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Li M, Garrison LP. Incorporating Real Option Value in Valuing Innovation: A Way Forward. PHARMACOECONOMICS 2024:10.1007/s40273-024-01352-4. [PMID: 38310635 DOI: 10.1007/s40273-024-01352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Considerable progress has been made in defining and measuring the real option value (ROV) of medical technologies. However, questions remain on how to estimate (1) ROV outside of life-extending oncology interventions; (2) the impact of ROV on costs and cost effectiveness; and (3) potential interactions between ROV and other elements of value. METHODS We developed a 'minimal modeling' approach for estimating the size of ROV that does not require constructing a full, formal cost-effectiveness model. We proposed a qualitative approach to assessing the level of uncertainty in the ROV estimate. We examined the potential impact of ROV on the incremental cost-effectiveness ratio as well as on the potential interactions between ROV and other elements of value. Lastly, we developed and presented a 15-item checklist for reporting ROV in value assessment. RESULTS The minimal modeling approach uses estimates on the efficacy of current treatment and potential future innovation, as well as success rate and length of new treatment development, and can be applied to all types of ROV across disease areas. ROV may interact with the conventional value, value of hope, productivity effects, and insurance value. The impact of ROV on cost effectiveness can be evaluated via threshold analysis. CONCLUSION The minimal modeling approach and the checklist developed in this paper simplifies and standardizes the estimation and reporting of ROV in value assessment. Systematically including and reporting ROV in value assessment will minimize bias and improve transparency, which will help improve the credibility of ROV research and acceptance by stakeholders.
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Affiliation(s)
- Meng Li
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA.
| | - Louis P Garrison
- The CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
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Özdemir D, Büssgen M. Effectiveness and cost-effectiveness of combination therapy versus monotherapy in malignant melanoma. J Pharm Policy Pract 2023; 16:106. [PMID: 37749653 PMCID: PMC10521452 DOI: 10.1186/s40545-023-00611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 09/16/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Until 2010, stage III or IV malignant melanoma (MM) had a poor prognosis. The discovery of immune checkpoint inhibitors (ICIs) in 2011 changed the treatment landscape. Promising results in patient survival with a checkpoint inhibitor prompted research into combination therapies. In 2016, the first combination therapy has been approved as first-line therapy for advanced MM. OBJECTIVE The aim of this work is to investigate to what extent combination therapy is (cost-)effective compared to monotherapy in stage III or IV MM. METHODS A systematic literature search was performed (Web of Science, PubMed, PubPharm, EconLit, and Cochrane Library); searching for publications published over the past decade that examine the cost-effectiveness in terms of cost/QALY and the effectiveness in terms of survival and response of combination therapy in comparison to monotherapy in stage III or IV MM patients. RESULTS A total of 11 randomized controlled trials (RCTs) and five cost-utility analyses met our inclusion criteria. Nine clinical trials demonstrated superiority of combination therapy over monotherapy. The combination of B-rapidly accelerated fibrosarcoma (BRAF) protein and mitogen-activated kinase (MEK) protein inhibitors is not cost-effective in any country. Three analyses demonstrate the cost-effectiveness of combination therapy with ICI compared to monotherapy. CONCLUSION Combination therapy is more effective compared to monotherapy. While combined ICIs are cost-effective compared to monotherapy, this is not the case for the combination of BRAF and MEK inhibitors.
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Affiliation(s)
| | - Melanie Büssgen
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany.
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Lopez-Vinueza C, Urrego-Reyes J, Gutierrez FRS, Wurcel V, Zhang S, Jiang S, Jiang R, Zambrano Harvey A, Dhankhar P, Sawhney B, Baluni G, Jain S, Bhadra D. Cost-Effectiveness of Pembrolizumab as an Adjuvant Treatment in Colombia for Melanoma Patients with Lymph Node Involvement After Complete Resection. Adv Ther 2023; 40:2836-2854. [PMID: 37129772 PMCID: PMC10219874 DOI: 10.1007/s12325-023-02484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/24/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION The KEYNOTE-054 trial found that adjuvant treatment with pembrolizumab improved recurrence-free survival versus placebo in completely resected high-risk stage III melanoma patients. We assessed the cost-effectiveness of adjuvant pembrolizumab in Colombia compared with watchful waiting, a widely used strategy despite the high risk of recurrence with surgery alone. METHODS A four-health state [recurrence-free (RF), locoregional recurrence (LR), distant metastases (DM), and death) Markov model was developed to assess the lifetime medical costs and outcomes (3% annual discount), along with cost-effectiveness ratios (ICERs). The transitions from the RF and LR states were modeled using KEYNOTE-054 data, and those from the DM state were modeled using data from the KEYNOTE-006 trial and a network meta-analysis of advanced treatments received after adjuvant pembrolizumab and watchful waiting. The health state utilities were derived from KEYNOTE-054 Euro-QoL data and literature. Costs are expressed in 2021 Colombian pesos (COP). RESULTS Over a 46-year time horizon, patients on adjuvant pembrolizumab and watchful waiting were estimated to gain 9.69 and 7.56 quality-adjusted life-years (QALYs), 10.83 and 8.65 life-years (LYs), and incur costs of COP 663,595,726 and COP 563,237,206, respectively. The proportion of LYs spent in RF state was 84.63% for pembrolizumab and 72.13% for watchful waiting, yielding lower subsequent treatment, disease management, and terminal care costs for pembrolizumab. Adjuvant pembrolizumab improved survival by 2.18 LYs and 2.13 QALYs versus watchful waiting. The ICER per QALY was COP 47,081,917, primarily driven by recurrence rates and advanced melanoma treatments. The deterministic sensitivity analysis results were robust and consistent across various reasonable inputs and alternative scenarios. At a willingness-to-pay threshold of COP 69,150,201 per QALY, the probability of pembrolizumab being cost-effective was 65.70%. CONCLUSION Pembrolizumab is cost-effective as an adjuvant treatment compared to watchful waiting among patients with high-risk stage III melanoma after complete resection in Colombia.
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Li SN, Wan X, Peng LB, Li YM, Li JH. Cost-effectiveness of immune checkpoint inhibition and targeted treatment in combination as adjuvant treatment of patient with BRAF-mutant advanced melanoma. BMC Health Serv Res 2023; 23:49. [PMID: 36653848 PMCID: PMC9847087 DOI: 10.1186/s12913-023-09058-7] [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: 06/20/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) and targeted treatments have improved the health outcomes of patients with advanced melanoma. However, due to the high cost of novel therapies, it is crucial to evaluate their value by considering both effectiveness and cost. To compare the cost-effectiveness of these novel agents (atezolizumab-vemurafenib-cobimetinib, vemurafenib-plus-cobimetinib, dabrafenib-plus-trametinib, and encorafenib-plus-binimetinib) for first-line treatment of metastatic melanoma with the BRAFV600 mutation. METHODS A patient-level model was developed to project the health outcomes of 4 strategies for patients with advanced melanoma. We estimated transition probabilities from the IMspire150 (ClinicalTrials.gov, NCT02908672), COMBI-AD (NCT01682083), and COLUMBUS (NCT01909453) trials using a parametric survival model. All health outcomes, including direct cost, quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER), were estimated from the US payer perspective. Lifetime cost, QALYs, life-years (LYs), and ICERs were calculated. Univariable and probabilistic sensitivity analyses were performed to test model robustness, along with multiple scenario analyses. RESULTS Of the 4 competing strategies, atezolizumab-vemurafenib-cobimetinib produced the best health outcomes, and the vemurafenib-cobimetinib strategy was the least expensive option. Atezolizumab-vemurafenib-cobimetinib, dabrafenib-plus-trametinib, and vemurafenib-cobimetinib formed the cost-effective frontier, indicating that the ordered ICERs were $325,113/QALYs for dabrafenib-plus-trametinib vs. vemurafenib-cobimetinib strategies and $2,247,500/QALYs for atezolizumab-vemurafenib-cobimetinib vs. dabrafenib-plus-trametinib strategies. Encorafenib-plus-binimetinib was dominated by the other 3 competing strategies. The drug price and first-line utility significantly influenced the model utcomes. CONCLUSIONS For BRAF-mutant advanced melanoma, the vemurafenib-cobimetinib strategy could be considered the most cost-effective treatment at the willingness-to-pay threshold of $150,000.
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Affiliation(s)
- Si Ni Li
- grid.216417.70000 0001 0379 7164Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011 China ,grid.10784.3a0000 0004 1937 0482The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hongkong, China ,grid.11835.3e0000 0004 1936 9262School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Xiaomin Wan
- grid.216417.70000 0001 0379 7164Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 China
| | - Liu Bao Peng
- grid.216417.70000 0001 0379 7164Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 China
| | - Ya Min Li
- grid.216417.70000 0001 0379 7164Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011 China
| | - Jian He Li
- grid.216417.70000 0001 0379 7164Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 China ,grid.216417.70000 0001 0379 7164Present address: The Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Changsha, 410011 Hunan China
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Baker T, Johnson H, Kotapati S, Moshyk A, Hamilton M, Kurt M, Paly VF. Cost-Utility of Nivolumab Plus Ipilimumab in First-Line Treatment of Advanced Melanoma in the United States: An Analysis Using Long-Term Overall Survival Data from Checkmate 067. PHARMACOECONOMICS - OPEN 2022; 6:697-710. [PMID: 36006606 PMCID: PMC9440167 DOI: 10.1007/s41669-022-00348-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the cost-utility of nivolumab plus ipilimumab (NIVO + IPI) versus other first-line therapies for advanced melanoma in the United States (US) from the third-party payer perspective. METHODS This analysis estimated total expected life-years (LYs), quality-adjusted LYs (QALYs), and costs for first-line treatments of advanced melanoma during a 30-year time horizon using indirect treatment comparisons based on time-varying hazard ratios (HRs) and a three-state partitioned survival model. Overall survival (OS) and progression-free survival reference curves were extrapolated based on 5-year follow-up from the phase III Checkmate 067 trial (NCT01844505). Comparators of NIVO + IPI were NIVO, IPI, pembrolizumab, dabrafenib plus trametinib, encorafenib plus binimetinib (ENCO + BINI), and vemurafenib plus cobimetinib. Drug acquisition costs, treatment administration costs, follow-up time, subsequent therapy data, and adverse event frequencies were obtained from published sources. Utility weights were estimated from Checkmate 067, which compared NIVO + IPI or NIVO monotherapy with IPI monotherapy as first-line therapy in advanced melanoma. A 3% annual discount rate was applied to costs and outcomes. Sensitivity scenarios for BRAF-mutant subgroups were conducted. RESULTS NIVO + IPI was estimated to generate the longest OS and the highest total costs versus all comparators, accruing 6.99 LYs, 5.70 QALYs, and $469,469 over the 30-year time horizon. The incremental cost utility of NIVO + IPI versus comparators ranged from $2130 per QALY (versus ENCO + BINI) to $76,169 per QALY (versus NIVO). In all base-case and most sensitivity analyses, the incremental cost-utility ratios for NIVO + IPI were below $100,000 per QALY. CONCLUSIONS NIVO + IPI is estimated to be a life-extending and cost-effective treatment versus other therapies in the US, with base-case incremental cost-utility ratios below $100,000 per QALY.
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Affiliation(s)
- Timothy Baker
- Global Health Economics, Outcomes Research and Epidemiology, ICON plc, ICON Clinical Research, 4131 Parklake Ave., Suite 600, Raleigh, NC, 27612, USA.
| | | | | | | | | | - Murat Kurt
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Victoria Federico Paly
- Global Health Economics, Outcomes Research and Epidemiology, ICON plc, ICON Clinical Research, 731Arbor Way, Suite 100, Blue Bell, PA, 19422, USA
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Wahler S, Müller A, Fuchs S, von der Schulenburg JM. Adjuvant treatment of high-risk melanoma - cost-effectiveness analysis of treatment options for BRAF 600 mutated tumors. HEALTH ECONOMICS REVIEW 2022; 12:8. [PMID: 35059911 PMCID: PMC8780795 DOI: 10.1186/s13561-021-00347-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/08/2021] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Until recently, adjuvant treatment options for higher stage resectable cutaneous melanoma were limited. Two studies with a similar set-up, published 2017, led to registration of targeted therapy for BRAF-mutated melanoma with dabrafenib and trametinib as well as of the immunotherapy with nivolumab irrespective of BRAF-mutation status. Both options have been positively assessed in Germany since 2019 for the adjuvant treatment of BRAF-V600 mutated melanoma. This study evaluates the cost-effectiveness of both treatment alternatives (dabrafenib/trametinib and nivolumab) against observation as a comparative therapy from the perspective of German statutory health funds. METHODS Partitioned survival analysis based on published survival curves for the investigated treatment options was used for a cohort model for the health states relapse free survival, progression, and death. The partitioned survival analysis approach was based on the survival curves published for the key studies Combi AD and Checkmate-238. The modelling was performed for the remaining lifetime for a cohort with starting age of 50 years. For extrapolation of the survival curves, convergence to general population mortality rates was assumed in the long term. Within the progression state, a Markov model uses three levels of progressions (locoregional, distant metastases with 1st and 2nd line treatment). Lifetime treatment costs were calculated using the German statutory health fund reimbursement scheme. Quality adjusted life years (QALYs) associated to the health states were adopted from previously published utilities based on the Combi AD study. RESULTS The treatment with dabrafenib/trametinib yielded an increase in quality adjusted life years of 2.28 QALY at an incremental lifetime cost of 86.1 T€. The incremental cost effectiveness ratio of dabrafenib/trametinib and nivolumab was comparable with 37.8 T€/QALY and 30.0 T€/QALY, respectively. Several sensitivity analyses proved the result to be insensitive. General model parameters like discount rate and length of the time horizon had stronger influence. For nivolumab, the model showed lower discounted lifetime costs (118.1 T€) compared to dabrafenib/trametinib [155.1 T€], associated with a lower gain in QALYs (1.64 years) compared to observation. CONCLUSION Both dabrafenib/trametinib and nivolumab turned out to be cost effective within internationally accepted Incremental Cost Effectiveness Ratio (ICER) thresholds with comparable cost effectiveness ratios.
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Affiliation(s)
- Steffen Wahler
- St. Bernward GmbH, Friedrich-Kirsten-Straße 40, D-22391, Hamburg, Germany.
| | - Alfred Müller
- Analytic Services GmbH, Jahnstr. 34c, D-80469, Munich, Germany
| | - Sabine Fuchs
- Novartis Pharma GmbH, Roonstr. 25, D-90429, Nuremberg, Germany
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Narsipur N, Bulla S, Yoo C, Do B, Tran K, Gu D, Zhong L, Wilson L. Cost-effectiveness of adding daratumumab or bortezomib to lenalidomide plus dexamethasone for newly diagnosed multiple myeloma. J Manag Care Spec Pharm 2021; 27:1691-1702. [PMID: 34818089 PMCID: PMC10391124 DOI: 10.18553/jmcp.2021.27.12.1691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Multiple myeloma survival rates are steadily increasing due to availability of new drug classes used in combination with corticosteroids and chemotherapy. The latest treatments are daratumumab or bortezomib in combination therapy with lenalidomide and dexamethasone (Rd). Daratumumab, a CD38-targeted, human IgG1k monoclonal antibody, and bortezomib, a proteasome inhibitor, are both approved as regimens for transplant-ineligible relapsed/refractory multiple myeloma (RRMM). There have been cost-effectiveness analyses for daratumumab and bortezomib use in RRMM, but there are limited data regarding cost-effectiveness for daratumumab or bortezomib use in newly diagnosed multiple myeloma patients who are ineligible for stem cell transplantation. OBJECTIVE: To compare the cost-effectiveness of 3 separate regimens-(1) daratumumab, lenalidomide, and dexamethasone triple therapy (DRd); (2) bortezomib and lenalidomide plus dexamethasone triple therapy (VRd); and (3) lenalidomide plus dexamethasone (Rd)-in patients with multiple myeloma ineligible for autologous stem cell transplant. METHODS: A 2-state Markov model was developed using a US health system perspective and lifetime time horizon. Transition probabilities were calculated from the latest progression-free survival data reported in two phase 3 randomized controlled trials-MAIA and SWOG S0777-and extrapolated using a Weibull distribution based on the Hoyle Henley method. National data sources were used to obtain costs in 2019 US dollars, discounted by 3%. Health state utilities from available literature were applied to each health state. Utility decrements for adverse events were individualized in each choice branch with utility decrement weighted by the percentage of patients who experienced the adverse event in the MAIA and SWOG S0777 trials. We assumed a treatment would be cost-effective at a willingness to pay (WTP) of $150,000 per progression-free quality-adjusted life-year ($/PFQALY). One-way and probabilistic sensitivity analyses were conducted. RESULTS: Rd standard therapy had the lowest overall cost at $329,867, followed by VRd at $385,434 and DRd with the highest overall total cost at $626,900. Rd was estimated to result in the least amount (1.24) of PFQALYs, followed by VRd at 1.35 PFQALYs and DRd at 1.52 PFQALYs. With a WTP threshold of $150,000 per PFQALY, VRd was not cost-effective compared with Rd standard therapy, with an incremental cost-effectiveness ratio (ICER) of $530,256 per PFQALY. DRd was not cost-effective compared with VRd (ICER = $1,396,318 per PFQALY), nor as compared with Rd standard therapy (ICER = $1060,832). One-way sensitivity analysis showed that our model was sensitive to cost of DRd, VRd, and Rd drugs. Probabilistic sensitivity analysis showed that only at a WTP threshold of $550,000 was VRd cost-effective for 40% of iterations. There were no reasonable WTP thresholds, up to $800,00, where DRd became more cost-effective than VRd. CONCLUSIONS: This study is the first analysis to directly compare the cost-effectiveness of 3 acceptable chemotherapy treatment regimens for patients with multiple myeloma ineligible for autologous stem cell transplant. Neither DRd nor VRd triple therapy were found to be cost-effective vs Rd. Further cost-effectiveness analyses that include overall survival data for daratumumab and bortezomib triple therapies are needed to demonstrate an ICER in QALYs. DISCLOSURES: No funding was received for this study. At the time of this study, Narsipur was a UCSF-Actelion Clinical Research and Medical Communications Fellow, unrelated to this study. The other authors have nothing to disclose.
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Affiliation(s)
- Nihal Narsipur
- UCSF-Actelion Clinical Research and Medical Communications Fellow, University of California, San Francisco
| | - Sabrina Bulla
- PharmD Candidates 2021, University of California, San Francisco
| | - Connie Yoo
- PharmD Candidates 2021, University of California, San Francisco
| | - Brenda Do
- PharmD Candidates 2021, University of California, San Francisco
| | - Kyle Tran
- PharmD Candidates 2021, University of California, San Francisco
| | - Dian Gu
- Institute for Health and Aging, University of California, San Francisco
| | | | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco
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Gil-Rojas Y, Lasalvia P, Hernández F, Castañeda-Cardona C, Castrillón-Correa J, Herrera D, Rosselli D. Cost-Effectiveness of the Dabrafenib Schedule in Combination With Trametinib Compared With Other Targeted Therapies, Immunotherapy, and Dacarbazine for the Treatment of Unresectable or Metastatic Melanoma With BRAFV600 Mutation in Colombia. Value Health Reg Issues 2021; 26:182-190. [PMID: 34673349 DOI: 10.1016/j.vhri.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/06/2021] [Accepted: 04/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Advanced melanoma accounts for 4% of malignant skin tumors, and approximately 80% of deaths are attributed to it. The most frequent mutation of the RAF gene is BRAFV600, which has been associated with a worse prognosis. The objective of the research was to evaluate the cost-effectiveness of the combined regimen of dabrafenib plus trametinib (D + T) compared with other targeted therapies, immunotherapy, and dacarbazine for the treatment of unresectable/metastatic melanoma with BRAFV600 mutation from the perspective of the Colombian health system. METHODS A partitioned survival model with 3 states (progression-free survival, progression, and death) was used to evaluate the cost-effectiveness for a time horizon of 20 years. Owing to the perspective of the analysis, only direct medical costs were taken into account. The efficacy of the evaluated treatment and the comparators were measured in terms of overall survival and progression-free survival. All costs were expressed in Colombian pesos as of 2018, and outcomes and costs were discounted at 5% annually. Two analysis scenarios were considered, one in which only monitoring and follow-up costs were included in the progression phase and another in which costs of acquisition of possible treatment sequences were also included. RESULTS In the first scenario (without postprogression medication costs), the combined D + T regimen was a dominant alternative to vemurafenib + cobimetinib but was not a cost-effective option compared with vemurafenib, nivolumab, ipilimumab, nivolumab + ipilimumab, pembrolizumab, and dacarbazine. In the second scenario (with drug costs in postprogression), D + T was dominant compared with vemurafenib + cobimetinib and cost-effective compared with nivolumab and pembrolizumab. Compared with other schemes, the incremental cost-effectiveness ratio was above the threshold of 3 gross domestic product per capita. Probabilistic sensitivity analyses showed that a willingness-to-pay threshold of Col$56 484 300 (US$19 108) per quality-adjusted life-year would not be reached at the current price of schema in Colombia. CONCLUSIONS The combined scheme could be a cost-effective and even a cost-saving alternative to vemurafenib + cobimetinib, nivolumab, and pembrolizumab if the costs associated with the use of other medications are taken into account after progression to the first line of treatment. Compared with the other comparators, it produces a greater number of quality-adjusted life-years, but the incremental cost-effectiveness ratio is above that of the willingness to pay.
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Affiliation(s)
- Yaneth Gil-Rojas
- Department of Economic Studies, Neuroeconomix, Bogotá, Colombia.
| | | | | | | | | | | | - Diego Rosselli
- Faculty of Medicine, Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Hospital San Ignacio, Bogotá, Colombia
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Zhou T, Sheng Y, Guan H, Meng R, Wang Z. Cost-Effectiveness Analysis of Vedolizumab Compared With Infliximab in Anti-TNF-α-Naïve Patients With Moderate-to-Severe Ulcerative Colitis in China. Front Public Health 2021; 9:704889. [PMID: 34490187 PMCID: PMC8417715 DOI: 10.3389/fpubh.2021.704889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/23/2021] [Indexed: 12/22/2022] Open
Abstract
Objective: To evaluate the cost effectiveness of vedolizumab vs. infliximab in the treatment of anti-tumor necrosis factor-alpha (TNF-α)-naïve patients with moderate-to-severe active ulcerative colitis (UC) in China. Methods: The costs and effectiveness of vedolizumab and infliximab in the treatment of anti-TNF-α naïve patients with moderate-to-severe active UC were compared using a hybrid decision tree model and a Markov model. From the perspective of the Chinese healthcare system, this study simulated the lifetime health benefits [quality-adjusted life-years (QALYs)] and costs (USD) for patients with UC from the induction phase to the maintenance phase, with an annual discount rate of 5%. The clinical efficacy and transition probability data were based on a previously published network meta-analysis. The health utility, surgical risk, biologic drug discontinuation rate, and mortality were derived from previous literature and the Chinese statistical yearbook. The cost data were based on China's drug purchase and biding platform and the results of a survey sent to clinicians in 18 tertiary hospitals. One-way and probabilistic sensitivity analyses (PSAs) were performed to validate the robustness of the models' assumptions and specific parameter estimates. Results: The results of the base-case analyses showed that compared with infliximab, vedolizumab led to a gain of 0.25 QALYs (9.56 vs. 9.31 QALYs) and was less expensive by $7,349 ($180,138 vs. 187,487), indicating that the use of vedolizumab was a dominant strategy. The results of one-way sensitivity analyses suggested that the annual discount rate and health-state costs had the greatest impact, but the results were otherwise consistent with those of the base-case analyses. The PSAs suggested that vedolizumab had a 98.6% probability of being effective at a threshold of 3 times the gross domestic product (GDP) per capita in China in 2020. Conclusion: Compared with infliximab, vedolizumab appears to be a more cost-effective option in the treatment of anti-TNF-α naïve adult patients with moderate-to-severe, active UC in China.
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Affiliation(s)
- Ting Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Yanan Sheng
- Medical Affairs, Takeda (China) International Trading Company, Beijing, China
| | - Haijing Guan
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China Center for Health Economic Research, Peking University, Beijing, China
| | - Rui Meng
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Zijing Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
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Paul E, Konidaris G, Cope S, Chen CI, Keeping S, Xu Y, Atsou K, Ayers D, Guyot P, Sasane M, Mojebi A, Kuznik A. Cost-effectiveness analysis of cemiplimab vs pembrolizumab for treatment of advanced cutaneous squamous cell carcinoma. J Manag Care Spec Pharm 2021; 27:1513-1525. [PMID: 34351214 PMCID: PMC10394223 DOI: 10.18553/jmcp.2021.21164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Most cutaneous squamous cell carcinomas (CSCCs) can be treated with surgical excision or radiation; however, approximately 1% of patients develop advanced disease. In 2018, the FDA approved cemiplimab-rwlc as the first programmed cell death-1 (PD-1) monoclonal antibody for the treatment of patients with metastatic CSCC or locally advanced CSCC who are not candidates for curative surgery or curative radiation. In June 2020, pembrolizumab, another PD-1 monoclonal antibody, was approved for the treatment of patients with recurrent or metastatic CSCC who are not candidates for curative surgery or radiation. We previously reported on the cost-effectiveness of cemiplimab vs historical standard of care for the treatment of advanced CSCC from a US perspective. OBJECTIVE: To estimate the cost-effectiveness of cemiplimab vs pembrolizumab for patients with advanced CSCC in the United States. METHODS: A "partitioned survival" framework was used to assess the cost-effectiveness of cemiplimab vs pembrolizumab. Clinical inputs were based on the most recent data cut of the phase 2 trials for cemiplimab (EMPOWER-CSCC-1; NCT02760498) and pembrolizumab (KEYNOTE-629). Progression-free survival and overall survival were extrapolated using parametric models until all patients had progressed or died. Health state utilities were derived from data collected in the EMPOWER-CSCC-1 trial. Costs included drug acquisition, drug administration, disease management, terminal care, and adverse events and were based on published 2020 US list prices. To assess model uncertainty, 1-way sensitivity and probabilistic sensitivity analyses (PSA) were conducted, alongside scenario analyses evaluating key modeling assumptions. RESULTS: In the base case, cemiplimab resulted in an incremental gain of 3.44 life-years (discounted) and incremental cost-effectiveness ratio (ICER) of $130,329 per quality-adjusted life-year (QALY) vs pembrolizumab. At a willingness-to-pay threshold of $150,000/QALY, PSA indicated a 71% probability that cemiplimab is cost-effective when compared with pembrolizumab. Scenario analysis resulted in ICERs ranging from $115,909 to $187,374. CONCLUSIONS: Findings suggest that cemiplimab is a cost-effective treatment for patients with advanced CSCC, compared with pembrolizumab. These results should be interpreted cautiously in the absence of head-to-head trials; however, in the absence of such data, these results can be used to inform health care decisions over resource allocation. DISCLOSURES: This study was supported by Regeneron Pharmaceuticals, Inc., and Sanofi. Paul, Cope, Keeping, Mojebi, and Ayers are employees of PRECISIONheor, which received funding to produce this work. Chen, Kuznik, and Xu are employees and stockholders of Regeneron Pharmaceuticals, Inc. Sasane is an employee and stockholder of Sanofi, Inc. Konidaris, Atsou, and Guyot are employees of Sanofi, Inc. The authors were responsible for all content and editorial decisions and received no honoraria related to the development of this publication.
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Affiliation(s)
- Eleanor Paul
- PRECISIONheor, Vancouver, British Columbia, Canada
| | | | - Shannon Cope
- PRECISIONheor, Vancouver, British Columbia, Canada
| | | | - Sam Keeping
- PRECISIONheor, Vancouver, British Columbia, Canada
| | - Yingxin Xu
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | | | - Dieter Ayers
- PRECISIONheor, Vancouver, British Columbia, Canada
| | | | | | - Ali Mojebi
- PRECISIONheor, Vancouver, British Columbia, Canada
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Cost-Effectiveness of Vedolizumab in the Treatment of Moderate-to-Severe Crohn's Disease in China. Adv Ther 2021; 38:4233-4245. [PMID: 34089502 PMCID: PMC8342392 DOI: 10.1007/s12325-021-01806-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/24/2021] [Indexed: 12/07/2022]
Abstract
INTRODUCTION To compare the cost-effectiveness of vedolizumab with that of conventional therapy in patients with moderate-to-severe active Crohn's disease (CD) in China. METHODS A decision tree and Markov model were built to predict the lifetime cost and health outcomes in the induction phase and maintenance phase of vedolizumab treatment and conventional therapy (a combination of corticosteroids, immunosuppressants, and aminosalicylates) in adult patients with moderate-to-severe active CD from the perspective of China's healthcare system. Clinical efficacy and health utility were derived from the GEMINI 2 and GEMINI 3 trials and published literature. Costs were mainly obtained from clinical physician surveys in China and are presented in 2020 US dollars. Health outcomes (quality-adjusted life years, QALYs) and costs were discounted at an annual rate of 5%. The incremental cost per QALY gained was used to compare the cost-effectiveness of the two treatments. One-way and probabilistic sensitivity analyses (PSAs) were performed to test the robustness of the model. RESULTS The model predicted more QALYs (9.92 vs 9.00 QALYs) and lower incurred costs ($288,284 vs $309,680) in vedolizumab than in conventional therapy in a mixed population (anti-TNF-naïve and anti-TNF-failure populations) over a lifetime horizon in the base-case analysis. Similar results were observed in the anti-TNF-naïve and anti-TNF-failure subgroups of patients with CD. One-way sensitivity analysis results suggested that health state cost was the most influential factor in the model. The PSA results supported the dominance of vedolizumab in the base-case analysis. CONCLUSION Vedolizumab appears to be a cost-effective strategy option in the treatment of adult patients with moderate-to-severe active CD in China in both anti-TNF-naïve and anti-TNF-failure populations.
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Mojtahed SA, Boyer NR, Rao SA, Gajewski TF, Tseng J, Turaga KK. Cost-Effectiveness Analysis of Adjuvant Therapy for BRAF-Mutant Resected Stage III Melanoma in Medicare Patients. Ann Surg Oncol 2021; 28:9039-9047. [PMID: 34129153 DOI: 10.1245/s10434-021-10288-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adjuvant therapy for stage III melanoma improves several measures of patient survival. However, decisions regarding inclusion of adjuvant therapies in the formularies of public payers necessarily consider the cost-effectiveness of those treatments. The objective of this study is to evaluate the cost-effectiveness of four recently approved adjuvant therapies for BRAF-mutant stage III melanoma in the Medicare patient population. METHODS In this cost-effectiveness analysis, a Markov microsimulation model was used to simulate the healthcare trajectory of patients randomized to receive either first-line targeted therapy (dabrafenib-trametinib) or immunotherapy (ipilimumab, nivolumab, or pembrolizumab). The base case was a 65-year-old Medicare patient with BRAF V600E-mutant resected stage III melanoma. Possible health states included recurrence-free survival, adverse events, local recurrence, distant metastases, and death. Transition probabilities were determined from published clinical trials. Costs were estimated from reimbursement rates reported by CMS and the Red Book drug price database. Primary outcomes were costs (US$), life years, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model robustness was evaluated using one-way and probabilistic sensitivity analyses. RESULTS Dabrafenib-trametinib provided 1.83 QALYs over no treatment and 0.23 QALYs over the most effective immunotherapy, pembrolizumab. Dabrafenib-trametinib was associated with an ICER of $95,758/QALY over no treatment and $285,863/QALY over pembrolizumab. Pembrolizumab yielded an ICER of $68,396/QALY over no treatment and dominated other immunotherapies. CONCLUSIONS Pembrolizumab is cost-effective at a conventional willingness-to-pay (WTP) threshold, but dabrafenib-trametinib is not. Though dabrafenib-trametinib offers incremental QALYs, optimization of drug pricing is necessary to ensure dabrafenib-trametinib is accessible at an acceptable WTP threshold.
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Affiliation(s)
- Saam A Mojtahed
- Pritzker School of Medicine, Division of Biological Sciences, University of Chicago, Chicago, IL, USA
| | - Nicole R Boyer
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Saieesh A Rao
- Pritzker School of Medicine, Division of Biological Sciences, University of Chicago, Chicago, IL, USA
| | - Thomas F Gajewski
- Department of Pathology, Division of Biological Sciences, University of Chicago, Chicago, IL, USA
| | - Jennifer Tseng
- Department of Surgery, Division of Biological Sciences, The University of Chicago, Chicago, IL, USA
| | - Kiran K Turaga
- Department of Surgery, Division of Biological Sciences, The University of Chicago, Chicago, IL, USA.
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Wu B, Shi L. Frontline BRAF Testing-Guided Treatment for Advanced Melanoma in the Era of Immunotherapies: A Cost-Utility Analysis Based on Long-term Survival Data. JAMA Dermatol 2021; 156:1177-1184. [PMID: 32697281 DOI: 10.1001/jamadermatol.2020.2398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance The effectiveness of immune checkpoint inhibitors (ICIs) and BRAF and MEK inhibitors has improved advanced melanoma recovery. However, it is unknown whether these novel therapies are cost-effective for newly diagnosed advanced melanoma with unknown BRAF status. Objective To compare the cost-utility of these novel agents and their combinations with or without BRAF gene testing guidance for treating newly diagnosed advanced melanoma with unknown BRAF status. Design and Setting A decision-analytic model was adopted to project the outcomes of 8 strategies containing different ICIs and BRAF and MEK inhibitors for newly diagnosed advanced melanoma with unknown BRAF pathogenic variant status. The key clinical data were derived from the CheckMate 067, KEYNOTE-006, COMBI-d, and COMBI-v trials, and the cost and health preference data were derived from the literature. Costs were estimated from the US payer perspective. Main Outcomes and Measures Costs, quality-adjusted life-years (QALYs), incremental cost-utility ratio (ICUR), and incremental net health benefits were calculated. Subgroup, 1-way, and probabilistic sensitivity analyses were performed. Results Of the 8 competing strategies, nivolumab plus ipilimumab without patient selection based on BRAF pathogenic variant testing yielded the most significant health outcome, and the nivolumab strategy was the cheapest option. The nivolumab, pembrolizumab, and nivolumab plus ipilimumab strategies formed the cost-effective frontier, which showed the ordered ICURs were $8593 (SD, $592 995)/QALY for pembrolizumab vs nivolumab and $125 593 (SD, $5 751 223)/QALY for nivolumab plus ipilimumab vs pembrolizumab. Other strategies, including the BRAF testing-guided strategies (BRAF pathogenic variant testing followed by corresponding regimens for BRAF wild and pathogenic variant tumors), were dominated or extended dominated. The most influential parameters were the treatment efficacy of these new regimens. Conclusions and Relevance For newly diagnosed advanced melanoma with unknown BRAF pathogenic variant status, nivolumab plus ipilimumab and pembrolizumab strategies are likely to be the most cost-effective options. BRAF and MEK inhibitors might be productively placed in a second-line setting after BRAF pathogenic variant is confirmed.
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Affiliation(s)
- Bin Wu
- Medical Decision and Economic Group, Ren Ji Hospital, Department of Pharmacy, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lizheng Shi
- Department of Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
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Wurcel V, Scherrer E, Aguiar-Ibanez R, Altuna JI, Carabajal F, Jain S, Baluni G. Cost-Effectiveness of Pembrolizumab for the Adjuvant Treatment of Melanoma Patients with Lymph Node Involvement Who Have Undergone Complete Resection in Argentina. Oncol Ther 2021; 9:167-185. [PMID: 33624271 PMCID: PMC8140053 DOI: 10.1007/s40487-021-00142-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/23/2021] [Indexed: 01/20/2023] Open
Abstract
Introduction The KEYNOTE-054 trial demonstrated that adjuvant pembrolizumab improves recurrence-free survival in completely resected stage III melanoma versus watchful waiting (hazard ratio [HR] = 0.57; 98.4% confidence interval [CI], 0.43–0.74). We evaluated the cost-effectiveness of pembrolizumab in Argentina, where watchful waiting is still widely used among these patients despite the high risk of recurrence with surgery alone. Methods A four-health state model was used (recurrence-free, locoregional recurrence [LR], distant metastases [DM], death). Lifetime medical costs to payers (72.08 Argentine pesos [AR$] = 1.00 U.S. dollar [USD]) and outcomes (3% annual discount) were assessed, together with incremental cost-effectiveness ratios (ICERs). First and LR→DM recurrences were modeled using KEYNOTE-054 and real-world data, respectively. No benefits of adjuvant treatment were assumed post-progression. Pre-DM and post-DM mortality was based on KEYNOTE-054 and on a network meta-analysis of advanced treatments expected in each arm, respectively. Utilities were derived from KEYNOTE-054 Euro-QoL data using an Argentinian algorithm, and from the literature. Public ex-factory drug prices were used. Results Patients in the pembrolizumab and the watchful waiting arms accrued 8.78 and 5.83 quality-adjusted life-years (QALYs), 9.91 and 6.98 life-years, and costs of AR$12,698,595 (176,174 USD) and AR$11,967,717 (166,034 USD), respectively. The proportion of life-years accrued that were recurrence-free was 80.8% and 56.9% in the pembrolizumab and the watchful waiting arms, respectively. Pembrolizumab patients gained 2.94 life-years and 2.96 QALYs versus watchful waiting; the ICER per QALY was AR$247,094 (3428 USD). Recurrence rates and advanced melanoma treatments were the key drivers of the ICER. At a threshold of AR$1,445,325 (29,935 USD) per QALY, pembrolizumab had an 83.5% probability of being cost-effective versus watchful waiting. Conclusions Adjuvant pembrolizumab after complete resection of melanoma with node involvement is highly cost-effective relative to watchful waiting in Argentina, across disease stage subgroups and BRAF mutational status. This strongly supports its coverage and reimbursement across the entire health system.
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Affiliation(s)
| | | | | | | | | | - Shrishti Jain
- Complete HEOR Solutions, CHEORS, North Wales, PA, USA
| | - Gargi Baluni
- Complete HEOR Solutions, CHEORS, North Wales, PA, USA
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Paly VF, Hikichi Y, Baker T, Itakura E, Chandran N, Harrison J. Economic evaluation of nivolumab combined with ipilimumab in the first-line treatment of advanced melanoma in Japan. J Med Econ 2020; 23:1542-1552. [PMID: 33000994 DOI: 10.1080/13696998.2020.1830781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS The objective of this study was to evaluate the cost-effectiveness of nivolumab in combination with ipilimumab (nivo + ipi) compared to current therapeutic alternatives in first-line treatment of patients with advanced melanoma from the Japanese national healthcare payer perspective using 48-month survival data from the CheckMate 067 Phase III trial. MATERIALS AND METHODS A three-state partitioned survival model was developed from projections of overall survival (OS) and progression-free survival (PFS) to estimate accrued quality-adjusted survival and costs over a 30-year time horizon. The analysis included nivo + ipi, nivolumab, and ipilimumab monotherapies (the three treatments included in CheckMate 067). Drug acquisition, administration, disease management, subsequent therapy, and adverse event (AE) costs were obtained via published sources and expert input (solicited via Delphi panel). AE frequencies were collected from the Checkmate 067 trial. Utility weights were estimated from the Checkmate 067 trial, based on Japanese tariffs. Results were presented as incremental cost-utility ratios (ICURs, cost per quality-adjusted life-year (QALY)). RESULTS Nivo + ipi had the greatest estimated survival among the three competing treatments, followed by nivolumab monotherapy accruing the second greatest survival. The incremental cost-effectiveness of nivo + ipi was ¥778,000 per QALY vs. nivolumab and ¥1,584,000 per QALY vs. ipilimumab. The results indicate that nivo + ipi is cost-effective in Japan when compared to a threshold of ¥7,500,000 per QALY. This finding was found to be generally robust to sensitivity and scenario analyses. LIMITATIONS Limitations include uncertainty in long-term survival extrapolations and lack of Japan-specific clinical data. CONCLUSIONS This analysis indicates that adding ipilimumab to nivolumab therapy represents a cost-effective new treatment option for patients with unresectable malignant melanoma in Japan.
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Affiliation(s)
| | | | - Timothy Baker
- Global HTA, Health Economics, Reimbursement & Outcomes, ICON plc, New York, NY, USA
| | | | - Nisha Chandran
- Global HTA, Health Economics, Reimbursement & Outcomes, ICON plc, Bangalore, India
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Tappenden P, Carroll C, Hamilton J, Kaltenthaler E, Wong R, Wadsley J, Moss L, Balasubramanian S. Cabozantinib and vandetanib for unresectable locally advanced or metastatic medullary thyroid cancer: a systematic review and economic model. Health Technol Assess 2020; 23:1-144. [PMID: 30821231 DOI: 10.3310/hta23080] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Medullary thyroid cancer (MTC) is a rare form of cancer that affects patients' health-related quality of life (HRQoL) and survival. Cabozantinib (Cometriq®; Ipsen, Paris, France) and vandetanib (Caprelsa®; Sanofi Genzyme, Cambridge, MA, USA) are currently the treatment modality of choice for treating unresectable progressive and symptomatic MTC. OBJECTIVES (1) To evaluate the clinical effectiveness and safety of cabozantinib and vandetanib. (2) To estimate the incremental cost-effectiveness of cabozantinib and vandetanib versus each other and best supportive care. (3) To identify key areas for primary research. (4) To estimate the overall cost of these treatments in England. DATA SOURCES Peer-reviewed publications (searched from inception to November 2016), European Public Assessment Reports and manufacturers' submissions. REVIEW METHODS A systematic review [including a network meta-analysis (NMA)] was conducted to evaluate the clinical effectiveness and safety of cabozantinib and vandetanib. The economic analysis included a review of existing analyses and the development of a de novo model. RESULTS The systematic review identified two placebo-controlled trials. The Efficacy of XL184 (Cabozantinib) in Advanced Medullary Thyroid Cancer (EXAM) trial evaluated the efficacy and safety of cabozantinib in patients with unresectable locally advanced, metastatic and progressive MTC. The ZETA trial evaluated the efficacy and safety of vandetanib in patients with unresectable locally advanced or metastatic MTC. Both drugs significantly improved progression-free survival (PFS) more than the placebo (p < 0.001). The NMA suggested that, within the symptomatic and progressive MTC population, the effects on PFS were similar (vandetanib vs. cabozantinib: hazard ratio 1.14, 95% credible interval 0.41 to 3.09). Neither trial demonstrated a significant overall survival benefit for cabozantinib or vandetanib versus placebo, although data from ZETA were subject to potential confounding. Both cabozantinib and vandetanib demonstrated significantly better objective response rates and calcitonin (CTN) and carcinoembryonic antigen (CEA) response rates than placebo. Both cabozantinib and vandetanib produced frequent adverse events, often leading to dose interruption or reduction. The assessment group model indicates that, within the EU-label population (symptomatic and progressive MTC), the incremental cost-effectiveness ratios (ICERs) for cabozantinib and vandetanib are > £138,000 per quality-adjusted life-year (QALY) gained. Within the restricted EU-label population (symptomatic and progressive MTC with CEA/CTN doubling times of ≤ 24 months), the ICER for vandetanib is expected to be > £66,000 per QALY gained. The maximum annual budget impact within the symptomatic and progressive population is estimated to be ≈£2.35M for cabozantinib and ≈£5.53M for vandetanib. The costs of vandetanib in the restricted EU-label population are expected to be lower. LIMITATIONS The intention-to-treat populations of the EXAM and ZETA trials are notably different. The analyses of ZETA subgroups may be subject to confounding as a result of differences in baseline characteristics and open-label vandetanib use. Attempts to statistically adjust for treatment switching were unsuccessful. No HRQoL evidence was identified for the MTC population. CONCLUSIONS The identified trials suggest that cabozantinib and vandetanib improve PFS more than the placebo; however, significant OS benefits were not demonstrated. The economic analyses indicate that within the EU-label population, the ICERs for cabozantinib and vandetanib are > £138,000 per QALY gained. Within the restricted EU-label population, the ICER for vandetanib is expected to be > £66,000 per QALY gained. FUTURE RESEARCH PRIORITIES (1) Primary research assessing the long-term effectiveness of cabozantinib and vandetanib within relevant subgroups. (2) Reanalyses of the ZETA trial to investigate the impact of adjusting for open-label vandetanib use using appropriate statistical methods. (3) Studies assessing the impact of MTC on HRQoL. STUDY REGISTRATION This study is registered as PROSPERO CRD42016050403. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Christopher Carroll
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Eva Kaltenthaler
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Sabapathy Balasubramanian
- Department of Oncology and Metabolism, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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An Economic Evaluation of Pembrolizumab Versus Other Adjuvant Treatment Strategies for Resected High-Risk Stage III Melanoma in the USA. Clin Drug Investig 2020; 40:629-643. [PMID: 32418051 PMCID: PMC7311503 DOI: 10.1007/s40261-020-00922-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Over the past 5 years, adjuvant treatment options for surgically resected stage III melanoma have expanded with the introduction of several novel immune checkpoint inhibitors and targeted therapies. Pembrolizumab, a programmed cell death protein 1 inhibitor, received US Food and Drug Administration approval in 2019 for resected high-risk stage III melanoma based on significantly longer recurrence-free survival versus placebo. This study evaluated the cost-effectiveness of pembrolizumab versus other adjuvant treatment strategies for resected high-risk stage III melanoma from a US health system perspective. METHODS A Markov cohort-level model with four states (recurrence-free, locoregional recurrence, distant metastases, death) estimated costs and quality-adjusted life-years (QALYs) for pembrolizumab versus routine observation and other adjuvant comparators: ipilimumab in the overall population; and dabrafenib + trametinib in the BRAF-mutation positive (BRAF+) subgroup. Transition probabilities starting from recurrence-free were estimated through parametric multi-state modeling based on phase 3 KEYNOTE-054 (NCT02362594) trial data for pembrolizumab and observation, and network meta-analyses for other comparators. Post-recurrence transitions were modeled based on electronic medical records data and trials in advanced/metastatic melanoma. Utilities were derived using quality-of-life data from KEYNOTE-054 and literature. Costs of treatment, adverse events, disease management, and terminal care were included. RESULTS Over a lifetime, pembrolizumab, ipilimumab, and observation were associated with QALYs of 9.24, 7.09, and 5.95 and total costs of $511,290, $992,721, and $461,422, respectively (2019 US dollars). Pembrolizumab was thus dominant (less costly, more effective) versus ipilimumab, with an incremental cost-effectiveness ratio of $15,155/QALY versus observation. In the BRAF+ subgroup, pembrolizumab dominated dabrafenib + trametinib and observation, decreasing costs by $62,776 and $11,250 and increasing QALYs by 0.93 and 3.10 versus these comparators, respectively. Results were robust in deterministic and probabilistic sensitivity analyses. CONCLUSIONS As adjuvant treatment for resected stage III melanoma, pembrolizumab was found to be dominant and therefore cost-effective compared with the active comparators ipilimumab and dabrafenib + trametinib. Pembrolizumab increased costs relative to observation in the overall population, with sufficient incremental benefit to be considered cost-effective based on typical willingness-to-pay thresholds.
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Bullement A, Podkonjak T, Robinson MJ, Benson E, Selby R, Hatswell AJ, Shields GE. Real-world evidence use in assessments of cancer drugs by NICE. Int J Technol Assess Health Care 2020; 36:1-7. [PMID: 32646531 DOI: 10.1017/s0266462320000434] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish how real-world evidence (RWE) has been used to inform single technology appraisals (STAs) of cancer drugs conducted by the National Institute for Health and Care Excellence (NICE). METHODS STAs published by NICE from April 2011 to October 2018 that evaluated cancer treatments were reviewed. Information regarding the use of RWE to directly inform the company-submitted cost-effectiveness analysis was extracted and categorized by topic. Summary statistics were used to describe emergent themes, and a narrative summary was provided for key case studies. RESULTS Materials for a total of 113 relevant STAs were identified and analyzed, of which nearly all (96 percent) included some form of RWE within the company-submitted cost-effectiveness analysis. The most common categories of RWE use concerned the health-related quality of life of patients (71 percent), costs (46 percent), and medical resource utilization (40 percent). While sources of RWE were routinely criticized as part of the appraisal process, we identified only two cases where the use of RWE was overtly rejected; hence, in the majority of cases, RWE was accepted in cancer drug submissions to NICE. DISCUSSION RWE has been used extensively in cancer submissions to NICE. Key criticisms of RWE in submissions to NICE are seldom regarding the use of RWE in general; instead, these are typically concerned with specific data sources and the applicability of these to the decision problem. Within an appropriate context, RWE constitutes an extremely valuable source of information to inform decision making; yet the development of best practice guidelines may improve current reporting standards.
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Affiliation(s)
| | | | | | | | - Ross Selby
- Global Oncology Business Unit, Takeda Pharmaceuticals International Co., London, UK
| | - Anthony J Hatswell
- Delta Hat, Nottingham, UK
- Department of Statistical Science, University College London, London, UK
| | - Gemma E Shields
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
- Azurite Research Ltd, Sheffield, UK
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Gibson EJ, Begum N, Koblbauer I, Dranitsaris G, Liew D, McEwan P, Yuan Y, Juarez-Garcia A, Tyas D, Pritchard C. Economic Evaluation of Single versus Combination Immuno-Oncology Therapies: Application of a Novel Modelling Approach in Metastatic Melanoma. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:241-252. [PMID: 32440174 PMCID: PMC7220542 DOI: 10.2147/ceor.s238725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/26/2020] [Indexed: 01/18/2023] Open
Abstract
Background Existing economic model frameworks may not adequately capture the atypical treatment response patterns in immuno-oncology (I-O) compared with conventional therapies and thus may fail to represent the full clinical value associated with disease dynamics and improved survival. Objective A cost-effectiveness analysis (CEA) of the I-O Regimen (nivolumab/ipilimumab) versus ipilimumab alone in advanced melanoma was carried out by applying a 5-state partitioned survival model (PSM) as a case study, to explore the I-O treatment response and clinical outcomes. The findings were compared with those of a conventional 3-state PSM. Materials and Methods The case study extends the conventional 3-state PSM, by separating the pre-progression state into non-responders and responders, and the post-progression state into normal and I-O progression to account for delayed treatment effects preceding clinical response. Model states were populated using patient-level data (where possible), mapping from the best overall response (BOR), and survival analysis with flexible and traditional parametric methods. Survival functions were applied to progression-free survival (PFS) and overall survival (OS) endpoints across treatment arms using the 4-year follow-up data (data available at the time of the research; since then 5-year follow-up data have been published) from the CheckMate 067 trial. Information on BOR was used as a means of differentiating the I-O treatment response in addition to the outcomes of progression-free and progressed disease. A UK National Health Service and personal social services (NHS/PSS) perspective over a lifetime horizon was used with outcomes discounted at 3.5% annually. Results The 5-state PSM generated an increase in quality adjusted life years (QALYs) in both treatment arms and gave a more granular description of patients’ health profiles compared with the traditional 3-state PSM. The incremental QALY increased by 13% (from 2.62 to 2.95 QALYs) and the incremental cost decreased by 12% (£29,125 to £25,678) with the 5-state model. In both models, the Regimen had an incremental cost-effectiveness ratio (ICER) relative to ipilimumab alone within the lower bound of the National Institute for Health and Care Excellence (NICE) reference range (£20,000 per QALY gained). Conclusion A 5-state economic model, incorporating relevant I-O health states, can be more informative to gain insight into treatment response and progression differences that are not commonly captured in existing economic models. Clinical trial endpoints, including those relating to treatment response, which are not directly reported in ongoing I-O trials, can be mapped on to the proposed modelled health states (although assumptions are required to do so). Improvements in reporting treatment response in future I-O clinical trials could help to further validate and improve the proposed model framework.
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Affiliation(s)
| | | | | | | | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Yong Yuan
- Bristol-Myers Squibb, Lawrenceville, NJ, USA
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20
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Kandel M, Dalle S, Bardet A, Allayous C, Mortier L, Dutriaux C, Guillot B, Leccia M, Dalac S, Legoupil D, Saiag P, Montaudie H, Arnault J, Brunet‐Possenti F, Grob J, DeQuatrebarbes J, Beylot‐Barry M, Lesimple T, Aubin F, Maubec E, Granel‐Brocard F, Stoebner P, Dupuy A, Dreno B, Michiels S, Lebbe C, Borget I. Quality‐of‐life assessment in French patients with metastatic melanoma in real life. Cancer 2019; 126:611-618. [DOI: 10.1002/cncr.32554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/10/2019] [Accepted: 08/21/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Marguerite Kandel
- Biostatistics and Epidemiology Service Gustave Roussy Institute Villejuif France
- Center for Research in Epidemiology and Population Health University of Paris‐Saclay University of Paris‐Sud, and Versailles‐Saint‐Quentin‐en‐Yvelines University French Institute of Health and Medical Research (INSERM) Villejuif France
| | - Stéphane Dalle
- Dermatology Unit, Cancer Research Center of Lyon Lyon University HospitalClaude Bernard University Lyon France
| | - Aurélie Bardet
- Biostatistics and Epidemiology Service Gustave Roussy Institute Villejuif France
- Center for Research in Epidemiology and Population Health University of Paris‐Saclay University of Paris‐Sud, and Versailles‐Saint‐Quentin‐en‐Yvelines University French Institute of Health and Medical Research (INSERM) Villejuif France
| | - Clara Allayous
- Dermatology Unit Clinical Investigation Center Public Hospital of Paris (AP‐HP)INSERM Unit 976, Paris Diderot University‐Saint‐Louis Hospital Paris France
| | - Laurent Mortier
- ONCO‐THAI INSERM Unit 1189, Lille University, Lille Hospital Lille France
| | | | | | | | | | | | - Philippe Saiag
- Dermatology Unit Ambroise Pare HospitalAP‐HP Boulogne‐Billancourt France
| | | | | | | | | | | | | | | | | | - Eve Maubec
- Dermatology Unit Avicennes HospitalAP‐HP Paris France
| | | | | | - Alain Dupuy
- Dermatology Unit Rennes Hospital Rennes France
| | | | - Stefan Michiels
- Biostatistics and Epidemiology Service Gustave Roussy Institute Villejuif France
- Center for Research in Epidemiology and Population Health University of Paris‐Saclay University of Paris‐Sud, and Versailles‐Saint‐Quentin‐en‐Yvelines University French Institute of Health and Medical Research (INSERM) Villejuif France
| | - Céleste Lebbe
- Dermatology Unit, Cancer Research Center of Lyon Lyon University HospitalClaude Bernard University Lyon France
| | - Isabelle Borget
- Biostatistics and Epidemiology Service Gustave Roussy Institute Villejuif France
- Center for Research in Epidemiology and Population Health University of Paris‐Saclay University of Paris‐Sud, and Versailles‐Saint‐Quentin‐en‐Yvelines University French Institute of Health and Medical Research (INSERM) Villejuif France
- Research Group in Law and Health Economics University Paris‐Sud Paris France
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21
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Bensimon AG, Zhou ZY, Jenkins M, Song Y, Gao W, Signorovitch J, Krepler C, Liu FX, Wang J, Aguiar-Ibáñez R. Cost-effectiveness of pembrolizumab for the adjuvant treatment of resected high-risk stage III melanoma in the United States. J Med Econ 2019; 22:981-993. [PMID: 31012765 DOI: 10.1080/13696998.2019.1609485] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/27/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
Abstract
Aims: To evaluate the cost-effectiveness of adjuvant pembrolizumab relative to observation alone following complete resection of high-risk stage III melanoma with lymph node involvement, from a US health system perspective. Materials and methods: A Markov cohort model with four health states (recurrence-free, locoregional recurrence, distant metastases, and death) was developed to estimate costs, life-years, and quality-adjusted life-years (QALYs) associated with pembrolizumab vs observation over a lifetime (46-year) horizon. Using a parametric multi-state modeling approach, transition probabilities starting from recurrence-free were estimated based on patient-level data from KEYNOTE-054 (NCT02362594), a direct head-to-head phase 3 trial. Post-recurrence transition probabilities were informed by real-world retrospective data and clinical trials in advanced melanoma. Health state utilities and adverse event-related disutility were derived from KEYNOTE-054 trial data and published literature. Costs of drug acquisition and administration, adverse events, disease management, and terminal care were estimated in 2018 US dollars. Deterministic and probabilistic sensitivity analyses were conducted to assess robustness. Results: Over a lifetime horizon, adjuvant pembrolizumab and observation were associated with total QALYs of 9.24 and 5.95, total life-years of 10.54 and 7.15, and total costs of $489,820 and $440,431, respectively. The resulting incremental cost-effectiveness ratios (ICERs) for pembrolizumab vs observation were $15,009/QALY and $14,550/life-year. Across the range of input values and assumptions tested in deterministic sensitivity analyses, pembrolizumab ranged from being a dominant strategy to having an ICER of $57,449/QALY vs observation. The ICER was below a willingness-to-pay threshold of $100,000/QALY in 90.2% of probabilistic simulations. Limitations: Long-term extrapolation of outcomes was based on interim results from KEYNOTE-054, with a median follow-up of 15 months. Conclusions: Based on common willingness-to-pay benchmarks, pembrolizumab is highly cost-effective compared with observation alone for the adjuvant treatment of completely resected stage III melanoma in the US.
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Affiliation(s)
| | | | | | - Yan Song
- Analysis Group Inc. , Boston , MA , USA
| | - Wei Gao
- Analysis Group Inc. , Boston , MA , USA
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22
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Zoratti MJ, Zhou T, Chan K, Levine O, Krahn M, Husereau D, Clifford T, Schunemann H, Guyatt G, Xie F. Health Utility Book (HUB)-Cancer: Protocol for a Systematic Literature Review of Health State Utility Values in Cancer. MDM Policy Pract 2019; 4:2381468319852594. [PMID: 31453359 PMCID: PMC6696850 DOI: 10.1177/2381468319852594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/08/2019] [Indexed: 11/16/2022] Open
Abstract
Background. Treatment options in oncology are rapidly advancing, and public payer systems are increasingly under pressure to adopt new but expensive cancer treatments. Cost-utility analyses (CUAs) are used to estimate the relative costs and effects of competing interventions, where health outcomes are measured using quality-adjusted life years (QALYs). Health state utility values (HSUVs) are used to reflect health-related quality of life or health status in the calculation of QALYs. To support reimbursement agencies in the appraisal of oncology drug submissions, which typically include a CUA component, we have proposed a systematic literature review of published HSUV estimates in the field of oncology. Methods. The following databases will be searched: MEDLINE, EMBASE, EconLit, and CINAHL. A team of reviewers, working independently and in duplicate, will evaluate abstracts and full-text publications for eligibility against broad inclusion criteria. Studies using a direct, indirect, or combination approach to eliciting preferences related to cancer or cancer treatments are eligible. Data extraction will capture details of study methodology, participants, health states, and corresponding HSUVs. We will summarize our findings with descriptive analyses at this stage. A pilot review in thyroid cancer is presented to illustrate the proposed methods. Discussion. This systematic review will generate a comprehensive summary of the oncology HSUV literature. As a component of the Health Utility Book (HUB) project, we anticipate that this work will assist both health economic modelers as well as critical reviewers in the development and appraisal of CUAs in oncology.
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Affiliation(s)
- Michael James Zoratti
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ting Zhou
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kelvin Chan
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Murray Krahn
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Don Husereau
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Tammy Clifford
- Canadian Institutes for Health Research, Ottawa, Ontario, Canada
| | - Holger Schunemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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23
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Li M, Basu A, Bennette C, Veenstra D, Garrison LP. How Does Option Value Affect the Potential Cost-Effectiveness of a Treatment? The Case of Ipilimumab for Metastatic Melanoma. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:777-784. [PMID: 31277824 DOI: 10.1016/j.jval.2019.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 01/22/2019] [Accepted: 02/14/2019] [Indexed: 05/17/2023]
Abstract
BACKGROUND Innovations that extend life can generate option value and cost of experiencing future technologies. OBJECTIVES To understand how consideration of option value may affect the potential cost-effectiveness of a treatment through a case study of ipilimumab for previously untreated metastatic melanoma. METHODS We estimated the cost-effectiveness of ipilimumab in 2 scenarios: a conventional scenario, for which we constructed the model using the standard methods that rely on efficacy data directly from the phase III trial of ipilimumab, and an option value scenario, where we incorporated future hypothetical improvements in mortality for metastatic melanoma owing to innovations. We developed 2 approaches to incorporate option value. In the first approach, we forecasted mortality trends based on historical trends from the Surveillance, Epidemiology, and End Results (SEER) Program registry. Alternatively, we identified drugs being studied in clinical trials at the time of ipilimumab's approval on clinicaltrials.gov and estimated their likelihood and timing of approval, potential efficacy, and cost. We accounted for increases in overall cancer treatment cost and unrelated medical cost in the option value scenario. RESULTS In the option value scenario, using the SEER approach, the incremental quality-adjusted life-years (QALYs) gained and the incremental cost increased by 6.2% and 3.8%, respectively, whereas the incremental cost-effectiveness ratio (ICER) decreased by 2.3% compared with the conventional scenario. Using the clinicaltrials.gov approach, the incremental QALY gained and the incremental cost increased by 7.5% and 7.1%, respectively, whereas the ICER decreased by 0.40%. CONCLUSIONS We developed generalizable approaches to estimating option value in cost-effectiveness analysis.
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Affiliation(s)
- Meng Li
- The Comparative Health Outcome, Policy, and Economics Institute, University of Washington, Seattle, WA, USA.
| | - Anirban Basu
- The Comparative Health Outcome, Policy, and Economics Institute, University of Washington, Seattle, WA, USA
| | | | - David Veenstra
- The Comparative Health Outcome, Policy, and Economics Institute, University of Washington, Seattle, WA, USA
| | - Louis P Garrison
- The Comparative Health Outcome, Policy, and Economics Institute, University of Washington, Seattle, WA, USA
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24
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Gibson EJ, Begum N, Koblbauer I, Dranitsaris G, Liew D, McEwan P, Yuan Y, Juarez-Garcia A, Tyas D, Pritchard C. Cohort versus patient level simulation for the economic evaluation of single versus combination immuno-oncology therapies in metastatic melanoma. J Med Econ 2019; 22:531-544. [PMID: 30638416 DOI: 10.1080/13696998.2019.1569446] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Model structure, despite being a key source of uncertainty in economic evaluations, is often not treated as a priority for model development. In oncology, partitioned survival models (PSMs) and Markov models, both types of cohort model, are commonly used, but patient responses to newer immuno-oncology (I-O) agents suggest that more innovative model frameworks should be explored. Objective: A discussion of the theoretical pros and cons of cohort level vs patient level simulation (PLS) models provides the background for an illustrative comparison of I-O therapies, namely nivolumab/ipilimumab combination and ipilimumab alone using patient level data from the CheckMate 067 trial in metastatic melanoma. PSM, Markov, and PLS models were compared on the basis of coherence with short-term clinical trial endpoints and long-term cost per QALY outcomes reported. Methods: The PSM was based on Kaplan-Meier curves from CheckMate 067 with 3-year data on progression free survival (PFS) and overall survival (OS). The Markov model used time independent transition probabilities based on the average trajectory of PFS and OS over the trial period. The PLS model was developed based on baseline characteristics hypothesized to be associated with disease as well as significant mortality and disease progression risk factors identified through a proportional hazards model. Results: The short-term Markov model outputs matched the 1-3 year clinical trial results approximately as well as the PSMs for OS but not PFS. The fixed (average) cohort PLS results corresponded as well as the PSMs for OS in the combination therapy arm and PFS in the monotherapy arm. Over the lifetime horizon, the PLS produced an additional 5.95 quality adjusted life years (QALYs) associated with combination therapy relative to ipilimumab alone, resulting in an incremental cost-effectiveness ratio (ICER) of £6,474 per QALY, compared with £14,194 for the PSMs which gave an incremental benefit of between 2.2 and 2.4 QALYs. The Markov model was an outlier (∼ £49,000 per QALY in the base case). Conclusions: The 4- and 5-state versions of the PSM cohort model estimated in this study deviate from the standard 3-state approach to better capture I-O response patterns. Markov and PLS approaches, by modeling state transitions explicitly, could be more informative in understanding I-O immune response, the PLS particularly so by reflecting heterogeneity in treatment response. However, both require a number of assumptions to capture the immune response effectively. Better I-O representation with surrogate endpoints in future clinical trials could yield greater model validity across all models.
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Affiliation(s)
| | | | | | | | - Danny Liew
- c Department of Epidemiology and Preventive Medicine , Monash University , Melbourne , Australia
| | - Phil McEwan
- d Health Economics and Outcomes Research Ltd , Cardiff , UK
| | - Yong Yuan
- e Bristol-Myers Squibb , Plainsboro , NJ , USA
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25
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Scott FI, Johnson FR, Bewtra M, Brensinger CM, Roy JA, Reed SD, Osterman MT, Mamtani R, Chen L, Yun H, Xie F, Curtis JR, Lewis JD. Improved Quality of Life With Anti-TNF Therapy Compared With Continued Corticosteroid Utilization in Crohn's Disease. Inflamm Bowel Dis 2019; 25:925-936. [PMID: 30535149 DOI: 10.1093/ibd/izy321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Corticosteroids (CS) and anti-TNF drugs are used to treat Crohn's disease (CD). In this study, we assessed the net health benefit of initiating anti-TNF therapy relative to additional CS use in CD using a novel combination of a retrospective cohort study and a simulation model. METHODS Using Medicaid data from 2001 to 2005 and Medicare data from 2006 to 2013, beneficiaries were identified with CD and CS use who subsequently received either an anti-TNF or reached a cumulative dose of >3000 mg CS during the year. By using overall and latent class-specific remission-time equivalent (RTE) estimates derived from discrete-choice experiments, mean 12-month cumulative RTEs were calculated after propensity score adjustment for baseline characteristics. A Markov model was constructed using transition probabilities derived from the retrospective cohort to perform additional sensitivity analyses of RTE estimates, analytic assumptions, and transition probabilities. Cumulative RTEs were calculated via Monte Carlo simulation in this model. RESULTS In the retrospective cohort, 1563 new anti-TNF initiators and 1563 propensity score-matched prolonged CS users were identified. Anti-TNF use was associated with greater mean RTEs at the end of 1 year (5.34 vs 4.54, incremental benefit: 0.79; 95% CI, 0.53-1.07). This benefit persisted in all latent classes. In the Markov model, anti-TNF therapy was the preferred strategy, and the results were robust in multiple sensitivity analysis and latent class analysis. CONCLUSIONS In both a retrospective cohort study and a simulation model, anti-TNF use was associated with improved quality of life, measured as RTEs, when compared with continued CS utilization for CD.
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Affiliation(s)
- Frank I Scott
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - F Reed Johnson
- Duke Clinical Research Institute, Duke University, Durham North Carolina, USA
| | - Meenakshi Bewtra
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A Roy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham North Carolina, USA
| | - Mark T Osterman
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronac Mamtani
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Huifeng Yun
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fenlong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Tarhini A, McDermott D, Ambavane A, Gupte-Singh K, Aponte-Ribero V, Ritchings C, Benedict A, Rao S, Regan MM, Atkins M. Clinical and economic outcomes associated with treatment sequences in patients with BRAF-mutant advanced melanoma. Immunotherapy 2018; 11:283-295. [PMID: 30563395 DOI: 10.2217/imt-2018-0168] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
AIM The cost-effectiveness of treatment sequences in BRAF-mutant advanced melanoma. MATERIALS & METHODS A discrete event simulation model was developed to estimate total costs and health outcomes over a patient's lifetime (30 years). Efficacy was based on the CheckMate 067/069 trials and a matching-adjusted-indirect comparison between immuno-oncology and targeted therapies. Safety, cost (in US dollars; US third-party payer perspective) and health-related quality-of-life inputs were based on published literature. RESULTS Estimated survival gain was higher for sequences initiating with anti-PD-1 + anti-CTLA-4 than for anti-PD-1 monotherapy or BRAF+MEK inhibitors. The incremental cost-effectiveness ratio per QALY gained for first-line anti-PD-1 + anti-CTLA-4 was US$54,273 versus first-line anti-PD-1 and $79,124 versus first-line BRAF+MEK inhibitors. CONCLUSION Initiating treatment with anti-PD-1 + anti-CTLA-4 was more cost-effective than initiation with anti-PD-1 monotherapy or BRAF+MEK inhibitors.
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Affiliation(s)
- Ahmad Tarhini
- Department of Hematology & Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, 44106, USA
| | - David McDermott
- Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | | | | | | | | | | | - Sumati Rao
- Bristol-Myers Squibb, Princeton, NJ, 08648, USA
| | - Meredith M Regan
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA
| | - Michael Atkins
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, 20007, USA
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27
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Retèl VP, Steuten LMG, Geukes Foppen MH, Mewes JC, Lindenberg MA, Haanen JBAG, van Harten WH. Early cost-effectiveness of tumor infiltrating lymphocytes (TIL) for second line treatment in advanced melanoma: a model-based economic evaluation. BMC Cancer 2018; 18:895. [PMID: 30219040 PMCID: PMC6139174 DOI: 10.1186/s12885-018-4788-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 09/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background An emerging immunotherapy is infusion of tumor infiltrating Lymphocytes (TIL), with objective response rates of around 50% versus 19% for ipilimumab. As an Advanced Therapeutic Medicinal Products (ATMP), TIL is highly personalized and complex therapy. It requests substantial upfront investments from the hospital in: expensive lab-equipment, staff expertise and training, as well as extremely tight hospital logistics. Therefore, an early health economic modelling study, as part of a Coverage with Evidence Development (CED) program, was performed. Methods We used a Markov decision model to estimate the expected costs and outcomes (quality-adjusted life years; QALYs) for TIL versus ipilimumab for second line treatment in metastatic melanoma patients from a Dutch health care perspective over a life long time horizon. Three mutually exclusive health states (stable disease (responders)), progressive disease and death) were modelled. To inform further research prioritization, Value of Information (VOI) analysis was performed. Results TIL is expected to generate more QALYs compared to ipilimumab (0.45 versus 0.38 respectively) at lower incremental cost (presently €81,140 versus €94,705 respectively) resulting in a dominant ICER (less costly and more effective). Based on current information TIL is dominating ipilimumab and has a probability of 86% for being cost effective at a cost/QALY threshold of €80,000. The Expected Value of Perfect Information (EVPI) amounted to €3 M. Conclusions TIL is expected to have the highest probability of being cost-effective in second line treatment for advanced melanoma compared to ipilimumab. To reduce decision uncertainty, a clinical trial investigating e.g. costs and survival seems most valuable. This is currently being undertaken as part of a CED program in the Netherlands Cancer Institute, Amsterdam, the Netherlands, in collaboration with Denmark.
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Affiliation(s)
- Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands. .,Department of Health Technology and Services Research, University of Twente, Postbus 217, 7500, AE, Enschede, the Netherlands.
| | - Lotte M G Steuten
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, P.O. Box 19024, Seattle, WA, 98109-1024, USA
| | - Marnix H Geukes Foppen
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Janne C Mewes
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Melanie A Lindenberg
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands.,Department of Health Technology and Services Research, University of Twente, Postbus 217, 7500, AE, Enschede, the Netherlands
| | - John B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands.,Department of Health Technology and Services Research, University of Twente, Postbus 217, 7500, AE, Enschede, the Netherlands
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28
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Hansson-Hedblom A, Almond C, Borgström F, Sly I, Enkusson D, Troelsgaard Buchholt A, Karlsson L. Cost-effectiveness of ustekinumab in moderate to severe Crohn's disease in Sweden. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:28. [PMID: 30123097 PMCID: PMC6090969 DOI: 10.1186/s12962-018-0114-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/26/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Human monoclonal antibody ustekinumab is a novel Crohn's disease (CD) treatment blocking pro-inflammatory cytokines interleukin-12 and 23. The study's objective was to assess cost-effectiveness of ustekinumab in moderate to severely active CD in Sweden. METHODS A cost-effectiveness model with an induction phase decision-tree structure and a maintenance phase Markov cohort structure was constructed. CD was represented by five health-states: remission, mild, moderate-severe, surgery and death. Ustekinumab was compared to adalimumab in patients who had failed conventional care, some of which had tried TNF-alpha-inhibitor(s) without experiencing treatment failure or side effects ("conventional care failure population") and to vedolizumab in patients previously failing TNF-alpha-inhibitor treatment. Discontinuation probabilities, utilities and ustekinumab induction efficacy were sourced from phase-III trials. Maintenance and comparator efficacy came from network-meta and treatment-sequence analyses. Resource use and unit costs were derived from literature and validated by clinical experts. The analysis had a societal perspective, a life-time time-horizon, and 2-year treatment duration. The results robustness was tested in univariate and probabilistic sensitivity analyses. Cost-effectiveness was estimated using quality-adjusted life-years (QALYs). RESULTS Ustekinumab dominated adalimumab in conventional care failure population (costs: - €6984, QALYs: + 0.232). In TNF-alpha-inhibitor failure population ustekinumab accrued 0.133 more QALYs than vedolizumab, yielding a €30,282 incremental cost-effectiveness ratio. Results were sensitive to decreasing the time horizon and increased treatment duration. At Swedish reference willingness-to-pay of €63,000 (SEK 600,000), ustekinumab had 94% probability of being cost-effective versus adalimumab, and 72% versus vedolizumab. CONCLUSIONS Results indicate ustekinumab dominates adalimumab in conventional care failure population, and is cost-effective versus vedolizumab in TNF-alpha-inhibitor failure population.
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Gibson EJ, Begum N, Koblbauer I, Dranitsaris G, Liew D, McEwan P, Tahami Monfared AA, Yuan Y, Juarez-Garcia A, Tyas D, Lees M. Modeling the economic outcomes of immuno-oncology drugs: alternative model frameworks to capture clinical outcomes. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:139-154. [PMID: 29563820 PMCID: PMC5848668 DOI: 10.2147/ceor.s144208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Economic models in oncology are commonly based on the three-state partitioned survival model (PSM) distinguishing between progression-free and progressive states. However, the heterogeneity of responses observed in immuno-oncology (I-O) suggests that new approaches may be appropriate to reflect disease dynamics meaningfully. MATERIALS AND METHODS This study explored the impact of incorporating immune-specific health states into economic models of I-O therapy. Two variants of the PSM and a Markov model were populated with data from one clinical trial in metastatic melanoma patients. Short-term modeled outcomes were benchmarked to the clinical trial data and a lifetime model horizon provided estimates of life years and quality adjusted life years (QALYs). RESULTS The PSM-based models produced short-term outcomes closely matching the trial outcomes. Adding health states generated increased QALYs while providing a more granular representation of outcomes for decision making. The Markov model gave the greatest level of detail on outcomes but gave short-term results which diverged from those of the trial (overstating year 1 progression-free survival by around 60%). CONCLUSION Increased sophistication in the representation of disease dynamics in economic models is desirable when attempting to model treatment response in I-O. However, the assumptions underlying different model structures and the availability of data for health state mapping may be important limiting factors.
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Affiliation(s)
| | - N Begum
- Wickenstones Ltd, Didcot, UK
| | | | - G Dranitsaris
- Augmentium Pharma Consulting Inc, Toronto, ON, Canada
| | - D Liew
- Department of Epidemiology and Preventive Medicine, Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - P McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - AA Tahami Monfared
- Bristol-Myers Squibb Canada, Saint-Laurent, QC Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Y Yuan
- Bristol-Myers Squibb, Princeton, NJ, USA
| | | | - D Tyas
- Bristol-Myers Squibb, Uxbridge, UK
| | - M Lees
- Bristol-Myers Squibb, Rueil-Malmaison, France
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Oh A, Tran DM, McDowell LC, Keyvani D, Barcelon JA, Merino O, Wilson L. Cost-Effectiveness of Nivolumab-Ipilimumab Combination Therapy Compared with Monotherapy for First-Line Treatment of Metastatic Melanoma in the United States. J Manag Care Spec Pharm 2018; 23:653-664. [PMID: 28530525 PMCID: PMC5960988 DOI: 10.18553/jmcp.2017.23.6.653] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The approval of new immunotherapies has dramatically changed the treatment landscape of metastatic melanoma. These survival gains come with trade-offs in side effects and costs, as well as important considerations for third-party payer systems, physicians, and patients. OBJECTIVE To develop a Markov model to determine the cost-effectiveness of nivolumab, ipilimumab, and nivolumab-ipilimumab combination as firstline therapy in metastatic melanoma, while accounting for differential effectiveness in programmed death-ligand 1 (PD-L1) positive and negative patients. METHODS A 3-state Markov model (PD-L1 positive stable disease, PD-L1 negative stable disease, and progression and/or death) was developed using a U.S. societal perspective with a lifetime time horizon of 14.5 years. Transition probabilities were calculated from progression-free (PF) survival data reported in the CheckMate-067 trial. Costs were expressed in 2015 U.S. dollars and were determined using national sources. Adverse event (AE) management was determined using immune-related AE (irAE) data from CheckMate-067, irAE management guides for nivolumab and ipilimumab, and treatment guidelines. Utilities were obtained from published literature, using melanoma-specific studies when available, and were weighted based on incidence and duration of irAEs. Base case, one-way sensitivity, and probabilistic sensitivity analyses were conducted. RESULTS Nivolumab-ipilimumab combination therapy was not the cost-effective choice ($454,092 per PF quality-adjusted life-year [QALY]) compared with nivolumab monotherapy in a base case analysis at a willingness-to-pay threshold of $100,000 per PFQALY. Combination therapy and nivolumab monotherapy were cost-effective choices compared with ipilimumab monotherapy. PD-L1 positive status, utility of nivolumab and combination therapy, and medication costs contributed the most uncertainty to the model. In a population of 100% PD-L1 negative patients, nivolumab was still the optimal treatment, but combination therapy had an improved incremental cost-effectiveness ratio (ICER) of $295,903 per PFQALY. Combination therapy became dominated by nivolumab, when 68% of the sample was PD-L1 positive. In addition, the cost of ipilimumab would have to decrease to < $21,555 per dose for combination therapy to have an ICER < $100,000 per PFQALY and to < $19,151 (a 42% reduction) to be more cost-effective than nivolumab monotherapy. CONCLUSIONS Nivolumab-ipilimumab combination therapy was not cost-effective compared with nivolumab monotherapy, which was the most cost-effective option. Professionals in managed care settings should consider the pharmacoeconomic implications of these new immunotherapies as they make value-based formulary decisions, and future cost-effectiveness studies are completed. DISCLOSURES No funding supported this study. Merino was a contractor with EMD Serono at the time of this study but does not have any conflicts of interest and did not receive any funding related to this study. All other authors have no financial disclosures and no conflicts of interest. All the authors contributed to the study concept and design. Tran, McDowell, and Barcelon took the lead in data collection, along with Oh, Keyvani, and Merino. All authors except Merino contributed to data interpretation. The manuscript was written by Oh, Tran, McDowell, and Wilson and revised by Oh, Tran, McDowell, Wilson, and Keyvani. This analysis was presented at Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting 2016, April 19-22, 2016, in San Francisco, California, and at the International Society for Pharmacoeconomics and Outcomes Research Annual International Meeting, May 21-25, 2016, in Washington DC.
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Affiliation(s)
- Anna Oh
- 1 Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco
| | - Dang M Tran
- 2 Department of Clinical Pharmacy, University of California, San Francisco
| | - Leann C McDowell
- 2 Department of Clinical Pharmacy, University of California, San Francisco
| | - Dor Keyvani
- 2 Department of Clinical Pharmacy, University of California, San Francisco
| | | | - Oscar Merino
- 2 Department of Clinical Pharmacy, University of California, San Francisco
| | - Leslie Wilson
- 2 Department of Clinical Pharmacy, University of California, San Francisco
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Wilson MR, Bergman A, Chevrou-Severac H, Selby R, Smyth M, Kerrigan MC. Cost-effectiveness of vedolizumab compared with infliximab, adalimumab, and golimumab in patients with ulcerative colitis in the United Kingdom. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:229-240. [PMID: 28271250 DOI: 10.1007/s10198-017-0879-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 02/16/2017] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To examine the clinical and economic impact of vedolizumab compared with infliximab, adalimumab, and golimumab in the treatment of moderately to severely active ulcerative colitis (UC) in the United Kingdom (UK). METHODS A decision analytic model in Microsoft Excel was used to compare vedolizumab with other biologic treatments (infliximab, adalimumab, and golimumab) for the treatment of biologic-naïve patients with UC in the UK. Efficacy data were obtained from a network meta-analysis using placebo as the common comparator. Other inputs (e.g., unit costs, adverse-event disutilities, probability of surgery, mortality) were obtained from published literature. Costs were presented in 2012/2013 British pounds. Outcomes included quality-adjusted life-years (QALYs). Costs and outcomes were discounted by 3.5% per year. Incremental cost-effectiveness ratios were presented for vedolizumab compared with other biologics. Univariate and multivariate probabilistic sensitivity analyses were conducted to assess model robustness to parameter uncertainty. RESULTS The model predicted that anti-tumour necrosis factor-naïve patients on vedolizumab would accrue more QALY than patients on other biologics. The incremental results suggest that vedolizumab is a cost-effective treatment compared with adalimumab (incremental cost-effectiveness ratio of £22,735/QALY) and dominant compared with infliximab and golimumab. Sensitivity analyses suggest that results are most sensitive to treatment response and transition probabilities. However, vedolizumab is cost-effective irrespective of variation in any of the input parameters. CONCLUSIONS Our model predicted that treatment with vedolizumab improves QALY, increases time in remission and response, and is a cost-effective treatment option compared with all other biologics for biologic-naïve patients with moderately to severely active UC.
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Affiliation(s)
- Michele R Wilson
- RTI Health Solutions, 300 Park Offices Drive, Research Triangle Park, NC, 27709, USA.
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Edwards SJ, Mavranezouli I, Osei-Assibey G, Marceniuk G, Wakefield V, Karner C. VivaScope® 1500 and 3000 systems for detecting and monitoring skin lesions: a systematic review and economic evaluation. Health Technol Assess 2018; 20:1-260. [PMID: 27483991 DOI: 10.3310/hta20580] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Skin cancer is one of the most common cancers in the UK. The main risk factor is exposure to ultraviolet radiation from sunlight or the use of sunbeds. Patients with suspicious skin lesions are first examined with a dermoscope. After examination, those with non-cancerous lesions are discharged, but lesions that are still considered clinically suspicious are surgically removed. VivaScope(®) is a non-invasive technology designed to be used in conjunction with dermoscopy to provide a more accurate diagnosis, leading to fewer biopsies of benign lesions or to provide more accurate presurgical margins reducing the risk of cancer recurrence. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of VivaScope(®) 1500 (Caliber Imaging and Diagnostics, Rochester, NY, USA; Lucid Inc., Rochester, NY, USA; or Lucid Inc., MAVIG GmbH, Munich, Germany) and VivaScope(®) 3000 (Caliber Imaging and Diagnostics, Rochester, NY, USA) in the diagnosis of equivocal skin lesions, and VivaScope 3000 in lesion margin delineation prior to surgical excision of lesions. DATA SOURCES Databases (MEDLINE, EMBASE and The Cochrane Library) were searched on 14 October 2014, reference lists of included papers were assessed and clinical experts were contacted for additional information on published and unpublished studies. METHODS A systematic review was carried out to identify randomised controlled trials (RCTs) or observational studies evaluating dermoscopy plus VivaScope, or VivaScope alone, with histopathology as the reference test. A probabilistic de novo economic model was developed to synthesise the available data on costs and clinical outcomes from the UK NHS perspective. All costs were expressed as 2014 prices. RESULTS Sixteen studies were included in the review, but they were too heterogeneous to be combined in a meta-analysis. One of two diagnostic studies that were deemed most representative of UK clinical practice reported that dermoscopy plus VivaScope 1500 was significantly more sensitive than dermoscopy alone in the diagnosis of melanoma (97.8% vs. 94.6%; p = 0.043) and significantly more specific than dermoscopy alone in the diagnosis of non-melanoma (92.4% vs. 26.74%; p < 0.000001). The results of another study suggest 100% [95% confidence interval (CI) 86.16% to 100%] sensitivity for dermoscopy plus VivaScope 1500 versus 100% (95% CI 91.51% to 100%) for dermoscopy alone. Specificity varied from 51.77% to 80.2% depending on the analysis set used. In terms of margin delineation with VivaScope, one study found that 17 out of 29 patients with visible lentigo maligna (LM) had subclinical disease of > 5 mm beyond the dermoscopically identified margin. Using 'optimistic' diagnostic data, the economic model resulted in an incremental cost-effectiveness ratio (ICER) of £8877 per quality-adjusted life-year (QALY) (£9362 per QALY), while the 'less favourable' diagnostic data resulted in an ICER of £19,095 per QALY (£25,453 per QALY) in the diagnosis of suspected melanomas. VivaScope was also shown to be a dominant strategy when used for the diagnostic assessment of suspected basal cell carcinoma (BCC). Regarding margin delineation of LM, mapping with VivaScope was cost-effective, with an ICER of £10,241 per QALY (£11,651 per QALY). However, when VivaScope was used for diagnosis as well as mapping of LM, then the intervention cost was reduced and VivaScope became a dominant strategy. LIMITATIONS There is an absence of UK data in the included studies and, therefore, generalisability of the results to the UK population is unclear. CONCLUSIONS The use of VivaScope appears to be a cost-effective strategy in the diagnostic assessment of equivocal melanomas and BCCs, and in margin delineation of LM prior to surgical treatment. FUTURE WORK High-quality RCTs are required in a UK population to assess the diagnostic accuracy of VivaScope in people with equivocal lesions. STUDY REGISTRATION This study is registered as PROSPERO CRD42014014433. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Middleton MR, Atkins MB, Amos K, Wang PF, Kotapati S, Sabater J, Beusterien K. Societal preferences for adjuvant melanoma health states: UK and Australia. BMC Cancer 2017; 17:689. [PMID: 29041898 PMCID: PMC5646133 DOI: 10.1186/s12885-017-3673-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 10/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND No studies have measured preference-based utility weights for specific toxicities and outcomes associated with approved and investigational adjuvant treatments for patients with resected high-risk melanoma. METHODS A cross-sectional study was conducted in the United Kingdom and Australia to obtain utilities for 14 adjuvant melanoma health states. One-on-one interviews were conducted using standard gamble; utility weights range from 0.0, dead, to 1.0, full health. Supplemental risk questions also were asked. RESULTS Among 155 participants (52% male; mean age, 46 years) "adjuvant treatment no toxicities" (0.89) was most preferred, followed by "induction treatment" (0.88), and "no treatment" (0.86). Participants least preferred "cancer recurrence" (0.62); the utility for "cancer recurrence and 10-year survival with treatment" was 0.70. Disutilities for grade 2 toxicities ranged from -0.06 for fatigue to -0.13 for hypophysitis. The mean maximum acceptable risk of a life-threatening event ranged from 30% for a 6% increase in the chance of remaining cancer free over 3 years to 40% for an 18% increase; Australian respondents were willing to take higher risks. CONCLUSION Reproducible health utilities for adjuvant melanoma health states were obtained from the general population in two countries. These utilities can be incorporated into treatment-specific cost-effectiveness evaluations.
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Affiliation(s)
- Mark R Middleton
- University of Oxford Department of Oncology, Roosevelt Drive, Oxford, OX3 7DQ, UK
| | - Michael B Atkins
- Georgetown-Lombardi Comprehensive Cancer Ctr, 3970 Reservoir Road, NW Research Building, Room E501, Washington, DC, 20057, USA
| | - Kaitlan Amos
- Outcomes Research Strategies in Health, Washington, DC, 20008, USA
| | - Peter Feng Wang
- Bristol-Myers Squibb Co, 3401 Princeton Pike, Lawrenceville, NJ, 08648, USA
| | - Srividya Kotapati
- Bristol-Myers Squibb Co, 3401 Princeton Pike, Lawrenceville, NJ, 08648, USA
| | - Javier Sabater
- Bristol-Myers Squibb S.A. Quintanavides, 15, 28050, Madrid, Spain
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Wilson MR, Azzabi Zouraq I, Chevrou-Severac H, Selby R, Kerrigan MC. Cost-effectiveness of vedolizumab compared with conventional therapy for ulcerative colitis patients in the UK. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:641-652. [PMID: 29081667 PMCID: PMC5652924 DOI: 10.2147/ceor.s135609] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To examine the clinical and economic impact of vedolizumab compared with conventional therapy in the treatment of moderately-to-severely active ulcerative colitis (UC) in the UK based on results of the GEMINI I trial. Methods A decision-analytic model in Microsoft Excel was used to compare vedolizumab with conventional therapy (aminosalicylates, corticosteroids, immunomodulators) for the treatment of patients with UC in the UK. We considered the following three populations: the overall intent-to-treat population from the GEMINI I trial, patients naïve to anti-TNF therapy, and those who had failed anti-TNF-therapy. Population characteristics and efficacy data were obtained from the GEMINI I trial. Other inputs (eg, unit costs, probability of surgery, mortality) were obtained from published literature. Time horizon was a lifetime horizon, with costs and outcomes discounted by 3.5% per year. One-way and probabilistic sensitivity analyses were conducted to measure the impact of parameter uncertainty. Results Vedolizumab had incremental cost-effectiveness ratios of £4,095/quality-adjusted life-year (QALY), £4,423/QALY, and £5,972/QALY compared with conventional therapy in the intent-to-treat, anti-TNF-naïve, and anti-TNF-failure populations, respectively. Patients on vedolizumab accrued more QALYs while incurring more costs than patients on conventional therapy. The sensitivity analyses showed that the results were most sensitive to induction response and transition probabilities for each treatment. Conclusion The results suggest that vedolizumab results in more QALYs and may be a cost-effective treatment option compared with conventional therapy for both anti-TNF-naïve and anti-TNF-failure patients with moderately-to-severely active UC.
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Pike E, Hamidi V, Saeterdal I, Odgaard-Jensen J, Klemp M. Multiple treatment comparison of seven new drugs for patients with advanced malignant melanoma: a systematic review and health economic decision model in a Norwegian setting. BMJ Open 2017; 7:e014880. [PMID: 28827234 PMCID: PMC5724191 DOI: 10.1136/bmjopen-2016-014880] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 05/31/2017] [Accepted: 07/03/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the relative effectiveness and cost-effectiveness of seven new drugs (cobimetinib, dabrafenib, ipilimumab, nivolumab, pembrolizumab, trametinib and vemurafenib) used for treatment of patients with advanced malignant melanoma in the Norwegian setting. DESIGN A multiple technology assessment. PATIENTS Patients with advanced malignant melanoma aged 18 or older. DATA SOURCES A systematic search for randomised controlled trials in relevant bibliographic databases. METHODS We performed network meta-analyses using both direct and indirect evidence with dacarbazine as a common comparator. We ranked the different treatments in terms of their likelihood of leading to the best results for each endpoint. The cost-utility analysis was based on a probabilistic discrete-time Markov cohort model. The model calculated the costs and quality-adjusted life years (QALYs) with different treatment strategies from a healthcare perspective. Sensitivity analysis was performed by means of Monte Carlo simulation. RESULTS Monotherapies with a programmed cell death 1 (PD-1) immune-checkpoint-inhibitor had a higher probability of good performance for overall survival than monotherapies with ipilimumab or BRAF/MEK inhibitors. The combination treatments had all similar levels of effectiveness to the PD-1 immune-checkpoint-inhibitors.PD-1 immune-checkpoint-inhibitors are more effective and more costly compared with ipilimumab in monotherapy. Nivolumab in combination with ipilimumab had higher costs and the same level of effectiveness as the PD-1 immune-checkpoint-inhibitors in monotherapy.BRAF/MEK inhibitor combinations (dabrafenib and trametinib or vemurafenib and cobimetinib) had both similar effectiveness and cost-effectiveness; however, the combination therapies are more likely to give higher quality adjusted life year gains than BRAF or MEK inhibitor monotherapies, but to a higher cost. CONCLUSIONS None of the drugs investigated can be considered cost-effective at what has normally been considered a reasonable willingness-to-pay (WTP) in Norway. Price reductions (from the official list prices) in the region of 63%-84% would be necessary for these drugs to be cost-effective at a WTP of €55 850 per QALY.
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Affiliation(s)
- Eva Pike
- Norwegian Institute of Public Health, Oslo, Norway
| | - Vida Hamidi
- Norwegian Institute of Public Health, Oslo, Norway
| | | | | | - Marianne Klemp
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Pharmacology, University of Oslo, Oslo, Norway
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Park SY, Park EJ, Suh HS, Ha D, Lee EK. Development of a transformation model to derive general population-based utility: Mapping the pruritus-visual analog scale (VAS) to the EQ-5D utility. J Eval Clin Pract 2017; 23:755-761. [PMID: 28194852 DOI: 10.1111/jep.12711] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Although nonpreference-based disease-specific measures are widely used in clinical studies, they cannot generate utilities for economic evaluation. A solution to this problem is to estimate utilities from disease-specific instruments using the mapping function. This study aimed to develop a transformation model for mapping the pruritus-visual analog scale (VAS) to the EuroQol 5-Dimension 3-Level (EQ-5D-3L) utility index in pruritus. METHODS A cross-sectional survey was conducted with a sample (n = 268) drawn from the general population of South Korea. Data were randomly divided into 2 groups, one for estimating and the other for validating mapping models. To select the best model, we developed and compared 3 separate models using demographic information and the pruritus-VAS as independent variables. The predictive performance was assessed using the mean absolute deviation and root mean square error in a separate dataset. RESULTS Among the 3 models, model 2 using age, age squared, sex, and the pruritus-VAS as independent variables had the best performance based on the goodness of fit and model simplicity, with a log likelihood of 187.13. The 3 models had similar precision errors based on mean absolute deviation and root mean square error in the validation dataset. No statistically significant difference was observed between the mean observed and predicted values in all models. CONCLUSIONS In conclusion, model 2 was chosen as the preferred mapping model. Outcomes measured as the pruritus-VAS can be transformed into the EQ-5D-3L utility index using this mapping model, which makes an economic evaluation possible when only pruritus-VAS data are available.
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Affiliation(s)
- Sun-Young Park
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Eun-Ja Park
- Department of Research Center for Drug Policy, Korea Institute for Health and Social Affairs, Seoul, South Korea
| | - Hae Sun Suh
- College of Pharmacy, Pusan National University, Busan, South Korea
| | - Dongmun Ha
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Eui-Kyung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
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Kohn CG, Zeichner SB, Chen Q, Montero AJ, Goldstein DA, Flowers CR. Cost-Effectiveness of Immune Checkpoint Inhibition in BRAF Wild-Type Advanced Melanoma. J Clin Oncol 2017; 35:1194-1202. [PMID: 28221865 PMCID: PMC5791832 DOI: 10.1200/jco.2016.69.6336] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Patients who are diagnosed with stage IV metastatic melanoma have an estimated 5-year relative survival rate of only 17%. Randomized controlled trials of recent US Food and Drug Administration-approved immune checkpoint inhibitors-pembrolizumab (PEM), nivolumab (NIVO), and ipilumumab (IPI)-demonstrate improved patient outcomes, but the optimal treatment sequence in patients with BRAF wild-type metastatic melanoma remains unclear. To inform policy makers about the value of these treatments, we developed a Markov model to compare the cost-effectiveness of different strategies for sequencing novel agents for the treatment of advanced melanoma. Materials and Methods We developed Markov models by using a US-payer perspective and lifetime horizon to estimate costs (2016 US$) and quality-adjusted life years (QALYs) for treatment sequences with first-line NIVO, IPI, NIVO + IPI, PEM every 2 weeks, and PEM every 3 weeks. Health states were defined for initial treatment, first and second progression, and death. Rates for drug discontinuation, frequency of adverse events, disease progression, and death obtained from randomized phase III trials were used to determine the likelihood of transition between states. Deterministic and probabilistic sensitivity analyses were conducted to evaluate model uncertainty. Results PEM every 3 weeks followed by second-line IPI was both more effective and less costly than dacarbazine followed by IPI then NIVO, or IPI followed by NIVO. Compared with the first-line dacarbazine treatment strategy, NIVO followed by IPI produced an incremental cost effectiveness ratio of $90,871/QALY, and first-line NIVO + IPI followed by carboplatin plus paclitaxel chemotherapy produced an incremental cost effectiveness ratio of $198,867/QALY. Conclusion For patients with treatment-naive BRAF wild-type advanced melanoma, first-line PEM every 3 weeks followed by second-line IPI or first-line NIVO followed by second-line IPI are the most cost-effective, immune-based treatment strategies for metastatic melanoma.
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Affiliation(s)
- Christine G. Kohn
- Christine G. Kohn, University of Saint Joseph School of Pharmacy; Christine G. Kohn, University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; Simon B. Zeichner, Daniel A. Goldstein, and Christopher R. Flowers, Winship Cancer Institute at Emory University; Qiushi Chen, Georgia Institute of Technology, Atlanta, GA; Alberto J. Montero, Cleveland Clinic, Cleveland, OH; and Daniel A. Goldstein, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Simon B. Zeichner
- Christine G. Kohn, University of Saint Joseph School of Pharmacy; Christine G. Kohn, University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; Simon B. Zeichner, Daniel A. Goldstein, and Christopher R. Flowers, Winship Cancer Institute at Emory University; Qiushi Chen, Georgia Institute of Technology, Atlanta, GA; Alberto J. Montero, Cleveland Clinic, Cleveland, OH; and Daniel A. Goldstein, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Qiushi Chen
- Christine G. Kohn, University of Saint Joseph School of Pharmacy; Christine G. Kohn, University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; Simon B. Zeichner, Daniel A. Goldstein, and Christopher R. Flowers, Winship Cancer Institute at Emory University; Qiushi Chen, Georgia Institute of Technology, Atlanta, GA; Alberto J. Montero, Cleveland Clinic, Cleveland, OH; and Daniel A. Goldstein, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Alberto J. Montero
- Christine G. Kohn, University of Saint Joseph School of Pharmacy; Christine G. Kohn, University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; Simon B. Zeichner, Daniel A. Goldstein, and Christopher R. Flowers, Winship Cancer Institute at Emory University; Qiushi Chen, Georgia Institute of Technology, Atlanta, GA; Alberto J. Montero, Cleveland Clinic, Cleveland, OH; and Daniel A. Goldstein, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel A. Goldstein
- Christine G. Kohn, University of Saint Joseph School of Pharmacy; Christine G. Kohn, University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; Simon B. Zeichner, Daniel A. Goldstein, and Christopher R. Flowers, Winship Cancer Institute at Emory University; Qiushi Chen, Georgia Institute of Technology, Atlanta, GA; Alberto J. Montero, Cleveland Clinic, Cleveland, OH; and Daniel A. Goldstein, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Christopher R. Flowers
- Christine G. Kohn, University of Saint Joseph School of Pharmacy; Christine G. Kohn, University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; Simon B. Zeichner, Daniel A. Goldstein, and Christopher R. Flowers, Winship Cancer Institute at Emory University; Qiushi Chen, Georgia Institute of Technology, Atlanta, GA; Alberto J. Montero, Cleveland Clinic, Cleveland, OH; and Daniel A. Goldstein, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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Bohensky MA, Pasupathi K, Gorelik A, Kim H, Harrison JP, Liew D. A Cost-Effectiveness Analysis of Nivolumab Compared with Ipilimumab for the Treatment of BRAF Wild-Type Advanced Melanoma in Australia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:1009-1015. [PMID: 27987627 DOI: 10.1016/j.jval.2016.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 05/09/2016] [Accepted: 05/18/2016] [Indexed: 05/25/2023]
Abstract
PURPOSE The aim of this study was to evaluate the cost-effectiveness of nivolumab versus ipilimumab for the treatment of previously untreated patients with BRAF-advanced melanoma (BRAF-AM) from an Australian health system perspective. METHODS A state-transition Markov model was constructed to simulate the progress of Australian patients with BRAF-AM. The model had a 10-year time horizon with outcomes discounted at 5% annually. For the nivolumab group, risks of progression and death were based on those observed in the nivolumab arm of a phase III trial (nivolumab vs. dacarbazine). Progression-free survival and overall survival were extrapolated using parametric survival modeling with a log-logistic distribution. In the absence of head-to-head evidence, overall survival and progression-free survival for ipilimumab were estimated on the basis of an indirect comparison using published data. Costs of managing AM were estimated from a survey of Australian clinicians. The cost of ipilimumab was based on the reimbursement price in Australia. The cost of nivolumab was based on expected reimbursement prices in Australia. Quality-of-life data were obtained within the trial using the EuroQol five-dimensional questionnaire. RESULTS Compared with ipilimumab, nivolumab therapy over 10 years was estimated to yield 1.58 life-years and 1.30 quality-adjusted life-years per person, at a (discounted) net cost of US $39,039 per person. The incremental cost-effectiveness ratios for nivolumab compared with ipilimumab were US $25,101 per year of life saved and $30,475 per quality-adjusted life-year saved. CONCLUSIONS Nivolumab is a cost-effective means of preventing downstream mortality and morbidity in patients with AM compared with ipilimumab in the Australian setting.
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Affiliation(s)
- Megan A Bohensky
- Melbourne EpiCentre, Royal Melbourne Hospital, and the University of Melbourne, Parkville, Victoria, Australia.
| | - Kumar Pasupathi
- Melbourne EpiCentre, Royal Melbourne Hospital, and the University of Melbourne, Parkville, Victoria, Australia
| | - Alexandra Gorelik
- Melbourne EpiCentre, Royal Melbourne Hospital, and the University of Melbourne, Parkville, Victoria, Australia
| | - Hansoo Kim
- Bristol-Myers Squibb Australia, Mulgrave, Victoria, Australia
| | | | - Danny Liew
- Melbourne EpiCentre, Royal Melbourne Hospital, and the University of Melbourne, Parkville, Victoria, Australia
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Amdahl J, Diaz J, Park J, Nakhaipour HR, Delea TE. Cost-effectiveness of pazopanib compared with sunitinib in metastatic renal cell carcinoma in Canada. ACTA ACUST UNITED AC 2016; 23:e340-54. [PMID: 27536183 DOI: 10.3747/co.23.2244] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In Canada and elsewhere, pazopanib and sunitinib-tyrosine kinase inhibitors targeting the vascular endothelial growth factor receptors-are recommended as first-line treatment for patients with metastatic renal cell carcinoma (mrcc). A large randomized noninferiority trial of pazopanib versus sunitinib (comparz) demonstrated that the two drugs have similar efficacy; however, patients randomized to pazopanib experienced better health-related quality of life (hrqol) and nominally lower rates of non-study medical resource utilization. METHODS The cost-effectiveness of pazopanib compared with sunitinib for first-line treatment of mrcc from a Canadian health care system perspective was evaluated using a partitioned-survival model that incorporated data from comparz and other secondary sources. The time horizon of 5 years was based on the maximum duration of follow-up in the final analysis of overall survival from the comparz trial. Analyses were conducted first using list prices for pazopanib and sunitinib and then by assuming that the prices of sunitinib and pazopanib would be equivalent. RESULTS Based on list prices, expected costs were CA$10,293 less with pazopanib than with sunitinib. Pazopanib was estimated to yield 0.059 more quality-adjusted life-years (qalys). Pazopanib was therefore dominant (more qalys and lower costs) compared with sunitinib in the base case. In probabilistic sensitivity analyses, pazopanib was dominant in 79% of simulations and was cost-effective in 90%-100% of simulations at a threshold cost-effectiveness ratio of CA$100,000. Assuming equivalent pricing, pazopanib yielded CA$917 in savings in the base case, was dominant in 36% of probabilistic sensitivity analysis simulations, and was cost-effective in 89% of simulations at a threshold cost-effectiveness ratio of CA$100,000. CONCLUSIONS Compared with sunitinib, pazopanib is likely to be a cost-effective option for first-line treatment of mrcc from a Canadian health care perspective.
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Affiliation(s)
- J Amdahl
- Policy Analysis Inc. ( pai ), Brookline, MA, U.S.A
| | - J Diaz
- Bristol-Myers Squibb, Twickenham, Greater London, U.K
| | - J Park
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, U.S.A
| | - H R Nakhaipour
- GlaxoSmith-Kline, Health Outcomes-Oncology, Mississauga, ON
| | - T E Delea
- Policy Analysis Inc. ( pai ), Brookline, MA, U.S.A
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Freeman K, Connock M, Cummins E, Gurung T, Taylor-Phillips S, Court R, Saunders M, Clarke A, Sutcliffe P. Fluorouracil plasma monitoring: systematic review and economic evaluation of the My5-FU assay for guiding dose adjustment in patients receiving fluorouracil chemotherapy by continuous infusion. Health Technol Assess 2016; 19:1-321, v-vi. [PMID: 26542268 DOI: 10.3310/hta19910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND 5-Fluorouracil (5-FU) is a chemotherapy used in colorectal, head and neck (H&N) and other cancers. Dose adjustment is based on body surface area (BSA) but wide variations occur. Pharmacokinetic (PK) dosing is suggested to bring plasma levels into the therapeutic range to promote fewer side effects and better patient outcomes. We investigated the clinical effectiveness and cost-effectiveness of the My5-FU assay for PK dose adjustment to 5-FU therapy. OBJECTIVES To systematically review the evidence on the accuracy of the My5-FU assay compared with gold standard methods [high-performance liquid chromatography (HPLC) and liquid chromatography-mass spectrometry (LC-MS)]; the effectiveness of My5-FU PK dosing compared with BSA; the effectiveness of HPLC and/or LC-MS compared with BSA; the generalisability of published My5-FU and PK studies; costs of using My5-FU; to develop a cost-effectiveness model. DATA SOURCES We searched MEDLINE, EMBASE, Science Citation Index and other databases between January and April 2014. METHODS Two reviewers independently screened titles and abstracts with arbitration and consensus agreement. We undertook quality assessment. We reconstructed Kaplan-Meier plots for progression-free survival (PFS) and overall survival (OS) for comparison of BSA and PK dosing. We developed a Markov model to compare My5-FU with BSA dosing which modelled PFS, OS and adverse events, using a 2-week cycle over a 20 year time horizon with a 3.5% discount rate. Health impacts were evaluated from the patient perspective, while costs were evaluated from the NHS and Personal Social Services perspective. RESULTS A total of 8341 records were identified through electronic searches and 35 and 54 studies were included in the clinical effectiveness and cost-effectiveness reviews respectively. There was a high apparent correlation between My5-FU, HPLC and LC-MS/mass spectrometer but upper and lower limits of agreement were -18% to 30%. Median OS were estimated as 19.6 [95% confidence interval (CI) 17.0 to 21.0] months for PK versus 14.6 (95% CI 14.1 to 15.3) months for BSA for 5-FU+folinic acid (FA); and 27.4 (95% CI 23.2 to 38.8) months for PK versus 20.6 (95% CI 18.4 to 22.9) months for BSA for FOLFOX6 in metastatic colorectal cancer (mCRC). PK versus BSA studies were generalisable to the relevant populations. We developed cost-effectiveness models for mCRC and H&N cancer. The base case assumed a cost per My5-FU assay of £ 61.03. For mCRC for 12 cycles of a oxaliplatin in combination with 5-fluorouracil and FA (FOLFOX) regimen, there was a quality-adjusted life-year (QALY) gain of 0.599 with an incremental cost-effectiveness ratio of £ 4148 per QALY. Probabilistic and scenario analyses gave similar results. The cost-effectiveness acceptability curve showed My5-FU to be 100% cost-effective at a threshold of £ 20,000 per QALY. For H&N cancer, again, given caveats about the poor evidence base, we also estimated that My5-FU is likely to be cost-effective at a threshold of £ 20,000 per QALY. LIMITATIONS Quality and quantity of evidence were very weak for PK versus BSA dosing for all cancers with no randomised controlled trials (RCTs) using current regimens. For H&N cancer, two studies of regimens no longer in use were identified. CONCLUSIONS Using a linked evidence approach, My5-FU appears to be cost-effective at a willingness to pay of £ 20,000 per QALY for both mCRC and H&N cancer. Considerable uncertainties remain about evidence quality and practical implementation. RCTs are needed of PK versus BSA dosing in relevant cancers.
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Affiliation(s)
| | - Martin Connock
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Tara Gurung
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mark Saunders
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
| | - Aileen Clarke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Medical School, University of Warwick, Coventry, UK
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Cost Effectiveness of Sequencing 34 Cancer-Associated Genes as an Aid for Treatment Selection in Patients with Metastatic Melanoma. Mol Diagn Ther 2016; 19:169-77. [PMID: 25926090 PMCID: PMC4469775 DOI: 10.1007/s40291-015-0140-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective To determine whether a next-generation sequencing (NGS) panel of 34 cancer-associated genes would cost-effectively aid in the treatment selection for patients with metastatic melanoma, compared with a single-site BRAF V600 mutation test. Methods A decision model was developed to estimate the costs and health outcomes of the two test strategies. The cost effectiveness of these two strategies was analyzed from a payer perspective over a 2-year time horizon with model parameters taken from the literature. Results In the base case, the gene sequencing panel strategy resulted in a cost of US$120,022 and 0.721 quality-adjusted life years (QALYs) per patient, whereas the single-site mutation test strategy resulted in a cost of US$128,965 and 0.704 QALYs. Thus, the gene sequencing panel strategy cost US$8943 less per patient and increased QALYs by 0.0174 per patient. Sensitivity analyses showed that, compared with the single-site mutation test strategy, the gene sequencing panel strategy had a 90.9 % chance of having reduced costs and increased QALYs, with the cost of the gene sequencing panel test having minimal effect on the incremental cost. Conclusion Compared with the single-site mutation test, the use of an NGS panel of 34 cancer-associated genes as an aid in selecting therapy for patients with metastatic melanoma reduced costs and increased QALYs. If the base-case results were applied to the 8900 patients diagnosed with metastatic melanoma in the USA each year, the gene sequencing panel strategy could result in an annual savings of US$79.6 million and a gain of 155 QALYs. Electronic supplementary material The online version of this article (doi:10.1007/s40291-015-0140-9) contains supplementary material, which is available to authorized users.
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Tarricone R, Abu Koush D, Nyanzi-Wakholi B, Medina-Lara A. A systematic literature review of the economic implications of chemotherapy-induced diarrhea and its impact on quality of life. Crit Rev Oncol Hematol 2016; 99:37-48. [DOI: 10.1016/j.critrevonc.2015.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 12/22/2015] [Accepted: 12/22/2015] [Indexed: 12/27/2022] Open
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Lester-Coll NH, Rutter CE, Bledsoe TJ, Goldberg SB, Decker RH, Yu JB. Cost-Effectiveness of Surgery, Stereotactic Body Radiation Therapy, and Systemic Therapy for Pulmonary Oligometastases. Int J Radiat Oncol Biol Phys 2016; 95:663-72. [PMID: 27055395 DOI: 10.1016/j.ijrobp.2016.01.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/06/2016] [Accepted: 01/12/2016] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Pulmonary oligometastases have conventionally been managed with surgery and/or systemic therapy. However, given concerns about the high cost of systemic therapy and improvements in local treatment of metastatic cancer, the optimal cost-effective management of these patients is unclear. Therefore, we sought to assess the cost-effectiveness of initial management strategies for pulmonary oligometastases. METHODS AND MATERIALS A cost-effectiveness analysis using a Markov modeling approach was used to compare average cumulative costs, quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) among 3 initial disease management strategies: video-assisted thoracic surgery (VATS) wedge resection, stereotactic body radiation therapy (SBRT), and systemic therapy among 5 different cohorts of patient disease: (1) melanoma; (2) non-small cell lung cancer adenocarcinoma without an EGFR mutation (NSCLC AC); (3) NSCLC with an EGFR mutation (NSCLC EGFRm AC); (4) NSCLC squamous cell carcinoma (NSCLC SCC); and (5) colon cancer. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to analyze uncertainty with regard to model parameters. RESULTS In the base case, SBRT was cost effective for melanoma, with costs/net QALYs of $467,787/0.85. In patients with NSCLC, the most cost-effective strategies were SBRT for AC ($156,725/0.80), paclitaxel/carboplatin for SCC ($123,799/0.48), and erlotinib for EGFRm AC ($147,091/1.90). Stereotactic body radiation therapy was marginally cost-effective for EGFRm AC compared to erlotinib with an incremental cost-effectiveness ratio of $126,303/QALY. For colon cancer, VATS wedge resection ($147,730/2.14) was the most cost-effective strategy. Variables with the greatest influence in the model were erlotinib-associated progression-free survival (EGFRm AC), toxicity (EGFRm AC), cost of SBRT (NSCLC SCC), and patient utilities (all histologies). CONCLUSIONS Video-assisted thoracic surgery wedge resection or SBRT can be cost-effective in select patients with pulmonary oligometastases, depending on histology, efficacy, and tolerability of treatment and patient preferences.
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Affiliation(s)
- Nataniel H Lester-Coll
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
| | - Charles E Rutter
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Trevor J Bledsoe
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Sarah B Goldberg
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
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Aristides M, Barlev A, Barber B, Gijsen M, Quinn C. Population preference values for health states in relapsed or refractory B-precursor acute lymphoblastic leukemia in the United Kingdom. Health Qual Life Outcomes 2015; 13:181. [PMID: 26573610 PMCID: PMC4647711 DOI: 10.1186/s12955-015-0377-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 11/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To date, reliable and comprehensive health-related quality of life data for patients with relapsed or refractory B-precursor acute lymphoblastic leukemia (ALL) have not been collected in clinical trials of the disease, and no utility studies have been published. The purpose of this study was to define and validate health states experienced by adults with relapsed/refractory B-precursor ALL, and to assign utility values to these health states using time-trade off methodology. METHODS This study was conducted in the UK in three phases. In the first phase, five health state descriptions were developed based on a recent clinical trial. The second phase validated the health state descriptions with clinicians and patients with experience of relapsed/refractory B-precursor ALL. The third phase involved prospective health state valuation using time-trade off methodology in a sample of the general public. The study was approved by the UK National Health Service Research Ethics Committee. RESULTS In total, 123 participants were recruited and included in the final analysis; all participants gave written, informed consent. Complete remission was the most preferred health state (mean utility [SEM], 0.86 [0.01]), followed by complete remission with partial hematological recovery (with minimal risk of bleeding or developing infection) (0.75 [0.02]); aplastic bone marrow (0.59 [0.02]); partial remission (0.50 [0.03]); and progressive disease (0.30 [0.04]). CONCLUSIONS This is the first study to report utility values for health states associated with relapsed/refractory B-precursor ALL. It was designed and conducted to align with NICE guidance on alternative methods for generating health state utility values when EQ-5D data are either unavailable or inappropriate. These utilities can be applied in future cost-effectiveness analyses of treatment for relapsed/refractory B-precursor ALL.
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Matter-Walstra K, Braun R, Kolb C, Ademi Z, Dummer R, Pestalozzi B, Schwenkglenks M. A cost-effectiveness analysis of trametinib plus dabrafenib as first-line therapy for metastatic BRAF V600-mutated melanoma in the Swiss setting. Br J Dermatol 2015; 173:1462-70. [DOI: 10.1111/bjd.14152] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 12/19/2022]
Affiliation(s)
- K. Matter-Walstra
- Institute of Pharmaceutical Medicine (ECPM); University of Basel; Klingelbergstraße 61 Basel CH-4056 Switzerland
- SAKK Coordinating Centre; Bern Switzerland
| | - R. Braun
- Department of Dermatology; University Hospital Zürich; Zürich Switzerland
| | - C. Kolb
- SAKK Coordinating Centre; Bern Switzerland
| | - Z. Ademi
- Institute of Pharmaceutical Medicine (ECPM); University of Basel; Klingelbergstraße 61 Basel CH-4056 Switzerland
| | - R. Dummer
- Department of Dermatology; University Hospital Zürich; Zürich Switzerland
| | - B.C. Pestalozzi
- SAKK Coordinating Centre; Bern Switzerland
- Department of Oncology; University Hospital Zürich; Zürich Switzerland
| | - M. Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM); University of Basel; Klingelbergstraße 61 Basel CH-4056 Switzerland
- Epidemiology, Biostatistics and Prevention Institute; University of Zürich; Zürich Switzerland
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Hashim H, Beusterien K, Bridges JFP, Amos K, Cardozo L. Patient preferences for treating refractory overactive bladder in the UK. Int Urol Nephrol 2015; 47:1619-27. [PMID: 26347077 DOI: 10.1007/s11255-015-1100-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 08/28/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate patient preferences for refractory overactive bladder (OAB) treatments: sacral neuromodulation (SNM), onabotulinum toxin A (Botox(®)), and percutaneous tibial nerve stimulation (PTNS). MATERIALS AND METHODS A cross-sectional Web survey was conducted with UK idiopathic OAB patients, recruited by a market research company. Preference was explored using direct questioning, comparing SNM, Botox, and PTNS, and via best-worst scaling (BWS). In BWS, patients prioritized subsets of 13 treatment characteristics (attributes) across 13 choice tasks, identifying the attribute they considered best and worst in each task. The attributes were those that were identified by patients in previous qualitative interviews as influential in treatment selection. BWS scores for each attribute, ranging from 1.0 (most favourable) to -1.0 (most unfavourable), were calculated based on the rates they were identified as best and as worst. To identify attributes that may influence treatment choice, BWS scores were compared among patients based on their most preferred treatment using analyses of variance; pairwise differences were assessed using Tukey's multiple comparisons test. RESULTS The study population (N = 139) was 77 % female, had a mean age of 49 years, and were diagnosed a mean of 6.1 years ago. All 13 attribute BWS scores were viewed positively (score > 0.0) or negatively (score < 0.0). Among the 127 (91 %) of patients who had experience with OAB medication only, most (≥80 %) were willing to try each of the three treatments; 57, 34, and 9 % most preferred PTNS, SNM, and Botox, respectively. Preferences for the attributes differed based on which treatment that patients preferred. Specifically, patients preferring SNM (PS) favoured 'implanted device in upper buttock' more than those preferring PTNS (PP) or Botox (PB). Compared to PB, PS also favoured 'sends signals between bladder and brain to help restore bladder function' and 'test phase'. PB favoured 'Botox (botulinum toxin) treatment' and 'treatment procedure delivered through the urethra' more than PS and PP. PP favoured the following more than PS and PB: 'needle inserted into ankle', 'minimal side effects' and 'treatment requires repeated visits over time'. CONCLUSION This study identified specific characteristics of specialized therapies for refractory OAB that may significantly influence patient preferences, which may be used to help inform treatment decision-making.
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Affiliation(s)
| | | | - John F P Bridges
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | - Linda Cardozo
- Urogynaecology Department, King's College Hospital, London, UK.
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Targeted Therapies Compared to Dacarbazine for Treatment of BRAF(V600E) Metastatic Melanoma: A Cost-Effectiveness Analysis. J Skin Cancer 2015; 2015:505302. [PMID: 26171248 PMCID: PMC4478371 DOI: 10.1155/2015/505302] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/26/2015] [Indexed: 12/19/2022] Open
Abstract
Purpose. Two BRAFV600E targeted therapies, dabrafenib and vemurafenib, have received US approval for treatment of metastatic melanoma in BRAFV600E patients, a mutation that affects ~50% of patients. We evaluated the cost-effectiveness of BRAF inhibitors and traditional chemotherapy for treatment of metastatic melanoma. Methods. A Markov model was developed using a societal perspective. Transition probabilities were derived from two Phase III registration trials comparing each BRAF inhibitor against dacarbazine. Costs were obtained from literature, national databases, and Medicare fee schedules. Utilities were obtained from published literature. Deterministic and probabilistic sensitivity analyses were run to test the impact of uncertainties. Results. The incremental cost-effectiveness ratio of dabrafenib was $149,035/QALY compared to dacarbazine. Vemurafenib was dominated by dabrafenib. Probabilistic sensitivity analysis showed that, at a willingness-to-pay (WTP) threshold of ≤$100,000/QALY, dacarbazine was the optimal treatment in ~85% of simulations. At a WTP threshold of ≥$150,000/QALY, dabrafenib was the optimal treatment. Conclusion. Compared with dacarbazine, dabrafenib and vemurafenib were not cost-effective at a willingness-to-pay threshold of $100,000/QALY. Dabrafenib is more efficient compared to vemurafenib. With few treatment options, dabrafenib is an option for qualifying patients if the overall cost of dabrafenib is reduced to $30,000–$31,000 or a WTP threshold of ≥$150,000/QALY is considered. More comparative data is needed.
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Johnston KM, McPherson E, Osenenko K, Vergidis J, Levy AR, Peacock S. Cost-effectiveness of therapies for melanoma. Expert Rev Pharmacoecon Outcomes Res 2015; 15:229-42. [PMID: 25703441 DOI: 10.1586/14737167.2015.1017563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Melanoma presents an important burden worldwide. Until recently, the prognosis for unresectable and metastatic melanoma was poor, with 10% of metastatic melanoma patients surviving for 2 years. The introduction of newer therapies including ipilimumab, vemurafenib, dabrafenib and trametinib improved progression-free survival, with additional benefits anticipated from the forthcoming class of programmed cell death 1 inhibitors. Cost of therapy and resulting cost-effectiveness is an important factor in determining patient access to specific treatments. The objective of this study was to review the published evidence regarding cost-effectiveness of melanoma therapies and provide an overview of the relative cost-effectiveness of available therapies by disease stage. For earlier-stage disease, IFN-α has been found to be cost-effective, although its clinical benefits have not been well established. For unresectable and metastatic melanoma, newer therapies provide benefits over standard-of-care chemotherapy, but comprehensive analyses will need to be conducted to determine the most cost-effective therapy.
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Hatswell AJ, Pennington B, Pericleous L, Rowen D, Lebmeier M, Lee D. Patient-reported utilities in advanced or metastatic melanoma, including analysis of utilities by time to death. Health Qual Life Outcomes 2014; 12:140. [PMID: 25214238 PMCID: PMC4173059 DOI: 10.1186/s12955-014-0140-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 08/28/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Health-related quality of life is often collected in clinical studies, and forms a cornerstone of economic evaluation. This study had two objectives, firstly to report and compare pre- and post-progression health state utilities in advanced melanoma when valued by different methods and secondly to explore the validity of progression-based health state utility modelling compared to modelling based upon time to death. METHODS Utilities were generated from the ipilimumab MDX010-20 trial (Clinicaltrials.gov Identifier: NCT00094653) using the condition-specific EORTC QLQ-C30 (via the EORTC-8D) and generic SF-36v2 (via the SF-6D) preference-based measures. Analyses by progression status and time to death were conducted on the patient-level data from the MDX010-20 trial using generalised estimating equations fitted in Stata®, and the predictive abilities of the two approaches compared. RESULTS Mean utility showed a decrease on disease progression in both the EORTC-8D (0.813 to 0.776) and the SF-6D (0.648 to 0.626). Whilst higher utilities were obtained using the EORTC-8D, the relative decrease in utility on progression was similar between measures. When analysed by time to death, both EORTC-8D and SF-6D showed a large decrease in utility in the 180 days prior to death (from 0.831 to 0.653 and from 0.667 to 0.544, respectively). Compared to progression status alone, the use of time to death gave similar or better estimates of the original data when used to predict patient utility in the MDX010-20 study. Including both progression status and time to death further improved model fit. Utilities seen in MDX010-20 were also broadly comparable with those seen in the literature. CONCLUSIONS Patient-level utility data should be analysed prior to constructing economic models, as analysis solely by progression status may not capture all predictive factors of patient utility and time to death may, as death approaches, be as or more important. Additionally this study adds to the body of evidence showing that different scales lead to different health state values. Further research is needed on how different utility instruments (the SF-6D, EORTC-8D and EQ-5D) relate to each other in different disease areas.
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Curl P, Vujic I, van ‘t Veer LJ, Ortiz-Urda S, Kahn JG. Cost-effectiveness of treatment strategies for BRAF-mutated metastatic melanoma. PLoS One 2014; 9:e107255. [PMID: 25198196 PMCID: PMC4157865 DOI: 10.1371/journal.pone.0107255] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 08/11/2014] [Indexed: 12/11/2022] Open
Abstract
Purpose Genetically-targeted therapies are both promising and costly advances in the field of oncology. Several treatments for metastatic melanoma with a mutation in the BRAF gene have been approved. They extend life but are more expensive than the previous standard of care (dacarbazine). Vemurafenib, the first drug in this class, costs $13,000 per month ($207,000 for a patient with median survival). Patients failing vemurafenib are often given ipilimumab, an immunomodulator, at $150,000 per course. Assessment of cost-effectiveness is a valuable tool to help navigate the transition toward targeted cancer therapy. Methods We performed a cost-utility analysis to compare three strategies for patients with BRAF+ metastatic melanoma using a deterministic expected-value decision tree model to calculate the present value of lifetime costs and quality-adjusted life years (QALYs) for each strategy. We performed sensitivity analyses on all variables. Results In the base case, the incremental cost-effectiveness ratio (ICER) for vemurafenib compared with dacarbazine was $353,993 per QALY gained (0.42 QALYs added, $156,831 added). The ICER for vemurafenib followed by ipilimumab compared with vemurafenib alone was $158,139. In sensitivity analysis, treatment cost had the largest influence on results: the ICER for vemurafenib versus dacarbazine dropped to $100,000 per QALY gained with a treatment cost of $3600 per month. Conclusion The cost per QALY gained for treatment of BRAF+ metastatic melanoma with vemurafenib alone or in combination exceeds widely-cited thresholds for cost-effectiveness. These strategies may become cost-effective with lower drug prices or confirmation of a durable response without continued treatment.
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Affiliation(s)
- Patti Curl
- University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Igor Vujic
- University of California San Francisco, San Francisco, California, United States of America
- The Rudolfstiftung Hospital, Vienna, Austria
| | - Laura J. van ‘t Veer
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
| | - Susana Ortiz-Urda
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
| | - James G. Kahn
- University of California San Francisco, San Francisco, California, United States of America
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