Cost-effectiveness analysis of pembrolizumab plus chemotherapy versus chemotherapy in untreated advanced pleural mesothelioma in the Chinese healthcare system

Our plain-English summary of Cost-effectiveness analysis of pembrolizumab plus chemotherapy versus chemotherapy in untreated advanced pleural mesothelioma in the Chinese healthcare system, by W. Lang, Y. He, C. Hou, et al (Frontiers in Pharmacology, 2024).

The study

• Authors: W. Lang, Y. He, C. Hou, H. Li, Q. Jiang, L. Mei
• Journal: Frontiers in Pharmacology
• Published: 2024;15:1402423
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objective: The combination of pembrolizumab and chemotherapy has demonstrated notable clinical advantages in improving overall survival than chemotherapy alone for patients with untreated advanced pleural mesothelioma. The purpose of this study was to assess its cost-effectiveness.

Materials And Methods: A Markov state-transition model was constructed using data from the IND227 phase 3 randomized clinical trial. Utility values for health states were taken from the IND227 trial, and direct medical costs were from the pertinent literature and local pricing data. Outcomes measured included quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), incremental net health benefit (INHB), and incremental net monetary benefit (INMB). To manage the uncertainty in the model, both probabilistic sensitivity analysis (PSA) and one-way sensitivity analysis (OWSA) were used.

Results: In the base-case analysis, pembrolizumab plus chemotherapy resulted in an incremental gain of 0.23 QALYs at an additional cost of $18,199.63, resulting in an ICER of $80,557.23/QALY. This was not favorable compared to China's willingness-to-pay (WTP) threshold of $38,042.49/QALY, with an INHB of -0.25 QALYs and an INMB of $-9,605.00. Subgroup analyses showed ICERs for pembrolizumab plus chemotherapy versus chemotherapy of $33,917.61 and $99,536.73 in non-epithelioid and epithelioid patients, respectively. PSA indicated probabilities of cost-effectiveness for pembrolizumab plus chemotherapy at 0.55%, 69.41%, and 0.14% for the entire population and the non-epithelioid and epithelioid subgroups, respectively.

Conclusion: In the Chinese healthcare system, the combination of pembrolizumab and chemotherapy did not prove to be more cost-effective than chemotherapy alone as an initial treatment for untreated advanced pleural mesothelioma, with the exception of patients who have non-epithelioid histology.

Copyright © 2025 Lang, He, Hou, Li, Jiang and Mei.

In plain English

This was an economic modelling study of a cancer treatment. It did not study asbestos exposure. The authors built a Markov computer model from published results of the IND227 trial. They asked whether adding the immunotherapy drug pembrolizumab to cisplatin-pemetrexed chemotherapy was cost-effective for untreated advanced pleural mesothelioma, from the viewpoint of the Chinese healthcare system over 10 years. For the whole population, the combination added 0.23 quality-adjusted life years (QALYs) at an extra cost of $18,199.63. That came to $80,557.23 per QALY, above the authors' threshold of $38,042.49 per QALY, which is three times China's 2023 per-capita GDP. The figure was $33,917.61 per QALY for non-epithelioid tumours, below the threshold, and $99,536.73 for epithelioid tumours. In probabilistic analysis, the chance that the combination was cost-effective was 0.55% overall, 69.41% for non-epithelioid and 0.14% for epithelioid patients. The authors concluded it was not more cost-effective than chemotherapy alone, except for non-epithelioid histology. They noted that the trial was run in Canada, Italy and France, and that quality-of-life values came from other published studies.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Cost-effectiveness analysis using a three-state Markov model built from published trial data (IND227), with one-way and probabilistic sensitivity analyses
• Who was studied: A modelled cohort of patients with advanced pleural mesothelioma unsuitable for surgery and without prior systemic therapy, based on the IND227 trial (conducted in Canada, Italy and France). The analysis took the perspective of the Chinese healthcare system and used a 10-year horizon. The number of trial patients is not given in the text.
• Exposure: Treatment, not asbestos. All patients received cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) every 3 weeks for up to six cycles. The pembrolizumab group also received pembrolizumab 200 mg every 3 weeks for up to 2 years. Costs were in 2023 US dollars at $1 = ¥7.0467.
• Main results:
  • Whole population: pembrolizumab plus chemotherapy cost $35,560.57 for 0.99 QALYs, versus $17,360.94 for 0.77 QALYs with chemotherapy alone. This was an incremental gain of 0.23 QALYs at an additional cost of $18,199.63, an ICER of $80,557.23 per QALY.
  • Whole population, at a willingness-to-pay threshold of $38,042.49 per QALY: incremental net health benefit of −0.25 QALYs and incremental net monetary benefit of $-9,605.00.
  • Non-epithelioid subgroup: ICER of $33,917.61 per QALY, below the threshold. Incremental net health benefit was 0.05 QALYs and incremental net monetary benefit was $2,085.28.
  • Epithelioid subgroup: ICER of $99,536.73 per QALY. Incremental net health benefit was −0.29 QALYs and incremental net monetary benefit was $-11,127.42.
  • Probabilistic sensitivity analysis, at the $38,042.49 threshold: probability that pembrolizumab plus chemotherapy was cost-effective was 0.55% for the entire population.
  • The same probability was 69.41% for the non-epithelioid subgroup and 0.14% for the epithelioid subgroup.
  • In one-way sensitivity analysis for the whole population, the cost of pembrolizumab, the quality-of-life value of progressive disease and the cost of bevacizumab had the largest influence on results.
• The authors' conclusion: The authors concluded that, in the Chinese healthcare system, pembrolizumab plus chemotherapy was not more cost-effective than chemotherapy alone as initial treatment for untreated advanced pleural mesothelioma, except in patients with non-epithelioid histology.
• Limitations the authors state:
  • The IND227 trial did not report quality-of-life (EQ-5D) data, so utility values were taken from the literature, adding uncertainty.
  • Clinical data came from a trial in Canada, Italy and France, which may introduce bias for a Chinese setting.
  • Subsequent treatment, drug selection and adverse events were not reported separately for the subgroups, so they were assumed to match the overall population.

Topics

Medical terms in this study, explained in our Lexicon: Pembrolizumab (Keytruda), Chemotherapy, Pleural Mesothelioma, Overall Survival, Clinical Trial, Non-epithelioid, Epithelioid, Histology.

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