Swiss Study Examines Cost-Effectiveness of Nivolumab vs Docetaxel in Advanced Nonsquamous NSCLC

Key Points

  • Giving nivolumab only to patients with positive PD-L1 tests compared to treating all patients with docetaxel or all patients with nivolumab was more cost-effective in both scenarios.
  • Treating all patients with nivolumab compared to all with docetaxel resulted in a ICER of CHF177,478/QALY gained, whereas, treating only patients with ≥1% or ≥10% PD-L1+ with nivolumab compared to docetaxel resulted in ICERs of CHF133,267/QALY and CHF124,891/QALY, respectively, both ICERs above the willingness-to-pay CHF100,000 threshold.
  • Treating patients with ≥1% or ≥10% PD-L1+ resulted in ICERs of CHF65,774/QALY and CHF37,860/QALY, respectively, resulting in ICERs below the willingness-to-pay threshold of CHF100,000/QALY.

Nivolumab, a checkpoint inhibitor approved for patients with squamous and nonsquamous non–small cell lung cancer (NSCLC) in 2015, is not cost-effective when compared to treatment with docetaxel, chemotherapy medication. However, a Swiss analysis showed the cost-effectiveness of nivolumab is improved when patients are treated with nivolumab based on programmed death-ligand 1 (PD-L1) positivity (PD-L1+), or if there is a reduction in dose or drug price. Results were published by Matter-Walstra et al in the Journal of Thoracic Oncology.

Nivolumab was recently approved for use in several countries as second-line treatment for patients with advanced squamous or nonsquamous NSCLC. There is a growing global concern over the cost and value of cancer care and treatment especially as it relates to recently approved cancer drugs like nivolumab. In December 2015, the United Kingdom National Institute for Health and Care Excellence (NICE) reported that for squamous NSCLC, nivolumab was not cost-effective per quality-adjusted life year (QALY) gained. Further, a 2016 Canadian study by Goeree et al comparing nivolumab to docetaxel and erlotinib in NSCLC found that nivolumab had the highest expected per-patient cost, but also improved per-patient life years and QALYs. While there are reports of nivolumab not being cost-effective in squamous NSCLC, it is a worthwhile endeavor to explore the cost-effectiveness of nivolumab on nonsquamous NSCLC.

Study Details

A group of Swiss investigators used a literature-based Markov modelling approach to calculate the incremental cost effectiveness ratio (ICER) for nivolumab compared to docetaxel in patients with nonsquamous NSCLC from Switzerland’s health-care system perspective. The model was constructed based on the clinical data from the CheckMate-057 study and compared: (1) all patients treated with docetaxel; (2) all patients treated with nivolumab; and (3) patients treated according to their PD-L1 status (≥ 1% or ≥ 10% tumor positivity by immunohistochemistry testing).

The primary measurement endpoint was the ICER expressed as cost per QALY gained using nivolumab compared to docetaxel in patients with NSCLC. The secondary endpoint was the ICER comparing PD-L1 testing with docetaxel or nivolumab. The ICERs were compared to a possible willingness-to-pay threshold of 100,000 Swiss francs (CHF) per QALY gained. The effect of reduction of dose and price of nivolumab on ICERs were also assessed. Effectiveness data were inferred from the progression-free survival and overall survival outcomes reported in the original CheckMate-057 trial publication and supplementary materials. Cost was established using Swiss public health-care prices when available.

Study Findings

Findings demonstrated that giving nivolumab only to patients with positive PD-L1 tests compared to treating all patients with docetaxel or all patients with nivolumab was more cost-effective in both scenarios. Treating all patients with nivolumab compared to all with docetaxel resulted in a ICER of CHF177,478/QALY gained, whereas treating only patients with ≥1% or ≥10% PD-L1 positivity with nivolumab compared to docetaxel resulted in ICERs of CHF133,267/QALY and CHF124,891/QALY, respectively; both ICERs are above the willingness-to-pay CHF100,000 threshold.

Although nivolumab for all patients was weakly dominated by the test-based strategies (and a comparison not justified from a health economic perspective), treating only PD-L1–positive patients with nivolumab vs all patients with nivolumab is more cost-effective. Treating patients with ≥ 1% or ≥ 10% PD-L1 positivity resulted in ICERs of CHF65,774/QALY and CHF37,860/QALY, respectively, resulting in ICERs below the willingness-to-pay threshold of CHF100,000/QALY. Further, reduction of dose to 1 mg/kg and reducing nivolumab’s price by at least 45% reduced ICERs to below the willingness-to-pay threshold.

The authors commented that, “The easiest way to improve cost-effectiveness is to lower drug prices. Depending on the setting, a cost reduction of nivolumab by at least 33% (nivolumab given to patients with PD-L1–positive tumors vs docetaxel) or 45% (nivolumab given to all patients vs docetaxel) resulted in ICERs below or near the willingness-to-pay threshold. It will be interesting to see if NICE reaches similar conclusions for nonsquamous NSCLC and if they can negotiate a lower price for nivolumab in the UK. Although our results are not directly generalizable to other countries, the Swiss system is comparable to the U.S. system and to many European countries in terms of patient care and cost. However, in our analysis, both PD-L1 test strategies (nivolumab only for those patients reaching the ≥ 1% or ≥ 10% positive thresholds) resulted in higher mean costs but also better effectiveness than treating all patients with nivolumab. PD-L1 testing should be considered in patients with nonsquamous NSCLC who are candidates for PD-L1 checkpoint inhibitor therapy.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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