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Gerbasi ME, Stellato D, Ghate SR, Ndife B, Moynahan A, Mishra D, Gunda P, Koruth R, Delea TE. Cost-effectiveness of dabrafenib and trametinib in combination as adjuvant treatment of BRAF V600E/K mutation-positive melanoma from a US healthcare payer perspective. J Med Econ 2019; 22:1243-1252. [PMID: 31223037 DOI: 10.1080/13696998.2019.1635487] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: The COMBI-AD trial demonstrated the efficacy and safety of dabrafenib and trametinib in combination vs placebo as adjuvant treatment of patients with BRAF V600E/K mutation-positive resected Stage IIIA (lymph node metastasis >1 mm), IIIB, or IIIC melanoma. This analysis evaluated the cost-effectiveness of dabrafenib and trametinib vs observation from a US healthcare payer perspective.Methods: This evaluation employed a non-homogeneous, semi-Markov, cohort model with health states for relapse-free survival (RFS), post-locoregional recurrence (LR), post-distant recurrence (DR) receiving first-line treatment, and post-DR receiving second-line treatment. A 50-year modeling time horizon was used. Transition probabilities were estimated based on individual patient data (IPD) from the COMBI-AD trial. Health-state utilities were estimated using EuroQol (EQ-5D) index values from COMBI-AD and published sources. Direct medical costs associated with treatment of melanoma were considered, including costs of BRAF mutation testing, medication and administration costs for adjuvant and metastatic treatments, costs of treating recurrence, and costs of adverse events. Costs and quality-adjusted life-years (QALYs) were discounted at 3.0% annually.Results: Compared with observation, adjuvant dabrafenib and trametinib was estimated to result in a gain of 2.15 QALYs at an incremental cost of $74,518. The incremental cost-effectiveness ratio (ICER) was estimated to be $34,689 per QALY. In deterministic sensitivity analyses, the ICER was sensitive to the cost of dabrafenib and trametinib and the distribution used for projecting RFS beyond the end of follow-up in the COMBI-AD trial. At a cost-effectiveness threshold of $100,000 per QALY, the probability that dabrafenib and trametinib is cost-effective was estimated to be 92%.Conclusions: Given generally-accepted cost-effectiveness threshold values in the US, dabrafenib plus trametinib is likely to be a cost-effective adjuvant therapy for patients with BRAF mutation positive melanoma. These results may be useful for policy-makers in their deliberations regarding reimbursement and access to this treatment.
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Affiliation(s)
| | | | | | - Briana Ndife
- Novartis Pharmaceuticals Corp, East Hanover, NJ, USA
| | | | | | | | - Roy Koruth
- Novartis Pharmaceuticals Corp, Hyderabad, India
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Sharma R, Koruth R, Kanters S, Druyts E, Tarhini A. Comparative efficacy and safety of dabrafenib in combination with trametinib versus competing adjuvant therapies for high-risk melanoma. J Comp Eff Res 2019; 8:1349-1363. [PMID: 31778073 DOI: 10.2217/cer-2019-0061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim To conduct a systematic literature review of high-risk resectable cutaneous melanoma adjuvant therapeutics and compare safety and efficacy. Methods: The systematic literature review included randomized controlled trials investigating: dabrafenib plus trametinib (DAB + TRAM), nivolumab, pembrolizumab, ipilimumab, vemurafenib, chemotherapy and interferons. Outcomes included overall survival (OS), relapse-free survival, distant metastasis-free survival and safety. All outcomes were synthesized using Bayesian network meta-analysis. Results: Across relapse-free survival, distant metastasis-free survival and OS, DAB + TRAM had the lowest estimated hazards of respective events relative to all other treatments (exception relative to nivolumab in OS). Differences were significant relative to placebo, chemotherapy, interferons and ipilimumab. Conclusion: DAB + TRAM has improved efficacy over historical treatment options (ipilimumab, interferons and chemotherapy) and comparable efficacy with other targeted and immune checkpoint inhibitors.
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Affiliation(s)
- Rohini Sharma
- Precision Xtract, Vancouver, British Columbia, V6H 3Y4, Canada
| | - Roy Koruth
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | - Steve Kanters
- Precision Xtract, Vancouver, British Columbia, V6H 3Y4, Canada
| | - Eric Druyts
- Precision Xtract, Vancouver, British Columbia, V6H 3Y4, Canada.,Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA.,Moffitt Comprehensive Cancer Center, Tampa, FL 33612, USA
| | - Ahmad Tarhini
- Moffitt Comprehensive Cancer Center, Tampa, FL 33612, USA
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Stellato D, Gerbasi ME, Ndife B, Ghate SR, Moynahan A, Mishra D, Gunda P, Koruth R, Delea TE. Budget Impact of Dabrafenib and Trametinib in Combination as Adjuvant Treatment of BRAF V600E/K Mutation-Positive Melanoma from a U.S. Commercial Payer Perspective. J Manag Care Spec Pharm 2019; 25:1227-1237. [PMID: 31663466 PMCID: PMC10398148 DOI: 10.18553/jmcp.2019.25.11.1227] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Before the approval of dabrafenib and trametinib in combination, there were no approved therapies in the adjuvant setting that target the RAS/RAF/MEK/ERK pathway. OBJECTIVE To evaluate the budget impact of dabrafenib and trametinib in combination for adjuvant treatment of patients with BRAF V600 mutation-positive resected Stage IIIA, IIIB, or IIIC melanoma from a U.S. commercial payer perspective using data from the COMBI-AD trial, as well as other sources. METHODS The budget impact of dabrafenib and trametinib in combination for patients with BRAF V600E/K mutation-positive, resected Stage IIIA, IIIB, or IIIC melanoma was evaluated from the perspective of a hypothetical population of 1 million members with demographic characteristics consistent with those of a commercially insured U.S. insurance plan (i.e., adults aged less than 65 years) using an economic model developed in Microsoft Excel. The model compared melanoma-related health care costs over a 3-year projection period under 2 scenarios: (1) a reference scenario in which dabrafenib and trametinib are assumed to be unavailable for adjuvant therapy and (2) a new scenario in which the combination is assumed to be available. Treatments potentially displaced by dabrafenib and trametinib were assumed to include observation, high-dose interferon alpha-2b, ipilimumab, and nivolumab. Costs considered in the model include those of adjuvant therapies and treatment of locoregional and distant recurrences. The numbers of patients eligible for treatment with dabrafenib and trametinib were based on data from cancer registries, published sources, and assumptions. Treatment mixes under the reference and new scenarios were based on market research data, clinical expert opinion, and assumptions. Probabilities of recurrence and death were based on data from the COMBI-AD trial and an indirect treatment comparison. Medication costs were based on wholesale acquisition cost prices. Costs of distant recurrence were from a health insurance claims study. RESULTS In a hypothetical population of 1 million commercially insured members, 48 patients were estimated to become eligible for treatment with dabrafenib and trametinib in combination over the 3-year projection period; in the new scenario, 10 patients were projected to receive such treatment. Cumulative costs of melanoma-related care were estimated to be $6.3 million in the reference scenario and $6.9 million in the new scenario. The budget impact of dabrafenib and trametinib in combination was an increase of $549 thousand overall and 1.5 cents per member per month. CONCLUSIONS For a hypothetical U.S. commercial health plan of 1 million members, the budget impact of dabrafenib and trametinib in combination as adjuvant treatment for melanoma is likely to be relatively modest and within the range of published estimates for oncology therapies. These results may assist payers in making coverage decisions regarding the use of adjuvant dabrafenib and trametinib in melanoma. DISCLOSURES Funding for this research was provided to Policy Analysis Inc. (PAI) by Novartis Pharmaceuticals. Stellato, Moynahan, and Delea are employed by PAI. Ndife, Koruth, Mishra, and Gunda are employed by Novartis. Ghate was employed by Novartis at the time of this study and is shareholder in Novartis, Provectus Biopharmaceuticals, and Mannkind Corporation. Gerbasi was employed by PAI at the time of this study and is currently an employee, and stockholder, of Sage Therapeutics. Delea reports grant funding from Merck and research funding from Amgen, Novartis, Sanofi, Seattle Genetics, Takeda, Jazz, EMD Serono, and 21st Century Oncology, unrelated to this work.
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Affiliation(s)
| | | | - Briana Ndife
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | | | | | - Dinesh Mishra
- Novartis Pharmaceuticals, Hyderabad, Telangana, India
| | - Praveen Gunda
- Novartis Pharmaceuticals, Hyderabad, Telangana, India
| | - Roy Koruth
- Novartis Pharmaceuticals, East Hanover, New Jersey
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Mohr P, Kiecker F, Soriano V, Dereure O, Mujika K, Saiag P, Utikal J, Koneru R, Robert C, Cuadros F, Chacón M, Villarroel RU, Najjar YG, Kottschade L, Couselo EM, Koruth R, Guérin A, Burne R, Ionescu-Ittu R, Perrinjaquet M, Zager JS. Adjuvant therapy versus watch-and-wait post surgery for stage III melanoma: a multicountry retrospective chart review. Melanoma Manag 2019; 6:MMT33. [PMID: 31871622 PMCID: PMC6923782 DOI: 10.2217/mmt-2019-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/11/2019] [Indexed: 12/11/2022] Open
Abstract
AIM To describe treatment patterns among patients with stage III melanoma who underwent surgical excision in years 2011-2016, and assess outcomes among patients who subsequently received systemic adjuvant therapy versus watch-and-wait. METHODS Chart review of 380 patients from 17 melanoma centers in North America, South America and Europe. RESULTS Of 129 (34%) patients treated with adjuvant therapy, 85% received interferon α-2b and 56% discontinued treatment (mostly due to adverse events). Relapse-free survival was significantly longer for patients treated with adjuvant therapy versus watch-and-wait (hazard ratio = 0.63; p < 0.05). There was considerable heterogeneity in adjuvant treatment schedules and doses. Similar results were found in patients who received interferon-based adjuvant therapy. CONCLUSION Adjuvant therapies with better safety/efficacy profiles will improve clinical outcomes in patients with stage III melanoma.
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Affiliation(s)
- Peter Mohr
- Department of Dermatology, Elbe Kliniken, Stade, Germany
| | - Felix Kiecker
- Department of Dermatology and Allergy, Skin Cancer Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Virtudes Soriano
- Department of Medical Oncology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Olivier Dereure
- Department of Dermatology and INSERM U1058 ‘pathogenesis and control of chronic infections’, University of Montpellier, Montpellier, France
| | - Karmele Mujika
- Department of Medical Oncology, Onkologikoa-Oncology Institute Gipuzkoa, Gipuzkoa, Spain
| | - Philippe Saiag
- Department of General and Oncologic Dermatology Ambroise Paré Hospital, APHP; EA 4340 ‘Biomarkers in cancerology and hemato-oncology’, UVSQ, Université Paris-Saclay, Boulogne-Billancourt, France
| | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany and Department of Dermatology, Venereology and Allergology; University Medical Center, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Rama Koneru
- RS McLaughlin Durham Regional Cancer Centre, Lakeridge Health, Oshawa, Oshawa, Ontario, Canada
| | - Caroline Robert
- Dermatology Unit, Gustave Roussy and Paris-Saclay University, Villejuif, France
| | - Florencia Cuadros
- Medical Oncology, Instituto de Oncologia de Rosario, Rosario, Santa Fe, Argentina
| | - Matias Chacón
- Departments of Medical and Surgical Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | - Yana G Najjar
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Lisa Kottschade
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Eva M Couselo
- Department of Medical Oncology, Vall d'Hebron Hospital and VHIO (Vall d'Hebron Institute of Oncology), Barcelona, Spain
| | - Roy Koruth
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | | | | | | | | | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL 33612, USA
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Schadendorf D, Hauschild A, Santinami M, Atkinson V, Mandalà M, Chiarion-Sileni V, Larkin J, Nyakas M, Dutriaux C, Haydon A, Robert C, Mortier L, Lesimple T, Plummer R, Schachter J, Dasgupta K, Manson S, Koruth R, Mookerjee B, Kefford R, Dummer R, Kirkwood JM, Long GV. Patient-reported outcomes in patients with resected, high-risk melanoma with BRAF V600E or BRAF V600K mutations treated with adjuvant dabrafenib plus trametinib (COMBI-AD): a randomised, placebo-controlled, phase 3 trial. Lancet Oncol 2019; 20:701-710. [PMID: 30928620 DOI: 10.1016/s1470-2045(18)30940-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND In the phase 3 COMBI-AD study, patients with resected, stage III melanoma with BRAFV600E or BRAFV600K mutations received adjuvant dabrafenib plus trametinib or placebo. The primary analysis showed that dabrafenib plus trametinib significantly improved relapse-free survival at 3 years. These results led to US Food and Drug Administration approval of dabrafenib plus trametinib as adjuvant treatment for patients with resected stage III melanoma with BRAFV600E or BRAFV600K mutations. Here, we report the patient-reported outcomes from COMBI-AD. METHODS COMBI-AD was a randomised, double-blind, placebo-controlled, phase 3 study done at 169 sites in 25 countries. Study participants were aged 18 years or older and had complete resection of stage IIIA (lymph node metastases >1 mm), IIIB, or IIIC cutaneous melanoma as per American Joint Committee on Cancer 7th edition criteria, with BRAFV600E or BRAFV600K mutations, and an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients were randomly assigned (1:1) via an interactive voice response system, stratified by mutation type and disease stage, to receive oral dabrafenib (150 mg twice daily) plus oral trametinib (2 mg once daily) or matching placebos for 12 months. Patients, physicians, and the investigators who analysed the data were masked to treatment allocation. The primary endpoint was relapse-free survival, reported elsewhere. Health-related quality of life, reported here, was a prespecified exploratory endpoint, and was assessed with the European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L) questionnaire in the intention-to-treat population. We used a mixed-model repeated-measures analysis to assess differences in health-related quality of life between groups. This study is registered with ClinicalTrials.gov, number NCT01682083. The trial is ongoing, but is no longer recruiting participants. FINDINGS Between Jan 31, 2013, and Dec 11, 2014, 870 patients were enrolled and randomly assigned to receive dabrafenib plus trametinib (n=438) or matching placebos (n=432). Data were collected until the data cutoff for analyses of the primary endpoint (June 30, 2017). The median follow-up was 34 months (IQR 28-39) in the dabrafenib plus trametinib group and 33 months (20·5-39) in the placebo group. During the 12-month treatment phase, there were no significant or clinically meaningful changes from baseline between groups in EQ-5D-3L visual analogue scale (EQ-VAS) or utility scores. During treatment, there were no clinically meaningful differences in VAS scores or utility scores in the dabrafenib plus trametinib group between patients who did and did not experience the most common adverse events. During long-term follow-up (range 15-48 months), VAS and utility scores were similar between groups and did not differ from baseline scores. At recurrence, there were significant decreases in VAS scores in both the dabrafenib plus trametinib group (mean change -6·02, SD 20·57; p=0·0032) and the placebo group (-6·84, 20·86; p<0·0001); the mean change in utility score also differed significantly at recurrence for both groups (dabrafenib plus trametinib -0·0626, 0·1911, p<0·0001; placebo -0·0748, 0·2182, p<0·0001). INTERPRETATION These findings show that dabrafenib plus trametinib did not affect patient-reported outcome scores during or after adjuvant treatment, and suggest that preventing or delaying relapse with adjuvant therapy could be beneficial in this setting. FUNDING Novartis.
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Affiliation(s)
- Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer Consortium, Heidelberg, Germany.
| | | | | | - Victoria Atkinson
- Princess Alexandra Hospital, Gallipoli Medical Research Foundation, University of Queensland, QLD, Australia
| | - Mario Mandalà
- Papa Giovanni XXIII Cancer Center Hospital, Bergamo, Italy
| | | | | | - Marta Nyakas
- Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Caroline Dutriaux
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Saint-André, Bordeaux, France
| | | | | | | | - Thierry Lesimple
- Medical Oncology Department, Centre Eugène Marquis, Rennes, France
| | - Ruth Plummer
- Northern Centre for Cancer Care, Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno-Oncology and Melanoma, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Roy Koruth
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | | | - Richard Kefford
- Macquarie University, Sydney, NSW, Australia; Melanoma Institute Australia, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia
| | - Reinhard Dummer
- University Hospital Zürich Skin Cancer Center, Zürich, Switzerland
| | - John M Kirkwood
- Melanoma Program, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Georgina V Long
- Melanoma Institute Australia, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia; Royal North Shore Hospital, Sydney, NSW, Australia; Mater Hospital, Sydney, NSW, Australia
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Abstract
We have developed a procedure for the quantitative refolding of the Link module from human tumor necrosis factor-stimulated gene 6. This significantly simplifies the previously described method of production of this protein domain (Day et al., Protein Expression Purif. 8, 1-16, 1996). The refolding is carried out under nondenaturing conditions at pH 6.0 in the presence of a 100-fold molar excess of beta-mercaptoethanol. After 2 days the starting material, which consists of three species that differ only with respect to their disulfide bond organization, has rearranged to give a single homogeneous species with the correct disulfide bridges. This method allows the production of about 20 mg of folded protein per liter of Escherichia coli culture.
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Affiliation(s)
- J D Kahmann
- Department of Biochemistry, University of Oxford, United Kingdom
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