Safety and effectiveness of classical and alternative sunitinib dosing schedules for metastatic renal cell carcinoma: a meta-analysis

2/1 dose schedule of sunitinib is superior than the 4/2 regimen for the first-line therapy of clear cell metastatic renal cell carcinoma - An Indian experience

BACKGROUND

Sunitinib remains the first-line treatment for favorable risk metastatic clear cell renal cell cancer (mccRCC). It was conventionally given in the 4/2 schedule; however, toxicity necessitated trying the 2/1 regimen. Regional variations in treatment response and toxicity are known, and there is no data from the Indian subcontinent about the outcomes of the alternative dosing schedule.

METHODS

Clinical records of all consecutive adult patients who received sunitinib as first-line therapy for histologically proven mccRCC following cytoreductive nephrectomy from 2010-2018 were reviewed. The primary objective was to determine the progression-free survival (PFS), and the secondary objectives were to evaluate the response rate (objective response rate and clinical benefit rate), toxicity, and overall survival. A list of variables having a biologically plausible association with outcome was drawn and multivariate inverse probability treatment weights (IPTW) analysis was done to determine the absolute effect size of dosing schedules on PFS in terms of "average treatment effect on the treated" and "potential outcome mean."

RESULTS

We found 2/1 schedule to be independently associated with higher PFS on IPTW analysis such that if every patient in the subpopulation received sunitinib by the 2/1 schedule, the average time to progression was estimated to be higher by 6.1 months than the 4/2 schedule. We also found 2/1 group to have a lower incidence than the 4/2 group for nearly all ≥ grade 3 adverse effects. Other secondary outcomes were comparable between both treatment groups.

CONCLUSION

Sunitinib should be given via the 2/1 schedule in Indian patients.

Comparative Evaluation of Safety and Efficacy of Alternate Schedule (AS) of Sunitinib in Asian and Non-Asian Patient Population for the Treatment of Metastatic Renal Cell Cancer (mRCC): A Meta-Analysis

Background: Treatment of metastatic renal cell carcinoma (mRCC) using traditional schedule (TS, 4/2) of Sunitinib is associated with higher adverse effects compared to the alternate schedule (AS, 2/1 upfront or when switched from TS). Objective: This meta-analysis aims to compare the safety, efficacy, and percentage of patients requiring dose reduction or dose interruption between Asian (AP) and non-Asian population (NAP) receiving AS of sunitinib. Methods: Electronic databases (PubMed, EMBASE, Cochrane Library) were searched to identify studies published in the English language between May 2009- May 2019, which included patients (>18 years) with mRCC receiving AS of sunitinib. Data were analyzed using the random effect model and t-test. P <  0.05 was considered statistically significant. Results: Of 1922, 16 studies were included (eight AP, eight NAP). Among all grade AEs, mucositis (RR:0.22; 95% CI:0.12–0.40), cardiotoxicity (RR: 0.52; 95% CI: 0.31–0.88), nausea (RR:0.21; 95% CI: 0.10–0.44), hand-foot syndrome (RR:0.33; 95% CI:0.13–0.83), rash (RR: 0.52; 95% CI: 0.34–0.79), and aspartate transaminase (RR:0.57; 95% CI:0.33–0.98) were more common in AP. Leukopenia (RR:2.57; 95% CI:1.47–4.49), proteinemia (RR:4.45; 95% CI:2.12–9.33), and stomatitis (RR:4.33; 95% CI:2.6–7.23) occurred more commonly in NAP. Further, PFS was significantly longer in NAP, while longer OS was observed in AP (p <  0.001). Dose reduction was significantly higher in AP than NAP (52.08% vs. 40.6%, p = 0.0088). Conclusion: Safety profile of AS of sunitinib was similar with variations in the efficacy, dose reduction between AP and NAP. Sunitinib dose or schedule modification may mitigate AEs and enhance efficacy outcomes in mRCC by extending the treatment duration.

Cost-effectiveness of pembrolizumab plus axitinib as first-line therapy for advanced renal cell carcinoma

Aim: To evaluate the cost-effectiveness of first-line treatments for advanced renal cell carcinoma with pembrolizumab plus axitinib compared with sunitinib from the US payer perspective. Patients & methods: A Markov model was developed for this purpose. The clinical data were obtained from the KEYNOTE-426 trial. Utility values and direct costs related to the treatments were gathered from the published studies. Results: The incremental cost-effectiveness ratios of pembrolizumab plus axitinib versus sunitinib was $249,704 per quality-adjusted life year, which was higher than a willingness-to-pay threshold of $150,000 per quality-adjusted life year. Conclusion: Pembrolizumab plus axitinib was not considered to be cost-effective versus sunitinib as a first-line treatment for patients with advanced renal cell carcinoma from the US payer perspective.

A Cost-Effectiveness Analysis: First-Line Avelumab Plus Axitinib Versus Sunitinib for Advanced Renal-Cell Carcinoma

Background

Compared with the standard of care with sunitinib, avelumab plus axitinib can increase progression-free survival in the first-line of advanced renal cell carcinoma (RCC), but the economic effect of the treatment is unknown. The purpose of the research was to evaluate the cost-effectiveness of the avelumab plus axitinib versus sunitinib in first-line treatment for advanced RCC from the US payer perspective.

Methods

A Markov model was developed to evaluate the economic and health outcomes of avelumab plus axitinib vs sunitinib in the first-line setting for advanced RCC. The clinical data were obtained from the JAVELIN Renal 101 Clinical Trials. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainty in the model. Health outcomes were measured in quality-adjusted life-years (QALYs).

Results

The incremental cost-effectiveness ratio (ICER) of avelumab plus axitinib compared with sunitinib was $565,232 per QALY, the costs were $884,626 and $669,838, QALYs were 3.67 and 3.29, respectively. Sensitivity analysis demonstrated that differences in utilities in PFS and after progression were the most influential factors within the model. When avelumab was at 30% of the full price or axitinib was at 40% of the full price, avelumab and axitinib were approved to be cost-effective if the WTP threshold was $150,000 per QALY. The subgroup analysis showed the ICER of avelumab plus axitinib compared with sunitinib for the patients with PD-L1–positive tumors was $588,105.

Conclusion

Avelumab plus axitinib in the first-line treatment was not cost-effective in comparison with sunitinib when the threshold of willingness to pay (WTP) was $150,000 per QALY.

Cost-effectiveness Analysis of Pembrolizumab Plus Axitinib Versus Sunitinib in First-line Advanced Renal Cell Carcinoma in China

BACKGROUND AND OBJECTIVES

In first-line treatment of advanced renal cell carcinoma (aRCC), the KEYNOTE-426 study demonstrated a significant progression-free survival and overall survival for pembrolizumab plus axitinib in comparison with sunitinib. The objective of the current study was to evaluate the cost effectiveness of pembrolizumab plus axitinib versus sunitinib for previously untreated patients with aRCC in China.

METHODS

A Markov model was used to estimate the costs and health outcomes of treatment of aRCC with sunitinib or pembrolizumab plus axitinib. Univariable and probabilistic sensitivity analyses were performed to determine the robustness of the model outcomes. Additional subgroup analyses were also performed. The primary outputs of the model included the total cost, life-years (LYs), quality-adjusted LYs (QALYs), and incremental cost-effectiveness ratio (ICER).

RESULTS

Pembrolizumab plus axitinib provided an additional 2.461 LYs (1.650 QALYs). The total cost per patient was US$178,725 for pembrolizumab plus axitinib and US$87,693 for sunitinib. The ICER for pembrolizumab plus axitinib was US$55,185/QALY versus sunitinib. Sensitivity analyses found the results to be most sensitive to pembrolizumab cost and overall hazard ratio. The results of subgroup analyses showed that the ICER remained greater than US$32,000/QALY across the all patient subgroups.

CONCLUSIONS

Pembrolizumab plus axitinib is not likely to be cost effective versus sunitinib for patients with previously untreated aRCC at a threshold value of US$29,306/QALY.