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Gao X, Cao K, Yang J, Liu L, Gao L. Recent advances in nanotechnology for programmed death ligand 1-targeted cancer theranostics. J Mater Chem B 2024; 12:3191-3208. [PMID: 38497358 DOI: 10.1039/d3tb02787b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Programmed cell death ligand 1 (PD-L1)/programmed cell death protein 1 (PD-1) checkpoint inhibitor-based immunotherapy has provided a unique and potent weapon against cancer in clinical practice. The likelihood of achieving beneficial effects from PD-L1/PD-1 immune checkpoint blockade (ICB) therapy is clinically assessed by detecting PD-L1 expression through invasive tissue biopsies. However, PD-L1 expression is susceptible to tumor heterogeneity and dynamic response to ICB therapy. Moreover, currently, anti-PD-L1 immunotherapy still faces challenges of the low targeting efficiency of antibody drugs and the risk of immune-associated adverse events. To overcome these issues, advanced nanotechnology has been developed for the purpose of quantitative, non-invasive, and dynamic analyses of PD-L1, and to enhance the efficiency of ICB therapy. In this review, we first introduce the nanoprobe-assisted in vitro/in vivo modalities for the selective and sensitive analysis of PD-L1 during the diagnostic and therapeutic process. On the other hand, the feasibility of fabricating diverse functional nanocarriers as smart delivery systems for precisely targeted delivery of PD-L1 immune checkpoint inhibitors and combined therapies is highlighted. Finally, the current challenges are discussed and future perspectives for PD-L1-targeted cancer theranostics in preclinical research and clinical settings are proposed.
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Affiliation(s)
- Xinxin Gao
- Department of Chemistry, College of Chemistry and Life Science, Beijing University of Technology, Beijing, 100124, China.
| | - Kai Cao
- Department of Chemistry, College of Chemistry and Life Science, Beijing University of Technology, Beijing, 100124, China.
| | - Jingru Yang
- Department of Chemistry, College of Chemistry and Life Science, Beijing University of Technology, Beijing, 100124, China.
| | - Linhong Liu
- Department of Chemistry, College of Chemistry and Life Science, Beijing University of Technology, Beijing, 100124, China.
| | - Liang Gao
- Department of Chemistry, College of Chemistry and Life Science, Beijing University of Technology, Beijing, 100124, China.
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Zheng Z, Fang L, Cai H. First-line treatment with durvalumab plus chemotherapy versus chemotherapy alone for metastatic non-small-cell lung cancer in the USA: a cost-effectiveness analysis. BMJ Open 2023; 13:e076383. [PMID: 38101853 PMCID: PMC10729208 DOI: 10.1136/bmjopen-2023-076383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/18/2023] [Indexed: 12/17/2023] Open
Abstract
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.
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Affiliation(s)
- Zhiwei Zheng
- Department of Pharmacy, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Ling Fang
- Department of Pharmacy, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Hongfu Cai
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
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Zhang H, Li L, Feng L, Zhou Z, Zhang X, Feng J, Liu Q. Biomarkers-Based Cost-Effectiveness of Toripalimab Plus Chemotherapy for Patients with Treatment-Naive Advanced Non-Small Cell Lung Cancer. Adv Ther 2023; 40:4945-4956. [PMID: 37715852 DOI: 10.1007/s12325-023-02679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/05/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION This study examined the cost-effectiveness of first-line toripalimab plus chemotherapy (TC) for patients with advanced non-small cell lung cancer (NSCLC), excluding patients with nonsquamous NSCLC and EGFR/ALK mutations. It further analyzed the cost-effectiveness of this strategy in biomarker-based subgroups, all within the context of the Chinese healthcare system. METHODS Eighteen Markov models with 21-day Markov cycle lengths and 30-year time horizons were constructed in this study. Clinical effectiveness data were derived from the CHOICE-01 trial. Health state utilities and costs data were obtained from various sources. The primary outputs were the calculation of incremental cost-effectiveness ratios (ICERs), which were then compared to a willingness-to-pay (WTP) threshold of $17,961 per quality-adjusted life-year (QALY). This comparison was used to determine the treatment that offered greater cost-effectiveness. To account for uncertainty in the model, sensitivity analyses were conducted. RESULTS For the overall patient population, the estimated ICER between first-line TC and placebo plus chemotherapy (PC) was $9445/QALY, significantly lower than the WTP threshold used in the model. In subgroups based on pathologic types, first-line TC had an ICER of $16,757/QALY for patients with nonsquamous NSCLC, slightly below the WTP threshold; first-line TC demonstrated dominance in patients with squamous NSCLC, indicating both better effectiveness and lower costs compared to first-line PC. In biomarkers-based subgroups, first-line TC was dominant over first-line PC in the subgroups with programmed cell death ligand 1 (PD-L1) expression ≥ 50% and SMARCA4 mutations. Moreover, first-line TC had ICERs lower than the WTP threshold in other subgroups, except for the subgroup with RB1 mutations. Sensitivity analysis confirmed the robustness of these findings. CONCLUSION From the perspective of the Chinese healthcare system, this study's findings suggested that first-line TC represents a cost-effective strategy for patients with advanced NSCLC. However, the cost-effectiveness of first-line TC varied across different subgroups when considering predictive biomarkers.
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Affiliation(s)
- Huixian Zhang
- Department of Clinical Pharmacy, Affiliated Hospital of Jining Medical University, Jining, China
| | - Lanfang Li
- Department of Clinical Pharmacy, Affiliated Hospital of Jining Medical University, Jining, China
| | - Lei Feng
- Department of Clinical Pharmacy, Affiliated Hospital of Jining Medical University, Jining, China
| | - Zhen Zhou
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Xin Zhang
- Department of Clinical Pharmacy, Affiliated Hospital of Jining Medical University, Jining, China
| | - Jianbo Feng
- Department of Oncology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Qiao Liu
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
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Wang L, Yang Z, Guo F, Chen Y, Wei J, Dai X, Zhang X. Research progress of biomarkers in the prediction of anti-PD-1/PD-L1 immunotherapeutic efficiency in lung cancer. Front Immunol 2023; 14:1227797. [PMID: 37465684 PMCID: PMC10351040 DOI: 10.3389/fimmu.2023.1227797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023] Open
Abstract
Currently, anti-PD-1/PD-L1 immunotherapy using immune checkpoint inhibitors is widely used in the treatment of multiple cancer types including lung cancer, which is a leading cause of cancer death in the world. However, only a limited proportion of lung cancer patients will benefit from anti-PD-1/PD-L1 therapy. Therefore, it is of importance to predict the response to immunotherapy for the precision treatment of patients. Although the expression of PD-L1 and tumor mutation burden (TMB) are commonly used to predict the clinical response of anti-PD-1/PD-L1 therapy, other factors such as tumor-specific genes, dMMR/MSI, and gut microbiome are also promising predictors for immunotherapy in lung cancer. Furthermore, invasive peripheral blood biomarkers including blood DNA-related biomarkers (e.g., ctDNA and bTMB), blood cell-related biomarkers (e.g., immune cells and TCR), and other blood-related biomarkers (e.g., soluble PD-L1 and cytokines) were utilized to predict the immunotherapeutic response. In this review, the current achievements of anti-PD-1/PD-L1 therapy and the potential biomarkers for the prediction of anti-PD-1/PD-L1 immunotherapy in lung cancer treatment were summarized and discussed.
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Affiliation(s)
- Luyao Wang
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Zongxing Yang
- Department of Clinical Laboratory, First Hospital of Jilin University, Changchun, China
| | - Fucheng Guo
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Yurong Chen
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Jiarui Wei
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Xiangpeng Dai
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Xiaoling Zhang
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
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Jiang X, Chen J, Zheng M, Jia H. Cost-effectiveness analysis of durvalumab as a maintenance treatment for patients with locally advanced, unresectable, stage Ⅲ nsclc in china. PLoS One 2022; 17:e0270118. [PMID: 35749385 PMCID: PMC9231800 DOI: 10.1371/journal.pone.0270118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 06/06/2022] [Indexed: 11/24/2022] Open
Abstract
Objective The aim of this study was to evaluate the cost-effectiveness of durvalumab compared with Best supportive care (BSC) after chemoradiotherapy in patients with stage III non-small cell lung cancer from healthcare system perspective in China. Methods A dynamic state transition model was adopted to simulate life time, direct medical costs and QALYs. In the base case scenario, for patients with unresectable, stage Ⅲ non-small cell lung cancer whose disease has not progressed after platinum-based chemoradiation therapy, the treatment group would use durvalumab whereas the control group would use BSC. Clinical data and health utility were derived from the patient-level data of Asian ethnicity in the PACIFIC trial. Cost of drug acquisition, follow-up, medical service, inspection, terminal care and adverse event treatment were considered in this model. The cost of durvalumab was calculated based on retail prices and Patient Assistance Program. Results In the base case, the durvalumab group yielded an additional 2.60 LYs and 2.37QALYs (discounted), causing an additional cost of 0.459 million RMB and 0.109 million RMB without and with PAP, so the ICER was 193,898 RMB/QALY and 46,093.12 RMB/QALY respectively. Conclusions This study demonstrated that durvalumab can improve the survival of patients with unresectable, stage Ⅲ non-small cell lung cancer whose disease has not progressed after platinum-based chemoradiation therapy and would be a cost-effective option compared with BSC at a willingness to pay (WTP) threshold of 212676 RMB (three times GDP per capita of China in 2019).
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Affiliation(s)
- Xiaotong Jiang
- Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinyu Chen
- China Health Economics Association, Beijing, China
- National Center for Medicine and Health Technology Assessment, Beijing, China
- * E-mail:
| | - Min Zheng
- Shenyang Pharmaceutical University, Shenyang, China
| | - Hanxue Jia
- Shenyang Pharmaceutical University, Shenyang, China
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Cost-effectiveness Analyses of Durvalumab Consolidation Therapy Versus no Consolidation Therapy After Chemoradiotherapy in Stage-III NSCLC. Lung Cancer 2022; 170:11-19. [DOI: 10.1016/j.lungcan.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 12/25/2022]
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Dunlop W, van Keep M, Elroy P, Perez ID, Ouwens MJNM, Sarbajna T, Zhang Y, Greystoke A. Cost Effectiveness of Durvalumab in Unresectable Stage III NSCLC: 4-Year Survival Update and Model Validation from a UK Healthcare Perspective. PHARMACOECONOMICS - OPEN 2022; 6:241-252. [PMID: 34532842 PMCID: PMC8864051 DOI: 10.1007/s41669-021-00301-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 04/20/2023]
Abstract
BACKGROUND In the phase III PACIFIC study, durvalumab improved survival versus placebo in patients with unresectable stage III non-small-cell lung cancer (NSCLC) whose disease had not progressed after platinum-based concurrent chemoradiotherapy. The appraisal by the UK's National Institute for Health and Care Excellence (NICE) included a cost-effectiveness analysis based on an early data readout from PACIFIC [March 2018 data cut-off (DCO); median follow-up duration 25.2 months; range 0.2-43.1]. Uncertainties regarding long-term survival outcomes with durvalumab led to some challenges in estimating the cost effectiveness of this therapy. OBJECTIVE Here, we validate the survival extrapolations used in the original company base-case analysis by benchmarking them against updated survival data from the 4-year follow-up analysis of PACIFIC (i.e. approximately 4 years after the last patient was randomised; March 2020 DCO; median follow-up duration 34.2 months; range 0.2-64.9). Moreover, we update the original analysis with these more mature survival data to examine the consistency of key economic outputs with the original analysis. METHODS The original analysis used a semi-Markov (state-transition) approach and was based on patients whose tumours expressed programmed cell death-ligand 1 on ≥ 1% of cells (to reflect the European licence for durvalumab). We benchmarked the survival extrapolations used in the original company base-case analysis against survival data from the 4-year follow-up of PACIFIC and updated the cost-effectiveness analysis with these more mature survival data. Early deaths avoided by the adoption of durvalumab into the UK Cancer Drugs Fund (CDF) in March 2019 were estimated using the 4-year follow-up survival data and an assumed uptake of 125 patients/year (lower estimate) and 367 patients/year (higher estimate). RESULTS The original company base-case analysis had a good visual fit with the observed overall survival (OS) distribution for the durvalumab arm and accurately predicted the 48-month OS rate (predicted 55%; observed 55%); by comparison, the fit was less precise for the placebo arm, for which the analysis underestimated the 48-month OS rate (predicted 32%; observed 38%). In the updated company base-case analysis, durvalumab yielded 2.51 incremental quality-adjusted life-years (QALYs) (- 0.43 vs. the original company base-case analysis), corresponding to an incremental cost-effectiveness ratio of £22,665/QALY (+£3298 vs. the original analysis), which falls within the upper bound of NICE's willingness-to-pay threshold (£30,000/QALY gained). We estimate that between 31 and 91 early patient deaths may have been avoided by the adoption of durvalumab into the CDF. CONCLUSIONS These findings reinforce the patient benefit observed with durvalumab in unresectable stage III NSCLC, support the routine use and cost effectiveness of this therapy, and demonstrate how appropriate modelling can inform the early adoption of therapies by payers to achieve patient benefit.
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Affiliation(s)
- Will Dunlop
- AstraZeneca Global Health Economics & Payer Evidence (Oncology), 1 Francis Crick Avenue, Cambridge Biomedical Campus, Cambridge, CB2 0AA, UK.
| | | | - Peter Elroy
- BresMed Netherlands, Utrecht, The Netherlands
| | | | | | - Tina Sarbajna
- AstraZeneca Global Health Economics & Payer Evidence (Oncology), 1 Francis Crick Avenue, Cambridge Biomedical Campus, Cambridge, CB2 0AA, UK
| | | | - Alastair Greystoke
- Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Yang T, Xiong Y, Zeng Y, Wang Y, Zeng J, Liu J, Xu S, Li LS. Current status of immunotherapy for non-small cell lung cancer. Front Pharmacol 2022; 13:989461. [PMID: 36313314 PMCID: PMC9606217 DOI: 10.3389/fphar.2022.989461] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/30/2022] [Indexed: 02/05/2023] Open
Abstract
Nowadays, lung cancer is still the deadliest oncological disease in the world. Among them, non-small cell lung cancer (NSCLC) accounts for 80%∼85% of all lung cancers, and its 5-year survival rate is less than 15%, making the situation critical. In the past decades, despite some clinical advances in conventional treatments, the overall survival rate of NSCLC is still not optimistic due to its unique physiological conditions and the frequent occurrence of tumor escape. In recent years, immunotherapy has become a new hot spot in lung cancer research, including antibody therapy and cell therapy, which have been developed and utilized one after another, especially immune checkpoint inhibitor (ICI). These approaches have effectively improved the overall survival rate and objective response rate of NSCLC patients by enhancing the immune capacity of the body and targeting tumor cells more effectively, which is more specific and less toxic compared with conventional chemotherapy, and providing more strategies for NSCLC treatment. In this paper, we reviewed the relevant targets, clinical progress and adverse reaction in monoclonal antibodies, antibody-drug conjugates, ICI, bispecific antibodies, T-cell receptor engineered T cell therapy (TCR-T), Chimeric antigen receptor T-cell immunotherapy (CAR-T), and also report on their combination therapy from the immune-related background to provide better NSCLC treatment and prospective.
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Fitzpatrick O, Naidoo J. Immunotherapy for Stage III NSCLC: Durvalumab and Beyond. LUNG CANCER (AUCKLAND, N.Z.) 2021; 12:123-131. [PMID: 34754256 PMCID: PMC8572112 DOI: 10.2147/lctt.s305466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
Immunocheckpoint inhibitors (ICIs) have altered the treatment landscape of a wide range of malignancies, including non-small cell lung cancer (NSCLC). This class of agents inhibits the interaction between PD1 and PDL1, and was shown to be efficacious in the landmark PACIFIC trial with 1 year of maintenance durvalumab (anti-PDL1 antibody). This trial demonstrated that its use as a consolidation treatment given after definitive chemoradiotherapy improved progression free survival and overall survival compared to standard-of-care treatment. In this review, we discuss both clinical trial and real-world data that have been published since PACIFIC that support the use of durvalumab for stage III unresectable NSCLC. In addition, we highlight specific populations that may require special considerations for the use of durvalumab in this setting, such as oncogene-addicted NSCLC, the toxicity of immunotherapy, and future directions in ICI research in stage III NSCLC.
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Affiliation(s)
- Orla Fitzpatrick
- Department of Oncology, Beaumont Hospital, RCSI University of Health Sciences, Dublin, Ireland
| | - Jarushka Naidoo
- Department of Oncology, Beaumont Hospital, RCSI University of Health Sciences, Dublin, Ireland
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, 21231, USA
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Chen X, Yang Z, Xiang G, Gu L, Qi Z, Wan B, Lu Y, Chang F, Zhu Y. Durvalumab consolidation therapy in patients with stage III non-small cell lung cancer after concurrent chemoradiation: a China-based cost-effectiveness analysis. Expert Rev Pharmacoecon Outcomes Res 2021; 22:647-654. [PMID: 34643129 DOI: 10.1080/14737167.2022.1993062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of durvalumab in post-chemoradiotherapy patients with unresectable stage III NSCLC from the Chinese healthcare system perspective. METHODS The study developed a five-health state Markov model to evaluate the cost-effectiveness of durvalumab consolidation therapy in post-chemoradiotherapy patients based on the PACIFIC clinical trial. Sensitivity and scenario analyses were performed to evaluate the model uncertainty. RESULTS Durvalumab consolidation therapy provided an additional 1.22 quality-adjusted life-years (QALYs), with an incremental cost of $24,397 compared to no consolidation therapy in unselected patients. Durvalumab consolidation therapy was cost-effective as it yielded an incremental cost-effectiveness ratio (ICER) of $20,000 per QALY gained at a willingness-to-pay (WTP) threshold of $31,494 per QALY. In the patient subgroup with PD-L1-expressing tumors (≥1%), durvalumab was associated with an ICER of $33,058/QALY, resulting in a slight skewing away from the given cost-effectiveness threshold. The sensitivity analysis showed that ICERs were most sensitive to the cost of durvalumab, the cost of pembrolizumab, and the body weight of patients, regardless of PD-L1 expression selection. CONCLUSION Durvalumab consolidation therapy is likely to be cost-effective in China, which indicates that expensive immunotherapies can gain clinical benefits at a justifiable cost in developing countries as well.
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Affiliation(s)
- Xuan Chen
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Zhiguang Yang
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China.,Department of Healthcare Reform, National Health Commission of the People's Republic of China, Beijing, China
| | - Guiyuan Xiang
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Lingna Gu
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Ziheng Qi
- Nanjing Foreign Language School, Nanjing, China
| | - Bin Wan
- Department of Health Insurance Management, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yun Lu
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Feng Chang
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Yumei Zhu
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
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