First-line nivolumab plus ipilimumab for unresectable MPM in China: a cost-effectiveness analysis

Our plain-English summary of First-line nivolumab plus ipilimumab for unresectable MPM in China: a cost-effectiveness analysis, by L. Yang, X. Song, W. Zeng, et al (Orphanet Journal of Rare Diseases, 2023).

The study

• Authors: L. Yang, X. Song, W. Zeng, Z. Zheng, W. Lin
• Journal: Orphanet Journal of Rare Diseases
• Published: 2023;18(1):326
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The regimen of nivolumab plus ipilimumab (NI) has been recommended by the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology-Malignant Pleural Mesothelioma (Version 1.2022) and Chinese Guidelines for the Clinical Diagnosis and Treatment of Malignant Pleural Mesothelioma (2021 edition) as the first-line treatment for Malignant Pleural Mesothelioma (MPM). But whether immunotherapy has a financial advantage over conventional chemotherapy (pemetrexed plus cisplatin/carboplatin, C) is uncertain.

Methods: Based on survival and safety data from the CheckMate 743 clinical trial (NCT02899299), a partitioned survival model was constructed using TreeAge Pro2022 software. The model cycle was set to 1 month and the study period was 10 years. The output indicators included total cost, quality-adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were used to assess the robustness of the results, considering only direct medical costs.

Results And Discussion: The ICER for group NI versus Group C was $375,656/QALY in all randomized patients, $327,943/QALY in patients with epithelioid histology, and $115,495/QALY in patients with non-epithelioid histology. The ICERs of all three different populations all exceeded the willingness-to-pay threshold (three times the per capita gross domestic product of China in 2021). The results of univariate sensitivity analysis showed that the price of pemetrexed and nivolumab had great influence on the analysis results. The results of the probabilistic sensitivity analysis show that the probability of the NI scheme being more economical in all three different populations was 0.

What Is New And Conclusion: From the perspective of the Chinese healthcare system, in patients with unresectable MPM, NI has no economic advantage over C.

© 2023. Institut National de la Santé et de la Recherche Médicale (INSERM).

In plain English

This was a computer-model cost-effectiveness analysis. It did not study asbestos exposure or enroll patients. Using published results of the CheckMate 743 trial, the authors modeled adults with unresectable malignant pleural mesothelioma (MPM) matching that trial's patients over 10 years, using the perspective and costs of the Chinese healthcare system. They compared first-line nivolumab plus ipilimumab (NI) with pemetrexed plus cisplatin or carboplatin (C), counting only direct medical costs. In the model, NI produced more quality-adjusted life years but higher costs. The extra cost per quality-adjusted life year was $375,656 for all randomized patients, $327,943 for patients with epithelioid histology and $115,495 for those with non-epithelioid histology. All three were above the threshold of $33,819 (three times China's 2021 per capita GDP). At that threshold, the probability that NI was more economical was 0 in all three groups. The authors concluded that, from the Chinese healthcare system's perspective, NI had no economic advantage over C. They noted that quality-of-life values were taken from non-small cell lung cancer research and that progression-free survival curves were not available separately for the histology subgroups.

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 partitioned survival model built from published trial data (CheckMate 743), with a 10-year time horizon, 1-month cycles, the Chinese healthcare system perspective, and direct medical costs only
• Who was studied: A modeled population matching the CheckMate 743 trial, not restricted to patients in China: adults (18 or older) with histologically confirmed unresectable malignant pleural mesothelioma and ECOG performance status 0 or 1. The trial curves used covered 303 NI vs 302 C patients overall, 229 vs 226 with epithelioid histology and 74 vs 76 with non-epithelioid histology. Model patients were assumed to be 69 years old and weigh 65 kg. Costs were taken from the Chinese healthcare system.
• Exposure: No asbestos exposure was studied. The comparison was between two treatments: nivolumab (3 mg/kg every 2 weeks) plus ipilimumab (1 mg/kg every 6 weeks), versus pemetrexed (500 mg/m2) with cisplatin (75 mg/m2) or carboplatin every 3 weeks for up to 6 cycles.
• Main results:
  • All randomized patients: NI gave 0.10 more QALYs than C at an incremental cost of $38,023, an ICER of $375,656 per QALY.
  • Patients with epithelioid histology: NI gave 0.12 more QALYs than C at an incremental cost of $38,002, an ICER of $327,943 per QALY.
  • Patients with non-epithelioid histology: NI gave 0.33 more QALYs than C at an incremental cost of $38,543, an ICER of $115,495 per QALY.
  • In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $33,819, the probability that NI was more economical than C was 0 in all three populations.
  • In the one-way sensitivity analysis for all randomized and epithelioid patients, the ICER stayed above the threshold however the main parameters were varied.
  • In the non-epithelioid population only, NI became cost-effective if the price of pemetrexed was greater than $5.41/mg. The authors considered a return to such a price unlikely because of centralized drug purchasing.
• The authors' conclusion: The authors concluded that, from the perspective of the Chinese healthcare system, nivolumab plus ipilimumab has no economic advantage over pemetrexed plus cisplatin/carboplatin for patients with unresectable MPM.
• Limitations the authors state:
  • CheckMate 743 did not provide progression-free survival curves for the histology subgroups, so the all-randomized PFS curve was used for all three models.
  • Only adverse events with a large difference in incidence were included. Their utility values and treatment costs came from published literature rather than real-world data.
  • Quality-of-life (utility) values were borrowed from non-small cell lung cancer studies because no accurate MPM values were available.
  • Adverse-event costs were not discounted and used 2020 cost data.
  • The study did not fully assess factors affecting patients' health-related quality of life.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Nivolumab (Opdivo), Ipilimumab (Yervoy), Unresectable, Pleural Mesothelioma, Immunotherapy, Chemotherapy, Pemetrexed (Alimta), Cisplatin.

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