Southeast Radiation Oncology Group, PA, Charlotte, NC, USA.
Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
Oral Oncol. 2017 Nov;74:49-55. doi: 10.1016/j.oraloncology.2017.09.017. Epub 2017 Sep 23.
Nivolumab is the first drug to demonstrate a survival benefit for platinum-refractory recurrent or metastatic head and neck cancer. We performed a cost-utility analysis to assess the economic value of nivolumab as compared to alternative standard agents in this context.
Using data from the CheckMate 141 trial, we constructed a Markov simulation model from the US payer's perspective to evaluate the cost-effectiveness of nivolumab compared to physician choice of either cetuximab, methotrexate or docetaxel. Alternative strategies considered included: single-agent cetuximab, methotrexate or docetaxel, or first testing for PD-L1 to select for nivolumab. Costs were extracted from Medicare and utilities from the literature and CheckMate. Probabilistic sensitivity analysis (PSA) was used to evaluate parameter uncertainty. $100,000/QALY was the primary threshold for cost-effectiveness.
When comparing nivolumab to the standard arm of CheckMate, nivolumab demonstrated an incremental cost-effectiveness ratio (ICER) of $140,672/QALY. When comparing standard therapies, methotrexate was the most cost-effective with similar results for docetaxel. Nivolumab was cost-effective compared to single-agent cetuximab (ICER $89,786/QALY). Treatment selection by PD-L1 immunohistochemistry did not markedly improve the cost-effectiveness of nivolumab. Factors likely to positively impact the cost-effectiveness of nivolumab include better baseline quality-of-life, poor tolerability of standard treatments and/or a lower cost of nivolumab.
Nivolumab is preferred to single-agent cetuximab but requires a willingness-to-pay of at least $150,000/QALY to be considered cost-effective when compared to docetaxel or methotrexate. Selection by PD-L1 does not markedly improve the cost-effectiveness of nivolumab. This informs patient selection and clinical care-path development.
纳武利尤单抗是首个在铂类难治性复发性或转移性头颈部癌中显示生存获益的药物。我们进行了一项成本效用分析，以评估在这种情况下纳武利尤单抗与其他标准药物相比的经济价值。
使用 CheckMate 141 试验的数据，我们从美国支付者的角度构建了一个马尔可夫模拟模型，以评估与医生选择西妥昔单抗、甲氨蝶呤或多西他赛相比，纳武利尤单抗的成本效益。考虑的替代策略包括：单药西妥昔单抗、甲氨蝶呤或多西他赛，或首先进行 PD-L1 检测以选择纳武利尤单抗。成本从医疗保险中提取，效用从文献和 CheckMate 中提取。概率敏感性分析（PSA）用于评估参数不确定性。10 万美元/QALY 是成本效益的主要阈值。
当将纳武利尤单抗与 CheckMate 的标准组进行比较时，纳武利尤单抗的增量成本效益比（ICER）为 140672 美元/QALY。当比较标准治疗时，甲氨蝶呤是最具成本效益的，多西他赛的结果相似。与单药西妥昔单抗相比，纳武利尤单抗具有成本效益（ICER 为 89786 美元/QALY）。PD-L1 免疫组织化学检测的治疗选择并没有显著改善纳武利尤单抗的成本效益。可能对纳武利尤单抗的成本效益产生积极影响的因素包括更好的基线生活质量、标准治疗的耐受性差和/或纳武利尤单抗的成本较低。
与单药西妥昔单抗相比，纳武利尤单抗更受青睐，但与多西他赛或甲氨蝶呤相比，需要至少 15 万美元/QALY 的支付意愿才能被认为具有成本效益。通过 PD-L1 选择并不能显著改善纳武利尤单抗的成本效益。这为患者选择和临床护理路径的发展提供了信息。
