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Cost Effectiveness of PD-L1-Based Test-and-Treat Strategy with Pembrolizumab as the First-Line Treatment for
Herbert H Loong1, Carlos K H Wong2, Linda Kam Suet Leung1
1Department of Clinical Oncology, State Key Laboratory in Oncology of South China, The Chinese University of Hong Kong, Hong Kong, Hong Kong.
Background:
Pembrolizumab, a monoclonal antibody against programmed death ligand 1 (PD-L1), is approved by several regulatory agencies for first-line treatment of metastatic non-small-cell lung cancer (NSCLC) with a PD-L1 tumor proportion score (TPS) ≥ 50% and no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase genomic tumor aberrations. This study was conducted from the perspective of the Hospital Authority in Hong Kong and aimed to evaluate the cost effectiveness of a biomarker (PD-L1) test-and-treat strategy (BTS), in which patients with a TPS ≥ 50% received pembrolizumab and other patients received platinum doublet chemotherapy versus all patients receiving platinum doublet chemotherapy.
Methods:
The model used a partitioned survival approach to estimate the incremental cost-effectiveness ratio (ICER) expressed as the cost per quality-adjusted life-year (QALY) gained. The clinical efficacy, utility and safety data were derived from the KN024 trial. Costs and health outcomes were projected over a 10-year time horizon and discounted at 3% per year. Costs for drug acquisition, PD-L1 testing, drug administration and disease management were used. Sensitivity analyses were conducted to evaluate the robustness of results.
Results:
The BTS approach led to an increase of 0.29 QALYs at an additional cost of Hong Kong dollars (HK$) 249,077 (US$31,933) compared with platinum doublet chemotherapy, resulting in an ICER of HK$865,189 (US$110,922) per QALY gained. This is lower than the World Health Organization cost-effectiveness threshold of three times the 2016 gross domestic product (GDP) per capita for Hong Kong of HK$1017,819 (US$130,490). Probabilistic sensitivity analyses showed a 59.4% chance that the ICER would be below this threshold.
Conclusion:
First-line treatment with pembrolizumab in a BTS to identify patients with NSCLC with PD-L1 TPS ≥ 50% can be considered cost effective in Hong Kong compared with platinum doublet chemotherapy based on a three-times GDP per capita threshold. However, local data on clinical efficacy and safety were not available to estimate overall survival (OS) and progression-free survival (PFS) specific to patients with NSCLC in Hong Kong. Further, uncertainty is inherent in the survival projections/extrapolation of PFS and OS beyond the trial period, and future research may help to further inform these parameters.
Insights
A biomarker (PD-L1) test-and-treat strategy using pembrolizumab for metastatic non-small-cell lung cancer (NSCLC) is cost-effective in Hong Kong. This approach identifies patients with high PD-L1 expression for targeted therapy, improving outcomes.
Area of Science:
- Oncology
- Health Economics
Background:
- Pembrolizumab is approved for first-line metastatic non-small-cell lung cancer (NSCLC) in patients with PD-L1 TPS ≥ 50% and no actionable mutations.
- This study evaluates the cost-effectiveness of a biomarker (PD-L1) test-and-treat strategy (BTS) versus standard chemotherapy in Hong Kong.
Purpose of the Study:
- To assess the cost-effectiveness of a PD-L1 biomarker test-and-treat strategy for first-line metastatic NSCLC in Hong Kong.
- To compare pembrolizumab treatment guided by PD-L1 expression against platinum doublet chemotherapy.
Main Methods:
- A partitioned survival model was used to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained.
- Clinical data from the KN024 trial informed efficacy, utility, and safety. A 10-year time horizon with a 3% discount rate was applied.
- Costs included drug acquisition, PD-L1 testing, administration, and disease management. Sensitivity analyses were performed.
Main Results:
- The BTS strategy yielded an additional 0.29 QALYs at an extra cost of HK$249,077 (US$31,933).
- The resulting ICER was HK$865,189 (US$110,922) per QALY gained, below the WHO threshold for Hong Kong (HK$1,017,819).
- Probabilistic sensitivity analyses indicated a 59.4% likelihood that the ICER falls below the cost-effectiveness threshold.
Conclusions:
- First-line pembrolizumab via a BTS for NSCLC patients with PD-L1 TPS ≥ 50% is considered cost-effective in Hong Kong.
- Limitations include the lack of local clinical data for OS and PFS specific to Hong Kong's NSCLC population.
- Further research is needed to address uncertainties in survival projections and inform treatment parameters.
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