious compared to the combination treatment strategy. The employment of combination therapy in cancer treatment has become increasingly widespread due to its ability to produce synergistic anticancer effects, mitigate toxicity associated with drugs, and inhibit multi-drug resistance by means of diverse mechanisms. Nanotechnology based combination therapy represents a promising avenue for the development of efficacious therapies for skin cancer within the context of this endeavour. The objective of this article is to provide a description of distinct challenges for efficient delivery of drugs via skin. This article also provides a summary of the various nanotechnology based combinatorial therapy available for skin cancer with their recent advances. This review also focuses on current status of clinical trials of such therapies.

Cost-effectiveness analysis of biologics for the treatment of chronic rhinosinusitis with nasal polyps in Canada

BACKGROUND

Dupilumab, omalizumab, and mepolizumab are the three biologics currently approved for use in CRSwNP in Canada. Despite evidence of efficacy, their cost-effectiveness, which is a key factor influencing prescribing patterns, has not yet been compared to each other.

METHODS

A cost-effectiveness model using quality-adjusted life years (QALYs) was constructed using a Decision Tree Markov analysis. A third-party healthcare payer perspective and a 10-year time horizon was used. A willingness-to-pay (WTP) threshold of 50,000 Canadian dollars (CAD) per QALY was used to determine cost-effectiveness. Dupilumab, omalizumab, and mepolizumab were each compared to each other.

RESULTS

Omalizumab was the most cost-effective biologic using current estimates of cost and efficacy in CRSwNP. Using omalizumab as a baseline, dupilumab had an ICER of $235,305/QALY. Mepolizumab was dominated by omalizumab and dupilumab at the current drug prices and estimates of efficacy. Sensitivity analyses determined that when increasing the WTP threshold to $150,000/QALY, dupilumab became cost-effective compared to omalizumab in 22.5% of simulation scenarios. Additionally, altering dosing frequency had a significant effect on cost-effectiveness.

CONCLUSION

When comparing the relative cost-effectiveness of biologics in recalcitrant CRSwNP, omalizumab currently appears to be the most cost-effective option. Future reductions in drug prices, adjustments to currently approved dosing regimens, better patient selection, and improvements in sinus surgery outcomes will challenge the current cost-effectiveness models and necessitate reassessment as treatments for CRSwNP continue to evolve.