Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Cancer Med. 2023 Apr;12(7):8838-8850. doi: 10.1002/cam4.5632. Epub 2023 Jan 18.
BACKGROUND: Researchers have not simultaneously compared the cost-effectiveness of six immunotherapies with chemotherapy for advanced non-small cell lung cancer. This study evaluated the cost-effectiveness across different programmed death-ligand 1 (PD-L1) levels. METHODS: A Markov model with lifetime horizon was created for seven regimens: pembrolizumab plus chemotherapy (pembro-chemo), nivolumab plus ipilimumab (nivo-ipi), nivolumab, ipilimumab plus chemotherapy (nivo-ipi-chemo), atezolizumab plus chemotherapy (atezo-chemo), atezolizumab, bevacizumab plus chemotherapy (atezo-beva-chemo), single-agent pembrolizumab, and chemotherapy alone. Input parameters were derived from trial data, a network meta-analysis, and other literature. We conducted the analysis from the perspective of US health care sector. RESULTS: For all patients without considering PD-L1 expression, the incremental cost-effectiveness ratio (ICER) of pembro-chemo versus chemotherapy was $183,299 per quality-adjusted life year (QALY). The preferred regimens based on ICERs differed by PD-L1 levels. For patients with PD-L1 ≥50%, pembrolizumab versus chemotherapy and pembro-chemo versus pembrolizumab resulted in ICERs of $96,189 and $198,913 per QALY, respectively. The other strategies were dominated. For patients with PD-L1 of 1%-49%, the ICER of pembro-chemo comparing to chemotherapy was $218,159 per QALY. The other regimens were dominated by pembro-chemo. For patients with PD-L1 <1%, nivo-ipi versus chemotherapy and nivo-ipi-chemo versus nivo-ipi resulted in ICERs of $161,277 and $881,975 per QALY, and the other regimens were dominated strategies. At the willingness-to-pay threshold of $150,000 per QALY, pembrolizumab had 87% and pembro-chemo had 1% probabilities being cost-effective in patients with PD-L1 ≥50% and 1%-49%, respectively. Nivo-ipi had a 34% probability being cost-effective in patients with PD-L1 <1%. CONCLUSIONS: The PD-L1 level should be incorporated into treatment decision-making. Our findings suggest that first-line pembrolizumab, pembro-chemo, and nivo-ipi are the preferred strategies for patients with PD-L1 ≥50%, 1%-49%, and <1%, respectively.
背景：研究人员尚未同时比较六种免疫疗法与化疗治疗晚期非小细胞肺癌的成本效益。本研究评估了不同程序性死亡配体 1（PD-L1）水平下的成本效益。
方法：为七种方案建立了一个具有终生视野的马尔可夫模型：帕博利珠单抗联合化疗（pembro-chemo）、纳武利尤单抗联合伊匹单抗（nivo-ipi）、纳武利尤单抗、伊匹单抗联合化疗（nivo-ipi-chemo）、阿替利珠单抗联合化疗（atezo-chemo）、阿替利珠单抗、贝伐珠单抗联合化疗（atezo-beva-chemo）、单药帕博利珠单抗和单纯化疗。输入参数来自试验数据、网络荟萃分析和其他文献。我们从美国医疗保健部门的角度进行了分析。
结果：对于所有不考虑 PD-L1 表达的患者，pembro-chemo 与化疗相比，每质量调整生命年（QALY）的增量成本效益比（ICER）为 183,299 美元。基于 ICER 的首选方案因 PD-L1 水平而异。对于 PD-L1≥50%的患者，帕博利珠单抗与化疗和 pembro-chemo 与帕博利珠单抗相比，ICER 分别为每 QALY 96,189 美元和 198,913 美元。其他策略被支配。对于 PD-L1 为 1%-49%的患者，pembro-chemo 与化疗相比，ICER 为每 QALY 218,159 美元。其他方案均被 pembro-chemo 所主导。对于 PD-L1<1%的患者，纳武利尤单抗联合化疗与纳武利尤单抗联合化疗相比，ICER 分别为每 QALY 161,277 美元和 881,975 美元，其他方案均被纳武利尤单抗联合化疗所主导。在每 QALY 150,000 美元的意愿支付阈值下，帕博利珠单抗在 PD-L1≥50%的患者中具有 87%的概率具有成本效益，而 pembro-chemo 具有 1%的概率具有成本效益。纳武利尤单抗在 PD-L1<1%的患者中具有 34%的概率具有成本效益。
结论：PD-L1 水平应纳入治疗决策。我们的研究结果表明，一线帕博利珠单抗、pembro-chemo 和 nivo-ipi 分别是 PD-L1≥50%、1%-49%和<1%患者的首选策略。
JAMA Netw Open. 2025-5-1
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