Assessing the impact of anti-PD-1/PD-L1 inhibitors on cancer care health and budget in Ireland

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Background: In Ireland, the incidence of cancer was estimated to be 30,272 in 2018 with approximately 9,621 deaths. Over the next five years, the incidence of all cancers is expected to increase by 39% in males and 27% in females. Despite chemotherapy being considered the SOC in many malignancies, it is associated with high levels of toxicity. The introduction of immunotherapy in oncology has revolutionized cancer care, offering improved health outcomes in a range of tumor types. Many treatment options with the potential for use in several cancer types has led to concerns around the long-term affordability of these products. The objective of the study is to estimate and inform current discussion around the potential public health and economic impact of PD-1/PD-L1 inhibitors in Ireland. Methods: The Health Impact Projection (HIP) model estimates the key clinical health and economic outcomes of PD-1/PD-L1 inhibitors in eight high incidence cancers, over a five-year period (2020–2024) compared to the SOC treatments. SOC includes chemotherapy, immuno-oncology treatments not part of the anti PD-1/PD-L1 class (e.g. ipilimumab) and radiotherapy. It includes an assessment of the relative health benefits such as life-years gained, and utility-adjusted life years gained while drawing on budget impact analysis for its structure and methods. The HIP compares the economic and health outcomes in two scenarios; a world without anti PD-1/PD-L1 treatments, to those obtained in a world where patients are treated with a mix of SOC and anti PD-1/PD-L1 treatments. Results: The model shows that over five years, the clinical benefits offered by the introduction of anti PD-1/PD-L1s include an additional 3,194 life-years, 2,411 progression-free life years, 2,638 quality-adjusted life years and the avoidance of 92 adverse events. PD-1/PD-L1 inhibitors produce an average annual budget impact that is equivalent to 0.32% of total healthcare expenditure. Amongst this figure is a reduced burden of indirect costs and end of life costs – both of which fall with anti PD-1/PD-L1s on the market. Conclusions: Ireland faces uncertainty in cancer care with pressure to reduce costs – the HIP helps demonstrate the value of anti PD-1/PD-L1s. Problems stem from a healthcare system that is fragmented and orientated towards dealing with acute conditions. Anti PD-1/PD-L1s are predicted to improve outcomes in Ireland with PFS gains being the largest. In 2020, the budget impact of this class in Ireland is expected to represent a somewhat significant portion of total expenditure on cancer medicines but a small portion of total healthcare expenditure. By projecting budget impact over a five year period, this model should help inform multi-annual budget planning for innovative oncology medicines. This model informs planning by helping quantify the impact of immuno-oncology treatments on health and budget in different scenarios.

Abstract PS9-68: Budget impact of Ontruzant for the treatment of breast cancer and gastric cancer in the United States

OBJECTIVES: Breast cancer is estimated to have the highest incidence among all cancers in the United States (US) in 2020. In turn, the incidence of gastric cancer is ranked fifteenth among all cancers in the US. Targeted therapies, such as trastuzumab, have drastically improved clinical outcomes for patients with over-expressive human epidermal growth factor receptor 2 (HER2+) in early-stage breast cancer (EBC) and metastatic breast cancer (MBC) as well as metastatic gastric cancer (MGC). However, due to the high cost of treatment and eligible patient population size, originator trastuzumab has caused patient affordability challenges and represents a high budget burden on payers. The objective of this study is to assess the potential financial impact associated with the use of intravenous (IV) trastuzumab biosimilar Ontruzant compared to the originator, in patients with HER2+ EBC, MBC and MGC from the US healthcare payer perspective. METHODS: A budget impact model with a 5-year time horizon was developed to compare costs ($; 2020) under scenarios with and without the entry of Ontruzant to a healthcare plan. Only direct costs were considered following a payer perspective. Drug acquisition costs were estimated based on the published wholesale acquisition cost (WAC) price. The target population consisted of incident HER2+ patients eligible to receive trastuzumab IV or subcutaneous. Epidemiological data were obtained from SEER database and Epic Oncology. Predictions on trastuzumab market share and Ontruzant uptake were based on internal market research. The model calculated the budget impact of Ontruzant by indication and across all indications. RESULTS: In a hypothetical healthcare plan with one million members, the number of incident patients treated with the trastuzumab class was estimated to range from 107 in year 1 to 100 in year 5 in HER2+ EBC and 17 to 16 in HER2+ MBC. About ten new patients with HER2+ MGC were estimated to be treated with trastuzumab or biosimilars each year in year 1 to 5. The market uptake of Ontruzant with the trastuzumab class was assumed 50% in year 1 and rising over time to 90% in year 5, which led to a total budget saving of $13,534,498 in EBC and MBC and $459,331 in MGC over the 5-year period for the healthcare plan. The model yielded an average saving of $1,859, $2,073 and $766 per treated member per month in EBC, MBC and MGC, respectively. The cost saving was mainly driven by the lower drug acquisition cost of Ontruzant compared to originator trastuzumab, as well as potential reduction of vial wastage due to the availability of Ontruzant multi-dose vials. CONCLUSIONS: Adding Ontruzant to the formulary for treatment of HER2+ breast cancer and gastric cancer and creating mechanisms to encourage providers to utilize Ontruzant instead of the reference branded agent, could lead to substantial cost-savings for the US healthcare payers; and consequently, improve access to treatments for the patients.

Citation Format: Min Huang, Puneet Singhal, Reshma Shinde, Sarah K Wilkes, Nirav Nagda, Yunni Yi, Stefano Lucherini. Budget impact of Ontruzant for the treatment of breast cancer and gastric cancer in the United States [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-68.

Treatment Options for Dementia with Lewy Bodies: A Network Meta-Analysis of Randomised Control Trials

INTRODUCTION

Dementia with Lewy bodies (DLB) is the third most common type of dementia after Alzheimer's disease (AD) and vascular dementia. Treatment is targeted at specific disease manifestations/symptoms. While donepezil is approved for the treatment of DLB in Japan, to date no other treatment has been approved for this indication anywhere in the world. Notwithstanding, many of the medications that are approved for AD are widely used in the treatment of DLB with varying degrees of success. Consequently, clinical evidence is limited, and there is a need to understand the comparative efficacy and safety of currently used therapies for DLB. The aim of this study was to conduct a network meta-analysis (NMA) to evaluate the outcomes of the available treatment options based on currently used trial endpoints.

METHODS

Using data from a previously published systematic review, we conducted an NMA to investigate the efficacy and safety of treatments in patients with DLB. Networks were based on change from baseline of efficacy endpoints (Mini-Mental State Examination; Neuropsychiatric Inventory; Unified Parkinson's Disease Rating Scale) and rate of safety events (overall adverse events [AEs]; discontinuations; discontinuations due to AEs; psychiatric events).

RESULTS

Focused around a common treatment option of placebo, the NMA comprised studies on donepezil, rivastigmine, memantine and quetiapine. Donepezil 3 mg, 5 mg and 10 mg doses were compared against each other and placebo. Overall, donepezil consistently performed better than the alternative treatments when compared to placebo for all efficacy and safety endpoints. However, the small sample size and/or heterogeneity of the studies led to uncertainty, resulting in no statistically significant differences favouring any treatment above another or placebo.

CONCLUSION

Despite the lack of statistical significance, when assessing the efficacy and safety outcomes for each drug in the evidence network, donepezil appeared to have a more favourable overall benefit/risk profile for patients with DLB. Further comparative trials are required to improve understanding of the true difference between existing and potential future treatment options.

Everolimus, lutetium-177 DOTATATE and sunitinib for advanced, unresectable or metastatic neuroendocrine tumours with disease progression: a systematic review and cost-effectiveness analysis

BACKGROUND

Neuroendocrine tumours (NETs) are a group of heterogeneous cancers that develop in cells in the diffuse neuroendocrine system.

OBJECTIVES

To estimate the clinical effectiveness of three interventions [everolimus (Afinitor^®; Novartis International AG, Basel, Switzerland), lutetium-177 DOTATATE (177Lu-DOTATATE) (Lutathera^®; Imaging Equipment Ltd, Radstock, UK) and sunitinib (Sutent^®; Pfizer Inc., New York, NY, USA)] for treating unresectable or metastatic NETs with disease progression and establish the cost-effectiveness of these interventions.

DATA SOURCES

The following databases were searched from inception to May 2016: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Daily, Epub Ahead of Print, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science.

REVIEW METHODS

We systematically reviewed the clinical effectiveness and cost-effectiveness literature on everolimus, 177Lu-DOTATATE and sunitinib for treating advanced, unresectable or metastatic progressive NETs. The following NET locations were considered separately: pancreas, gastrointestinal (GI) tract and lung, and GI tract (midgut only). We wrote a survival partition cohort-based economic evaluation in Microsoft Excel^® 2013 (Microsoft Corporation, Redmond, WA, USA) from the UK NHS and Personal Social Services perspective. This comprised three health states: (1) progression-free survival (PFS), (2) progressed disease and (3) death.

RESULTS

Three randomised controlled trials (RCTs), RADIANT-3 [RAD001 in Advanced Neuroendocrine Tumors, Third Trial; pancreatic NETs (pNETs): everolimus vs. best supportive care (BSC)], A6181111 (pNETs: sunitinib vs. BSC) and RADIANT-4 (RAD001 in Advanced Neuroendocrine Tumors, Fourth Trial; GI and lung NETs: everolimus vs. BSC), met the inclusion criteria for the clinical effectiveness systematic review. The risk of bias was low. Although the NETTER-1 (Neuroendocrine Tumors Therapy) RCT, of 177Lu-DOTATATE plus 30 mg of octreotide (Sandostatin^®, Novartis) compared with 60 mg of octreotide, was excluded from the review, we nonetheless present the results of this trial, as it informs our estimate of the cost-effectiveness of 177Lu-DOTATATE. The pNETs trials consistently found that the interventions improved PFS and overall survival (OS) compared with BSC. Our indirect comparison found no significant difference in PFS between everolimus and sunitinib. Estimates of OS gain were confounded because of high rates of treatment switching. After adjustment, our indirect comparison suggested a lower, but non-significant, hazard of death for sunitinib compared with everolimus. In GI and lung NETs, everolimus significantly improved PFS compared with BSC and showed a non-significant trend towards improved OS compared with BSC. Adverse events were more commonly reported following treatment with targeted interventions than after treatment with BSC. In the base case for pNETs, assuming list prices, we estimated incremental cost-effectiveness ratios (ICERs) for everolimus compared with BSC of £45,493 per quality-adjusted life-year (QALY) and for sunitinib compared with BSC of £20,717 per QALY. These ICERs increased substantially without the adjustment for treatment switching. For GI and lung NETs, we estimated an ICER for everolimus compared with BSC of £44,557 per QALY. For GI (midgut) NETs, the ICERs were £199,233 per QALY for everolimus compared with BSC and £62,158 per QALY for a scenario analysis comparing 177Lu-DOTATATE with BSC. We judge that no treatment meets the National Institute for Health and Care Excellence's (NICE) end-of-life criteria, although we cannot rule out that sunitinib in the A6181111 trial does.

LIMITATIONS

A RCT with included comparators was not identified for 177Lu-DOTATATE. The indirect treatment comparison that our economic analysis was based on was of a simple Bucher type, unadjusted for any differences in the baseline characteristics across the two trials.

CONCLUSIONS

Given NICE's current stated range of £20,000-30,000 per QALY for the cost-effectiveness threshold, based on list prices, only sunitinib might be considered good value for money in England and Wales.

FUTURE WORK

Further analysis of individual patient data from RADIANT-3 would allow assessment of the robustness of our findings. The data were not made available to us by the company sponsoring the trial.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041303.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.