The effect of PD-L1 testing on the cost-effectiveness and economic impact of immune checkpoint inhibitors for the second-line treatment of NSCLC
A partir de données de 4 essais randomisés, cette étude analyse, dans un contexte américain, le rapport coût-efficacité du nivolumab, du pembrolizumab et de l'atézolizumab en traitement de seconde ligne chez des patients atteints d'un cancer du poumon non à petites cellules, en fonction de l'utilisation d'un test immunohistochimique mesurant l'expression tumorale de PD-L1 pour sélectionner les patients
Background: Immune checkpoint inhibitors improve outcomes compared to chemotherapy in lung cancer. Tumor PD-L1 receptor expression is being studied as a predictive biomarker. The objective of this study was to assess the cost-effectiveness and economic impact of second-line treatment with nivolumab, pembrolizumab, and atezolizumab with and without the use of PD-L1 testing for patient selection. Design: We developed a decision-analytic model to determine the cost-effectiveness of PD-L1 assessment and second-line immunotherapy versus docetaxel. The model used outcomes data from randomized clinical trials (RCTs) and drug acquisition costs from the United States. Thereafter, we used epidemiologic data to estimate the economic impact of the treatment. Results: We included four RCTs (2 with NIVOLUMAB, 1 with PEMBROLIZUMAB, and 1 with ATEZOLIZUMAB). The incremental QALY for nivolumab was 0.417 among squamous tumors and 0.287 among non-squamous tumors and the ICER were $155,605 and $187,685, respectively. The QALY gain in the base case for atezolizumab was 0.354 and the ICER was $215,802. Compared with treating all patients, the selection of patients by PD-L1 expression improved incremental QALY by up to 183% and decreased the ICER by up to 65%. Pembrolizumab was studied only in patients whose tumors expressed PD-L1. The QALY gain was 0.346 and the ICER was $98,421. Patient selection also reduced the budget impact of immunotherapy. Conclusion: The use of PD-L1 expression as a biomarker increases cost-effectiveness of immunotherapy but also diminishes the number of potential life-years saved.