Cost-Effectiveness of Frontline Treatment for Advanced Renal Cell Carcinoma in the Era of Immunotherapies

Pazopanib-induced trismus in a young male with metastatic renal cell carcinoma: a case report and literature review

The treatment landscape of advanced kidney cancer has radically changed over the years. Targeting tumor angiogenesis from historical cytokines to multi-tyrosine kinase inhibitors and recently the advent of immunotherapy resulted in a radical improvement in survival but presented substantial challenges in terms of toxicity management. In countries where the access to immune checkpoints inhibitors is still very limited, tyrosine-kinase inhibitors remain the optimal choice. The toxicity profile of these agents can influence both the clinician and the patient's preference for one molecule over another. This report describes the case of a young man treated with Pazopanib in a first-line setting for stage IV renal carcinoma who developed trismus under treatment. The occurrence of this off-target toxicity has made the patient ineligible for anti-angiogenic drugs. Although side effects of tyrosine kinase inhibitors seem manageable and reversible, some less known and unusual effects may evolve into severe and irreversible complications.

Cost-Effectiveness of the First Line Treatment Options For Metastatic Renal Cell Carcinoma in India

PURPOSE

Tyrosine kinase inhibitors such as sunitinib and pazopanib are the mainstay of treatment of metastatic renal cell carcinoma (mRCC) in India. However, pembrolizumab and nivolumab have shown significant improvement in the median progression-free survival and overall survival among patients with mRCC. In this study, we aimed to determine the cost-effectiveness of the first-line treatment options for the patients with mRCC in India.

METHODS

A Markov state-transition model was used to measure the lifetime costs and health outcomes associated with sunitinib, pazopanib, pembrolizumab/lenvatinib, and nivolumab/ipilimumab among patients with first-line mRCC. Incremental cost per quality-adjusted life-year (QALY) gained with a given treatment option was compared against the next best alternative and assessed for cost-effectiveness using a willingness to pay threshold of one-time per capita gross-domestic product of India. The parameter uncertainty was analyzed using the probabilistic sensitivity analysis.

RESULTS

We estimated the total lifetime cost per patient of ₹ 0.27 million ($3,706 US dollars [USD]), ₹ 0.35 million ($4,716 USD), ₹ 9.7 million ($131,858 USD), and ₹ 6.7 million ($90,481 USD) for the sunitinib, pazopanib, pembrolizumab/lenvatinib, and nivolumab/ipilimumab arms, respectively. Similarly, the mean QALYs lived per patient were 1.91, 1.86, 2.75, and 1.97, respectively. Sunitinib incurs an average cost of ₹ 143,269 ($1,939 USD) per QALY lived. Therefore, sunitinib at current reimbursement rates (₹ 10,000 per cycle) has a 94.6% probability of being cost-effective at a willingness to pay threshold of 1-time per capita gross-domestic product (₹ 168,300) in the Indian context.

CONCLUSION

Our findings support the current inclusion of sunitinib under India's publicly financed health insurance scheme.

Cost-effectiveness of immune checkpoint inhibition and targeted treatment in combination as adjuvant treatment of patient with BRAF-mutant advanced melanoma

BACKGROUND

Immune checkpoint inhibitors (ICIs) and targeted treatments have improved the health outcomes of patients with advanced melanoma. However, due to the high cost of novel therapies, it is crucial to evaluate their value by considering both effectiveness and cost. To compare the cost-effectiveness of these novel agents (atezolizumab-vemurafenib-cobimetinib, vemurafenib-plus-cobimetinib, dabrafenib-plus-trametinib, and encorafenib-plus-binimetinib) for first-line treatment of metastatic melanoma with the BRAF^V600 mutation.

METHODS

A patient-level model was developed to project the health outcomes of 4 strategies for patients with advanced melanoma. We estimated transition probabilities from the IMspire150 (ClinicalTrials.gov, NCT02908672), COMBI-AD (NCT01682083), and COLUMBUS (NCT01909453) trials using a parametric survival model. All health outcomes, including direct cost, quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER), were estimated from the US payer perspective. Lifetime cost, QALYs, life-years (LYs), and ICERs were calculated. Univariable and probabilistic sensitivity analyses were performed to test model robustness, along with multiple scenario analyses.

RESULTS

Of the 4 competing strategies, atezolizumab-vemurafenib-cobimetinib produced the best health outcomes, and the vemurafenib-cobimetinib strategy was the least expensive option. Atezolizumab-vemurafenib-cobimetinib, dabrafenib-plus-trametinib, and vemurafenib-cobimetinib formed the cost-effective frontier, indicating that the ordered ICERs were $325,113/QALYs for dabrafenib-plus-trametinib vs. vemurafenib-cobimetinib strategies and $2,247,500/QALYs for atezolizumab-vemurafenib-cobimetinib vs. dabrafenib-plus-trametinib strategies. Encorafenib-plus-binimetinib was dominated by the other 3 competing strategies. The drug price and first-line utility significantly influenced the model utcomes.

CONCLUSIONS

For BRAF-mutant advanced melanoma, the vemurafenib-cobimetinib strategy could be considered the most cost-effective treatment at the willingness-to-pay threshold of $150,000.

Economic evaluation of first-line nivolumab plus cabozantinib for advanced renal cell carcinoma in China

Background

In the Checkmate9ER trial, first-line treatment with nivolumab combined with cabozantinib (NI + CA) has shown efficacy for advanced renal cell carcinoma. This study aims to evaluate the impact of the health and economic outcomes of NI + CA in China.

Methods

Clinical efficacy data were derived from pivotal phase III CheckMate 9ER trial. A three-state partitioned survival model was established based on disease progression. Progression-free survival and overall survival of NI + CA vs. sunitinib were fitted with log-logistic and log-normal distributions, respectively. Mixture cure, non-mixture cure, and Royston/Parmar spline models were used to evaluate model robustness. The results derived the computational cost from the Chinese healthcare system perspective. The primary outcomes were quality-adjusted life-years (QALYs), total cost in US dollars, as well as incremental cost-effectiveness ratios (ICERs) at the willingness-to-pay threshold in China. One-way and probabilistic sensitivity analysis were also used to assess the robustness of the model.

Results

In the base-case analysis result, 0.86 additional QALYs could be obtained in the NI+CA (3.84 QALYs) versus the sunitinib strategy (2.97 QALYs). The ICER of NI+CA compared with the sunitinib strategy was US$292,945 per QALY. The ICER value in the NI+CA strategy was higher than the Chinese willingness-to-pay threshold of US$38,024 per QALY. Although NI+CA can improve long-term patient survival significantly over sunitinib in the treatment of advanced renal cell carcinoma, it is unlikely to be cost-effective due to high cost. The results of the one-way sensitivity analysis showed that drug cost, health utility value at the stage of disease progression, and subsequent treatment proportion had a greater impact on the stability of ICER values.

Conclusions

Nivolumab combined with cabozantinib can prolong the life of patients with advanced renal cell carcinoma and improve their quality of life, but there is a corresponding increase in medical cost. The NI + CA strategy is unlikely to be considered cost-effective in the treatment of advanced RCC from the perspective of Chinese healthcare system.

Cost-Effectiveness of Lenvatinib Plus Pembrolizumab or Everolimus as First-Line Treatment of Advanced Renal Cell Carcinoma

Background

In this study, compared to sunitinib as one of the available treatment options, we aimed to evaluate the cost-effectiveness of lenvatinib plus pembrolizumab or everolimus as first-line treatment for advanced renal cell carcinoma (RCC) patients in a Chinese health system setting.

Methods

A partitioned survival model was developed to simulate patient disease and death. Transition probabilities and adverse reaction data were obtained from the CLEAR trial. The utility value was derived from literature. Costs were based on the Chinese drug database and local charges. Sensitivity analyses and were performed to assess the robustness of the model. Outcomes were measured as quality-adjusted life-years (QALYs), cumulative cost (COST), and incremental cost-effectiveness ratio (ICER).

Results

The model predicted that the expected mean result in the lenvatinib plus pembrolizumab group (2.60 QALYs) was superior to that in the sunitinib group (2.13 QALYs) to obtain 0.47 QALYs, but the corresponding cost was 1,253,130 yuan greater, resulting in an ICER of 2,657,025 RMB/QALYs. Compared with the sunitinib group, the lenvatinib plus everolimus group (2.17 QALYs) gained 0.04 QALYs, with an additional cost of 32,851 yuan, resulting in an ICER of 77,6202 RMB/QALYs.

Conclusions

Lenvatinib plus pembrolizumab or everolimus has no economic advantage over sunitinib in treating advanced RCC in the Chinese healthcare system.