Economic Evaluation of Nivolumab (NIVO) Plus Ipilimumab (IPI) Combination as First-Line Treatment for Patients with Advanced Melanoma in Canada

• Published in: Value in health 2017-10, Vol.20 (9), p.A441-A442
• Main Authors: Quon, P, Xiao, Y, Sorensen, S, Schultz, M, Tahami Monfared, AA
• Format: Article
• Language: English
• Subjects: Cancer therapies; Clinical research; Clinical trials; Cost analysis; Critical incidents; Data processing; Discontinued; Drug abuse; Efficacy; Extrapolation; Health care management; Immunotherapy; Medical prognosis; Medical treatment; Melanoma; Monoclonal antibodies; Motivation; Patients; Pembrolizumab; Quality adjusted life years; Skin melanoma; Survival; Targeted cancer therapy
• ISSN: 1098-3015; 1524-4733
• DOI: 10.1016/j.jval.2017.08.248

OBJECTIVES: To evaluate cost-effectiveness of NIVO+IPI combination as first-line treatment for patients with advanced melanoma from the Canada's public healthcare system perspective. METHODS: A partitioned-survival model was developed to determine long-term clinical and economic outcomes of immunotherapy management for advanced melanoma over a 20-year time horizon. NIVO+IPI combination was compared to other immunotherapies in the base case: nivolumab monotherapy, ipilimumab, and pembrolizumab.Two treatment durations for pembrolizumab were considered: until disease progression, or for a maximum of 24 months. Clinical data, including survival estimates and time to treatment discontinuation from an interim analysis (cut-off data: 13-Sep-2016) of CheckMate-067 in the intention-to-treat population, were used for treatments involving nivolumab and ipilimumab. Efficacy of pembrolizumab was estimated using indirect comparisons. The model used Kaplan Meier estimates from clinical trials with extrapolation based on parametric functions and literature data. A Canadian cross-sectional study was used to elicit utilities for advanced melanoma. Cost data were obtained from published literature, including drug acquisition, treatment administration, adverse event, and clinical management of advanced melanoma. Scenario analyses were used to examine cost of subsequent systemic treatments following disease progression. RESULTS: Over a 20-year time horizon, NIVO+IPI combination had better outcomes and was cost-effective compared to all other immunotherapies, when assuming a cost-effectiveness threshold of $50,000 to $100,000/QALY. Compared to nivolumab monotherapy and ipilimumab, the incremental cost-effectiveness ratios (ICERs) were $47,119 and $66,750 per QALY, respectively. The ICER improved when costs of subsequent therapies were considered. Compared to pembrolizumab with a 24-month maximum treatment duration, the ICER was $85,436 per QALY. When assuming treatment until progression, pembrolizumab was dominated by NIVO+IPI with greater costs and lower clinical benefits. CONCLUSIONS: Despite the advent of effective new therapies for the management of advanced melanoma, prognosis remains poor for some patients. Compared to other immunotherapies, NIVO+IPI offers marked benefit, and is a cost-effective treatment option.