Cost-effectiveness analysis of selective first-line use of biologics for unresectable RAS wild-type left-sided metastatic colorectal cancer

Treatment of Metastatic Colorectal Cancer: ASCO Guideline

PURPOSE

To develop recommendations for treatment of patients with metastatic colorectal cancer (mCRC).

METHODS

ASCO convened an Expert Panel to conduct a systematic review of relevant studies and develop recommendations for clinical practice.

RESULTS

Five systematic reviews and 10 randomized controlled trials met the systematic review inclusion criteria.

RECOMMENDATIONS

Doublet chemotherapy should be offered, or triplet therapy may be offered to patients with previously untreated, initially unresectable mCRC, on the basis of included studies of chemotherapy in combination with anti-vascular endothelial growth factor antibodies. In the first-line setting, pembrolizumab is recommended for patients with mCRC and microsatellite instability-high or deficient mismatch repair tumors; chemotherapy and anti-epidermal growth factor receptor therapy is recommended for microsatellite stable or proficient mismatch repair left-sided treatment-naive RAS wild-type mCRC; chemotherapy and anti-vascular endothelial growth factor therapy is recommended for microsatellite stable or proficient mismatch repair RAS wild-type right-sided mCRC. Encorafenib plus cetuximab is recommended for patients with previously treated BRAF V600E-mutant mCRC that has progressed after at least one previous line of therapy. Cytoreductive surgery plus systemic chemotherapy may be recommended for selected patients with colorectal peritoneal metastases; however, the addition of hyperthermic intraperitoneal chemotherapy is not recommended. Stereotactic body radiation therapy may be recommended following systemic therapy for patients with oligometastases of the liver who are not considered candidates for resection. Selective internal radiation therapy is not routinely recommended for patients with unilobar or bilobar metastases of the liver. Perioperative chemotherapy or surgery alone should be offered to patients with mCRC who are candidates for potentially curative resection of liver metastases. Multidisciplinary team management and shared decision making are recommended. Qualifying statements with further details related to implementation of guideline recommendations are also included.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.

Cost-effectiveness Analysis of Monoclonal Antibodies in the First-line Treatment of RAS Wild-type Metastatic Colorectal Cancer: A Systematic Review

PURPOSE

First-line treatment with monoclonal antibodies (bevacizumab, cetuximab, and panitumumab) for RAS wild-type metastatic colorectal cancer (mCRC) has advanced. The costs of drugs targeted to mCRC are high. This systematic review aimed to summarize the cost-effectiveness of monoclonal antibodies in the first-line treatment of RAS wild-type mCRC.

METHODS

We searched 5 databases to find original-research cost-effectiveness analyses of monoclonal antibodies used in the first-line treatment of patients with RAS wild-type mCRC. Three reviewers independently evaluated all of the records to be screened.

FINDINGS

A total of 15 articles, 12 cost-effectiveness analyses, and 3 cost-utility analyses were identified. The reporting of identified articles was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. They were assigned to 1 of 6 categories based on the combination of the intervention and control groups, the most common of which was cetuximab + chemotherapy versus bevacizumab + chemotherapy. The results of the cost-effectiveness analyses may have varied because of the differences in settings, such as country, study population, RAS mutation status, efficacy data, and model structure, in which each study was conducted.

IMPLICATIONS

Although treatment with monoclonal antibodies has demonstrated efficacy in terms of life-years gained and progression-free survival, the most cost-effective treatment among monoclonal antibodies remains controversial; however, most of the studies that compared a monoclonal antibody + chemotherapy versus chemotherapy alone reported that chemotherapy alone was a cost-effective strategy. Future studies are needed to evaluate the cost-effectiveness of treating patients with mCRC using biomarker-driven precision medicine.

Cost-Effectiveness of Anti-Epidermal Growth Factor Receptor Therapy Versus Bevacizumab in KRAS Wild-Type (WT), Pan-RAS WT, and Pan-RAS WT Left-Sided Metastatic Colorectal Cancer

Objectives

We aimed to compare the economic value of chemotherapy plus anti-epidermal growth factor receptor (anti-EGFR) monoclonal antibody (mAb) against chemotherapy with bevacizumab (Bev, an anti-vascular endothelial growth factor mAb) as first-line treatment in KRAS wild-type (WT), pan-RAS WT and pan-RAS WT left-sided metastatic colorectal cancer (mCRC) patients from the Hong Kong societal perspective.

Materials and Methods

We developed Markov models and 10-year horizon to estimate costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of chemotherapy plus anti-EGFR therapy against chemotherapy plus Bev in KRAS WT, pan-RAS WT, and pan-RAS WT left-sided mCRC. We considered two times of the local gross domestic product per capita (GDPpc) as the willingness-to-pay (WTP) threshold (2× GDPpc; US$97,832).

Results

Adding anti-EGFR mAb to chemotherapy provides additional 0.24 (95% confidence interval [CI] 0.19-0.29), 0.32 (95% CI 0.27-0.37), and 0.57 (95% CI 0.49-0.63) QALY compared to adding Bev in KRAS WT, pan-RAS WT, and left-sided pan-RAS WT mCRC populations respectively. The corresponding ICER is US$106,847 (95% CI 87,806-134,523), US$88,565 (95% CI 75,678-105,871), US$76,537 (95% CI 67,794-87,917) per QALY gained, respectively.

Conclusions

Anti-EGFR therapy is more cost-effective than Bev as a first-line targeted therapy in left-sided pan-RAS WT and pan-RAS WT, with ICER <US$100,000/QALY, compared to KRAS WT mCRC population.