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

Cost-utility of sintilimab plus chemotherapy vs chemotherapy as first-line treatment of advanced gastric or gastroesophageal junction cancer in China

OBJECTIVES

ORIENT-16, a phase III clinical trial conducted at 62 hospitals in China, reported that add-on sintilimab (Sin) to chemotherapy (Chemo) had favorable efficacy (p < 0.05) for patients with advanced HER2-negative gastric or gastroesophageal junction cancer (GC/GEJC). This study aimed to evaluate the cost-utility of the Sin+Chemo based on results of ORIENT-16 from the perspective of Chinese healthcare payers.

METHODS

A three-state partitioned survival model was developed to simulate the 10-year life expectancy and total healthcare costs for patients with advanced HER2-negative GC/GEJC. Primary measure outcomes were: cost, quality-adjusted life-years (QALYs), and incremental cost-utility ratios (ICURs). Sensitivity/scenario analyses were conducted to assess the model robustness.

RESULTS

In all patients, Sin+Chemo vs Chemo increased costs by $6,472, additionally providing 0.61 QALYs, resulting in an ICUR of $10,610/QALY. While, in PD-L1 combined positive score ≥ 5 cohort, the ICUR was $9,738/QALYs. The ICUR was most sensitive to the utility of progression-free survival. The probabilistic sensitivity analysis showed that add-on Sin had a 100% probability of being cost-effective at a willingness-to-pay threshold of $18,625/QALY gained.

CONCLUSIONS

Sin+Chemo is a cost-effective first-line treatment option for advanced HER2-negative GC/GEJC in China.

CLINICAL TRIAL REGISTRATION

ORIENT-16, www.clinicaltrials.gov, identifier is NCT03745170.

Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis

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

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

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

Cost-Effectiveness Analysis of Camrelizumab Plus Rivoceranib Versus Sorafenib as a First-Line Therapy for Unresectable Hepatocellular Carcinoma in the Chinese Health Care System

BACKGROUND AND OBJECTIVES

Camrelizumab plus rivoceranib showed significant clinical benefits in progression-free survival and overall survival compared to sorafenib in patients with unresectable hepatocellular carcinoma (HCC). This study aimed to assess its cost effectiveness from the perspective of Chinese health care system.

METHODS

A Markov state-transition model was developed based on the Phase 3 randomized CARES-310 clinical trial data. Health state utility values were obtained from the CARES-310 clinical trial, and direct medical costs were derived from the relevant literature and local charges. The measured outcomes included quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER). Probabilistic and one-way sensitivity analyses were performed to assess the uncertainty of the model.

RESULTS

In the base-case analysis, the incremental effectiveness and cost of camrelizumab plus rivoceranib versus sorafenib were 0.41 QALYs and $13,684.84, respectively, resulting in an ICER of $33,619.98/QALY, lower than the willingness-to-pay threshold of China ($35,864.61/QALY). Subgroup analyses revealed that the ICERs of camrelizumab plus rivoceranib versus sorafenib were $35,920.01 and $29,717.98 in patients with ALBI grade 1 and grade 2, respectively. One-way sensitivity analyses indicated that the cost of camrelizumab, the proportion of patients receiving subsequent treatment in the camrelizumab plus rivoceranib group, and the cost of rivoceranib were the most significant factors in the base-case analysis. Probabilistic sensitivity analysis suggested that the probabilities of cost effectiveness of camrelizumab plus rivoceranib were 61.27%, 51.46%, and 82.78% for any grade, and ALBI grade 1 and grade 2, respectively.

CONCLUSIONS

Camrelizumab plus rivoceranib was more cost effective than sorafenib as first-line therapy for unresectable HCC in the Chinese setting.

Immune checkpoint inhibitors plus chemotherapy for HER2-negative advanced gastric/gastroesophageal junction cancer: a cost-effectiveness analysis

Background

Nivolumab plus chemotherapy (NC) was recently approved as the first-line intervention for human epidermal growth factor receptor 2-negative advanced gastric/gastroesophageal junction cancer (GC/GEJC). Moreover, in the latest KEYNOTE-859 (NCT03675737), pembrolizumab plus chemotherapy (PC) was demonstrated to produce remarkable patient survival outcomes.

Objectives

The clinicians and patients need to assess NC and PC preference for cancer drugs.

Design

The cost-effective analysis.

Methods

In an economic assessment of the United States, United Kingdom, and Chinese healthcare systems using a Markov model simulated patients with GC/GEJC, two treatment decision branches with three health states and a tracked time horizon of 15 years were developed. The overall cost and efficacy outcomes of first-line strategies PC and NC were evaluated at willingness-to-pay (WTP) thresholds of different national, including life-years (LYs), quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and incremental net-health benefit (INHB). Sensitivity and subgroup analyses were considered.

Results

Given a WTP threshold of $150,000, $60,161, and $37,653 per QALY in the United States, United Kingdom, and China, respectively, both PC and NC achieved QALYs of 1.67 and 1.65 (2.51 and 2.48 LYs), 1.65 and 1.63 (2.48 and 2.45 LYs), and 1.60 and 1.58 (2.40 and 2.37 LYs), with total costs of $242,444 and $232,617, $148,367 and $127,737, and $16,693 and $24,016, respectively. Based on our sensitivity analysis, the programmed death-1 inhibitors cost produced the largest impact on the outcome. In addition, the cost-effectiveness probabilities of PC were 38.3%, 4.1%, and 100% in the three aforementioned countries, respectively.

Conclusion

In the case of the Chinese payers' perspective, PC appeared more dominant as first-line therapy for advanced GC/GEJC patients, whereas NC was preferred in the United States and United Kingdom.

Pembrolizumab alone or in combination with chemotherapy versus chemotherapy for advanced gastric cancer: A cost-effectiveness analysis

PURPOSE

The KEYNOTE-062 trial demonstrated the efficacy and safety of pembrolizumab for advanced gastric cancer (GC). The current study evaluated the cost-effectiveness of pembrolizumab alone or in combination with chemotherapy versus chemotherapy for advanced GC from the perspective of the United States and China. And the results will provide evidence and data support for more drug selection-related decisions and research in the future.

METHODS

A partitioned survival approach with three states was created for treatment of advanced GC. The survival data were derived from KEYNOTE-062 trial and the individual patient data were generated by a specific algorithm. We fitted 21 survival functions to each treatment arm and selected the most suitable distribution type for each one. Direct costs and utility values were collected from the published, available database. Cost, quality-adjusted life-years (QALYs), and incremental cost-utility ratios (ICURs) were considered as the primary measure outcomes. One-way and probabilistic sensitivity analyses were performed to assess the reliability of the analyses.

RESULTS

In the base-case analysis of combined positive score (CPS) ≥1 patients, the ICUR of pembrolizumab plus chemotherapy versus chemotherapy in American and Chinese setting is $345,209/QALY and $186,802.6/QALY, respectively. And the ICUR of pembrolizumab versus chemotherapy is $473,650/QALY and $377,753/QALY in the context of the US and China, respectively. For CPS≥10 patients, the ICUR of pembrolizumab plus chemotherapy versus chemotherapy in American and Chinese setting is $483,742/QALY and $262,965/QALY, respectively. And that of pembrolizumab versus chemotherapy is $96,550/QALY and $67,896/QALY in the context of the US and China.

CONCLUSION

Compared with chemotherapy, either pembrolizumab plus chemotherapy or pembrolizumab monotherapy is not regarded as a cost-effective strategy for patients with CPS≥1, advanced gastric cancer in the current American and Chinese setting. But pembrolizumab monotherapy for CPS≥10 patients would become a cost-effective option in the American setting.

Cost-effectiveness analysis of zolbetuximab plus mFOLFOX6 as the first-line treatment for CLDN18.2-positive, HER2-negative advanced gastric or Gastroesophageal Adenocarcinoma

Background: The SPOTLIGHT trial demonstrated that zolbetuximab plus mFOLFOX6 (ZOL-FO) as a first-line regimen compared with placebo plus mFOLFOX6 (PLB-FO) conferred clinical benefits to patients with CLDN18.2-positive, HER2-negative advanced gastric or gastroesophageal junction (G/GEJ) adenocarcinoma. However, due to the high cost of zolbetuximab, whether ZOL-FO is cost-effective compared with PLB-FO is unclear. This study aimed to evaluate the cost-effectiveness of ZOL-FO as a first-line treatment option for CLDN18.2-positive, HER2-negative advanced G/GEJ adenocarcinoma from the perspective of the Chinese healthcare system. Methods: Markov models with three different health states were developed to assess the cost-effectiveness of ZOL-FO as a first-line treatment option for CLDN18.2-positive, HER2-negative advanced G/GEJ adenocarcinoma. Clinical efficacy data were obtained from the SPOTLIGHT trial; the drug's cost was calculated at national bid prices, and other costs and utility values were obtained from the published literature. Outcomes included total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). The model's robustness was verified using one-way sensitivity and probabilistic sensitivity analyses. Results: The ZOL-FO group gained 1.64 QALYs at $87,746.35, while the PLB-FO group gained 1.23 QALYs at $11,947.81. The ICER for ZOL-FO versus PLB-FO was $185,353.28 per QALY gained. The parameters exerting an important impact on the model results were the price of zolbetuximab, body surface area, and progression-free survival utility. At a willingness-to-pay threshold of $38,201/QALY, ZOL-FO had a 0% probability of cost-effectiveness compared with PLB-FO. Conclusion: From the perspective of the Chinese healthcare system, ZOL-FO is unlikely to be cost-effective as the first-line treatment option for CLDN18.2-positive, HER2-negative advanced G/GEJ adenocarcinoma.

Efficacy and safety of envafolimab in the treatment of advanced dMMR/MSI‑H solid tumors: A single‑arm meta‑analysis

In November 2021, the National Medical Products Administration (China) approved the marketing of envafolimab injection for the treatment of advanced defective mismatch repair (dMMR)/high microsatellite instability (MSI-H) solid tumors. Envafolimab became the first domestic PD-L1 inhibitor approved in China and the first worldwide approved subcutaneously injectable PD-L1 inhibitor. To the best of our knowledge, there are no reports of systematic analyses regarding the use of envafolimab in the treatment of advanced dMMR/MSI-H solid tumors. The present study was a single-arm meta-analysis performed on data systematically searched and retrieved from literature published on PubMed, Web of Science, Cochrane Library, China National Knowledge Infra-structure and Wan Fang databases on 1 October 2022. Quality assessment using the 20 items developed by the Canadian Institute of Health Economics. Data heterogenicity was evaluated using the I2 statistics. For datasets with I2>50%, the cumulative incidence and 95% CI for the outcomes of interests were calculated using the random effects model, whereas for I2<50% the fixed effects model was used. The current meta-analysis included four studies enrolling 181 patients with advanced dMMR/MSI-H solid tumors. The pooled objective remission rate was 29.53% (95% CI, 8.61-50.45%). The pooled disease control rate was 60.58% (95% CI, 31.79-89.38%). The pooled median progression-free survival was 4.89 months (95% CI, 1.86-7.93 months). The pooled overall survival (OS) rate was 73.38% (95% CI, 65.76-80.99%). The pooled 6-month and 12-month OS rates were 75.80% (95% CI, 57.02-94.58%) and 69.32% (95% CI, 51.92-86.72%), respectively. The combined data on the incidence of treatment-emergent adverse events (TEAEs) of any grade from all the studies was 77.19% (95% CI, 63.15-91.23%). Most of the adverse reactions were mild and the rate of 3/4 grade TEAE was 10.37% (95% CI, 6.14-14.60%). Gevokizumab was effective and safe in the treatment of patients with advanced dMMR/MSI-H solid tumors and its convenience could significantly improve patient compliance; therefore, the clinical application of envafolimab is promising.

Galectin-1-mediated high NCAPG expression correlates with poor prognosis in gastric cancer

Galectin-1 (Gal1) and non-SMC condensin I complex, subunit G (NCAPG) are associated with metastasis in several malignant tumors. However, their precise roles in gastric cancer (GC) remain uncertain. This study explored the clinical significance and relationship of Gal1 and NCAPG in GC. Gal1 and NCAPG expressions were significantly up-regulated in GC compared to adjacent non-cancerous tissues by immunohistochemistry (IHC) and Western blotting. Besides, methods including stable transfection, quantitative real-time reverse transcription PCR, Western blotting, Matrigel invasion and wound-healing assays in vitro, were also conducted. IHC scores for Gal1 and NCAPG had a positive correlation in GC tissues. High Gal1 or NCAPG expression significantly correlated with poor prognosis in GC, and Gal1 combined with NCAPG had a synergetic effect on the prediction of GC prognosis. Gal1 overexpression in vitro enhanced NCAPG expression, cell migration, and invasion in SGC-7901 and HGC-27 cells. Simultaneous Gal1 overexpression and NCAPG knockdown in GC cells partly rescued the migrative and invasive abilities. Thus, Gal1 promoted GC invasion through increased NCAPG expression. The present study demonstrated the prognostic significance of the combination of Gal1 and NCAPG in GC for the first time.

First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma: a cost-effectiveness analysis

Background

The CheckMate-649 trial compared nivolumab plus chemotherapy (NC) with chemotherapy alone as first-line treatment for advanced gastric cancer (GC), gastroesophageal junction cancer (GEJC), and esophageal adenocarcinoma (EAC) and showed significant benefits to progression-free survival and overall survival. This study evaluated the lifetime cost-effectiveness of NC versus chemotherapy alone in patients with GC/GEJC/EAC from the perspective of the US payers.

Methods

A 10-year partitioned survival model was constructed to evaluate the cost-effectiveness of NC and chemotherapy alone and measured the health achievements in quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and life-years. Health states and transition probabilities were modeled from the survival data from the CheckMate-649 clinical trial (NCT02872116). Only direct medical costs were considered. One-way and probabilistic sensitivity analyses were conducted to assess the robustness of the results.

Results

On comparing the chemotherapy, we found that NC incurred substantial health costs, resulting in ICERs of $240,635.39/QALY, $434,182.32/QALY, and $386,715.63/QALY for the model of patients with programmed cell death-ligand 1 (PD-L1) combined positive score (CPS) ⩾5, PD-L1 CPS ⩾1, and all-treated patients, respectively. All ICERs were significantly higher than the willingness-to-pay threshold value of $150,000/QALY. The main influencing factors were the cost of nivolumab, the utility value of the progression-free disease, and the discount rate.

Conclusion

Compared with chemotherapy alone, NC may not be a cost-effective option for treating advanced GC, GEJC, and EAC in the United States.

Cost-effectiveness of nivolumab plus ipilimumab versus chemotherapy as first-line therapy in advanced non-small cell lung cancer

OBJECTIVES

First-line treatment with nivolumab plus ipilimumab has been shown to improve overall survival (OS) and progression-free survival (PFS) for patients with advanced non-small cell lung cancer (NSCLC). The current study evaluated the cost-effectiveness of nivolumab plus ipilimumab versus chemotherapy in advanced NSCLC from the perspective of Chinese healthcare system.

METHODS

A three state-transition Markov model was employed to evaluate the cost and effectiveness of nivolumab plus ipilimumab versus chemotherapy in the first-line treatment of advanced NSCLC. Key clinical data in the model were derived from Part 1 of the phase 3 CheckMate 227 trial (NCT02477826). Costs and utilities were obtained from published literatures. The main endpoints of the model were costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to assess the model uncertainty.

RESULTS

Nivolumab plus ipilimumab was associated with an increase in overall cost of $95,867.82 and improved effectiveness of 0.98 QALYs compared with chemotherapy, yielding an ICER of $97,676.24 per QALY. In one-way sensitivity analysis, the variables that had the greatest influence on the ICER were hazard ratio for OS and body weight. In probabilistic analysis, nivolumab plus ipilimumab had a 0% probability of being cost-effective at a willingness-to-pay (WTP) threshold of $37,663.26/QALY in China. However, the combination therapy would become cost-effective when the cost of nivolumab and ipilimumab were discounted by 65%.

CONCLUSION

First-line nivolumab plus ipilimumab treatment for advanced NSCLC was found to be not cost-effective compared with chemotherapy at a WTP threshold of $37,663.26/QALY in China.