A systematic review of economic evaluations in second and later lines of therapy for the treatment of non-small cell lung cancer

Cost-effectiveness analyses of targeted therapy and immunotherapy for advanced non-small cell lung cancer in the United States: a systematic review

Introduction: Mutation-targeting and immuno-oncology drugs are revolutionizing the treatment of advanced non-small cell lung cancer (NSCLC). Cost-effectiveness analyses (CEA) of these drugs have been conducted using various analytical methods and cost-effectiveness thresholds. This systematic review provides a comprehensive summary of the available evidence.Area covered: PubMed, Embase, and Cochrane Library were used to select for CEA of targeted therapies for NSCLC in the United States published between 2008 and 2020. Among the 28 included studies, a majority were published from 2017 to 2020 (n = 18) and more than half targeted non-squamous NSCLC (n = 15). The most frequently evaluated therapy was pembrolizumab (n = 11), followed by bevacizumab (n = 8) and erlotinib (n = 4). After 2009, all included studies applied $100,000 or more thresholds. Thresholds of studies supported by industry (median = $150,000) were more distributed than those of studies supported by nonprofits (median = $100,000).Expert commentary: Medications of interest have changed and are individualized to particular mutations. The cost-effectiveness thresholds varied among sponsors but generally trended to increase over time. This review provides an overview of the available cost-effectiveness findings for stakeholders and contributes to evidence-based practice.

A systematic review of pharmacoeconomic evaluations of erlotinib in the first-line treatment of advanced non-small cell lung cancer

OBJECTIVE

To review and assess the quality of the available evidence on the cost-effectiveness of erlotinib in the first-line treatment of advanced non-small cell lung cancer (NSCLC).

METHODS

A systematic review was conducted to identify full-text original economic evaluations of erlotinib in the first-line treatment of advanced NSCLC written in English and published from the year 2000 onwards. Study characteristics and results were recorded and compared. The quality of the studies was assessed by the Quality of Health Economic Studies (QHES) questionnaire.

RESULTS

Eleven out of 130 papers were chosen for this review. Comparative regimens consisted of a best supportive care, reverse strategy, bevacizumab, cisplatin plus pemetrexed, carboplatin plus gemcitabine or gefitinib. The methods most used in these studies were modeling and sensitivity analysis and cost-effectiveness analysis. All of the studies evaluated direct costs and used quality-adjusted life-year (QALY) and life-years gained (LYG) as outcome, with 3% and 3.5% discount rate. The studies assigned ICER that ranged from dominant to I$305,510.31/QALY and from I$31,209.55/LYG to I$66,540.20/LYG. Based on the willingness to pay threshold, seven studies concluded that erlotinib was cost-effective, two studies showed that erlotinib was cost-effective on specific patients with certain conditions, and two studies comparing erlotinib with reverse strategy did not find a difference in cost-effectiveness. The high quality of these studies was confirmed using the QHES tool: the mean score was 75.77 out of 100 (SD 9.38).

CONCLUSION

Most of these high-quality studies suggested that erlotinib was cost-effective in the first-line treatment of advanced NSCLC.

Synergistic anticancer effects of andrographolide and paclitaxel against A549 NSCLC cells

CONTEXT

Paclitaxel (PTX) is widely used in chemotherapy for cancer treatment; however, it has some serious side effects. Andrographolide (Andro) is a potential cancer therapeutic agent isolated from Andrographis paniculata (Burm. f.) Nees (Acanthaceae).

OBJECTIVE

The objective of this study is to evaluate the effects of PTX combined with Andro against A549 cells.

MATERIALS AND METHODS

The effects of 24-48 h treatment with 0.48-60.75 nM PTX and 5.10-328.0 μM Andro on cellular proliferation, apoptosis, cell cycle and intracellular reactive oxygen species (ROS) were determined by sulphorhodamine B assay, Annexin V-FITC/PI apoptosis detection, PI staining and ROS assay, respectively. Synergy was determined using combination index. The antitumour efficacy of 20 mg/kg PTX with 100 mg/kg Andro was studied in a xenograft murine model.

RESULTS

IC₅₀ value of the PTX combined with Andro against A549 cells was 0.5-7.4 nM, which was significantly lower than that of PTX (15.9 nM). PTX with 10 μM Andro caused (1.22-1.27)-fold apoptosis and 1.7-fold ROS accumulation compared with PTX alone. N-Acetylcysteine, a ROS scavenger, blocked this synergy in vitro. In contrast, G2/M phase cell cycle arrest resulting from PTX was not potentiated by Andro. Moreover, PTX in combination with Andro inhibited the growth of A549 transplanted tumours by 98%.

DISCUSSION AND CONCLUSION

The results indicate that the combination of PTX and Andro exert significant synergistic anticancer effect on A549 cells in vitro and in vivo. The synergy may be the result of the accumulation of ROS. The combination of Andro and PTX represents a potential strategy for the treatment of A549 cells.

The role of docetaxel in the treatment of non-small cell lung cancer lung cancer: an update

INTRODUCTION

Non-small cell lung cancer lung cancer (NSCLC) is a devastating disease, with poor prognosis for patients with metastatic disease. The management of these patients has evolved during the past decade, challenging the role of cytotoxic chemotherapy as the only available treatment option. Nevertheless, chemotherapy still retains a dominant position for the majority of both treatment naïve and pretreated patients. Among the chemotherapeutic agents, docetaxel is one of the most commonly used in 1st and subsequent treatment lines, even in the current era of precision medicine. Areas covered: We searched Medline, Embase, Scopus and Cochrane Library for randomized phase III trials that evaluated docetaxel in various clinical settings of NSCLC and for meta-analyses of such trials and we present all relevant data regarding the pharmacology and clinical use of docetaxel in NSCLC. Expert commentary: Despite its diminishing role, docetaxel in combination with novel targeted agents remains an important option of the therapeutic armamentarium in advanced NSCLC.

The Melanoma MAICare Framework: A Microsimulation Model for the Assessment of Individualized Cancer Care

Recently, new but expensive treatments have become available for metastatic melanoma. These improve survival, but in view of the limited funds available, cost-effectiveness needs to be evaluated. Most cancer cost-effectiveness models are based on the observed clinical events such as recurrence- free and overall survival. Times at which events are recorded depend not only on the effectiveness of treatment but also on the timing of examinations and the types of tests performed. Our objective was to construct a microsimulation model framework that describes the melanoma disease process using a description of underlying tumor growth as well as its interaction with diagnostics, treatments, and surveillance. The framework should allow for exploration of the impact of simultaneously altering curative treatment approaches in different phases of the disease as well as altering diagnostics. The developed framework consists of two components, namely, the disease model and the clinical management module. The disease model consists of a tumor level, describing growth and metastasis of the tumor, and a patient level, describing clinically observed states, such as recurrence and death. The clinical management module consists of the care patients receive. This module interacts with the disease process, influencing the rate of transition between tumor growth states at the tumor level and the rate of detecting a recurrence at the patient level. We describe the framework as the required input and the model output. Furthermore, we illustrate model calibration using registry data and data from the literature.

Theoretical Foundations and Practical Applications of Within-Cycle Correction Methods

Background. Modeling guidelines recommend applying a half-cycle correction (HCC) to outcomes from discrete-time state-transition models (DTSTMs). However, there is still no consensus on why and how to perform the correction. The objective was to provide theoretical foundations for HCC and to compare (both mathematically and numerically) the performance of different correction methods in reducing errors in outcomes from DTSTMs. Methods. We defined 7 methods from the field of numerical integration: Riemann sum of rectangles (left, midpoint, right), trapezoids, life-table, and Simpson’s 1/3rd and 3/8th rules. We applied these methods to a standard 3-state disease progression Markov chain to evaluate the cost-effectiveness of a hypothetical intervention. We solved the discrete- and continuous-time (our gold standard) versions of the model analytically and derived expressions for various outcomes including discounted quality-adjusted life-years, discounted costs, and incremental cost-effectiveness ratios. Results. The standard HCC method gave the same results as the trapezoidal rule and life-table method. We found situations where applying the standard HCC can do more harm than good. Compared with the gold standard, all correction methods resulted in approximation errors. Contrary to conventional wisdom, the errors need not cancel each other out or become insignificant when incremental outcomes are calculated. We found that a wrong decision can be made with a less accurate method. The performance of each correction method vastly improved when a shorter cycle length was selected; Simpson’s 1/3rd rule was the fastest method to converge to the gold standard. Conclusion. Cumulative outcomes in DTSTMs are prone to errors that can be reduced with more accurate methods like Simpson’s rules. We clarified several misconceptions and provided recommendations and algorithms for practical implementation of these methods.

Medical care costs incurred by patients with smoking-related non-small cell lung cancer treated at the National Cancer Institute of Mexico

BACKGROUND

Smoking is a public health problem in Mexico and worldwide; its economic impact on developing countries has not been well documented. The aim of this study was to assess the direct medical costs attributable to smoking incurred by lung cancer patients treated at the National Cancer Institute of Mexico (INCan).

METHODS

The study was conducted at INCan in 2009. We carried out a cost of illness (COI) methodology, using data derived from an expert panel consensus and from medical chart review. A panel of experts developed a diagnostic-therapeutic guide that combined the hospital patient pathways and the infrastructure, human resources, technology, and services provided by the medical units at INCan. Cost estimates in Mexican pesos were adjusted by inflation and converted into US Dollars using the 2013 FIX exchange rate for foreign transactions (1 USD = 13.06 Mexican pesos).

RESULTS

A 297 incident cases diagnosed with any type of lung cancer were analyzed. According to clinical stage, the costs per patient were 13,456; 35,648; 106,186; and 144,555 USD, for lung cancer stages I, II, III, and IV respectively. The weighted average annual cost/patient was and 139,801 USD and the average annual cost/patient that was attributable to smoking was 92,269 USD. This cost was independent of the clinical stage, with stage IV representing 96% of the annual cost. The total annual cost of smoking-related lung cancer at INCan was 19,969,781 USD.

CONCLUSIONS

The medical care costs of lung cancer attributable to smoking represent a high cost both for INCan and the Mexican health sector. These costs could be reduced if all provisions established in the Framework Convention of Tobacco Control of the World Health Organization were implemented in Mexico.

A systematic review of the cost-effectiveness of targeted therapies for metastatic non-small cell lung cancer (NSCLC)

Background

Non-small cell lung cancer (NSCLC) imposes a substantial burden on patients, health care systems and society due to increasing incidence and poor survival rates. In recent years, advances in the treatment of metastatic NSCLC have resulted from the introduction of targeted therapies. However, the application of these new agents increases treatment costs considerably. The objective of this article is to review the economic evidence of targeted therapies in metastatic NSCLC.

Methods

A systematic literature review was conducted to identify cost-effectiveness (CE) as well as cost-utility studies. Medline, Embase, SciSearch, Cochrane, and 9 other databases were searched from 2000 through April 2013 (including update) for full-text publications. The quality of the studies was assessed via the validated Quality of Health Economic Studies (QHES) instrument.

Results

Nineteen studies (including update) involving the MoAb bevacizumab and the Tyrosine-kinase inhibitors erlotinib and gefitinib met all inclusion criteria. The majority of studies analyzed the CE of first-line maintenance and second-line treatment with erlotinib. Five studies dealt with bevacizumab in first-line regimes. Gefitinib and pharmacogenomic profiling were each covered by only two studies. Furthermore, the available evidence was of only fair quality.

Conclusion

First-line maintenance treatment with erlotinib compared to Best Supportive Care (BSC) can be considered cost-effective. In comparison to docetaxel, erlotinib is likely to be cost-effective in subsequent treatment regimens as well. The insights for bevacizumab are miscellaneous. There are findings that gefitinib is cost-effective in first- and second-line treatment, however, based on only two studies. The role of pharmacogenomic testing needs to be evaluated. Therefore, future research should improve the available evidence and consider pharmacogenomic profiling as specified by the European Medicines Agency. Upcoming agents like crizotinib and afatinib need to be analyzed as well.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2466-14-192) contains supplementary material, which is available to authorized users.

Targeted therapy for lung cancer: reviewing the cost and its effect on treatment decisions

SUMMARY 

Novel targeted therapies that improve outcome in advanced lung cancer should be adopted. However, given the high costs of targeted therapies and companion molecular testing, the affordability and cost–effectiveness of novel agents are of growing relevance in policy decisions. Incremental cost–effectiveness ratios in excess of US$200,000 per quality-adjusted life year have been described in published literature evaluating currently approved agents. Differing willingness to pay thresholds in different countries determine which therapies will be funded in a given healthcare system. Cost-containment strategies to address costs of molecular testing and drug acquisition need to be implemented. Drug manufacturers, healthcare payers and oncologists have a shared responsibility to ensure that novel therapies are affordable and accessible to patients in need.

A non-linear beta-binomial regression model for mapping EORTC QLQ- C30 to the EQ-5D-3L in lung cancer patients: a comparison with existing approaches

BACKGROUND

The performance of the Beta Binomial (BB) model is compared with several existing models for mapping the EORTC QLQ-C30 (QLQ-C30) on to the EQ-5D-3L using data from lung cancer trials.

METHODS

Data from 2 separate non small cell lung cancer clinical trials (TOPICAL and SOCCAR) are used to develop and validate the BB model. Comparisons with Linear, TOBIT, Quantile, Quadratic and CLAD models are carried out. The mean prediction error, R(2), proportion predicted outside the valid range, clinical interpretation of coefficients, model fit and estimation of Quality Adjusted Life Years (QALY) are reported and compared. Monte-Carlo simulation is also used.

RESULTS

The Beta-Binomial regression model performed 'best' among all models. For TOPICAL and SOCCAR trials, respectively, residual mean square error (RMSE) was 0.09 and 0.11; R(2) was 0.75 and 0.71; observed vs. predicted means were 0.612 vs. 0.608 and 0.750 vs. 0.749. Mean difference in QALY's (observed vs. predicted) were 0.051 vs. 0.053 and 0.164 vs. 0.162 for TOPICAL and SOCCAR respectively. Models tested on independent data show simulated 95% confidence from the BB model containing the observed mean more often (77% and 59% for TOPICAL and SOCCAR respectively) compared to the other models. All algorithms over-predict at poorer health states but the BB model was relatively better, particularly for the SOCCAR data.

CONCLUSION

The BB model may offer superior predictive properties amongst mapping algorithms considered and may be more useful when predicting EQ-5D-3L at poorer health states. We recommend the algorithm derived from the TOPICAL data due to better predictive properties and less uncertainty.

Critical appraisal of pemetrexed in the treatment of NSCLC and metastatic pulmonary nodules

Pemetrexed, a new multitarget antifolate antineoplastic agent, has significantly improved the overall survival in nonsquamous non-small-cell lung cancer patients. Presently, pemetrexed is recommended for first line treatment in combination with platinum derivatives, for second line treatment as a single agent and, more recently, as maintenance treatment after first line chemotherapy. In this article we critically appraise the status of pemetrexed including pharmacodynamics, pharmacokinetics, toxicity, and the cost effectiveness of pemetrexed, as well as the predictive biomarkers for pemetrexed based chemotherapy.