Chasing the survival curve tail: The effect on cost-effectiveness of nivolumab for second-line treatment of advanced renal cell carcinoma

Abstract

Background: Treatment of metastatic cancer has been revolutionized in recent years with the incorporation of immunotherapy. In some metastatic settings there is a clear plateau in the overall survival curve, representing long-term survivors. As survival data is still immature with immunotherapy in most cancers it is unclear how to tackle the unknown tail of the survival curve, as it greatly affects the presumed effectiveness. To further understand this issue we present here the example of CEA of nivolumab in 2nd line RCC. Method(s): A Markov model was developed to compare the costs and effectiveness of nivolumab with those of everolimus or placebo in the second-line treatment of advanced RCC. Health outcomes were measured in life-years and quality-adjusted lifeyears (QALYs). Drug costs were based on Medicare reimbursement rates in 2016. Model robustness was addressed in univariable and probabilistic sensitivity analyses. We examined the effect of different anticipated ends of the survival curve on the cost effectiveness. Result(s): The total mean cost per-patient of nivolumab versus everolimus was $101,070 and $50,935, respectfully. Nivolumab generated a gain of 0.24 LYs (0.34 QALYs) over everolimus and 0.89 LYs (0.96 QALYs) over placebo. The incremental costeffectiveness ratio (ICER) for nivolumab was $146,532/QALY versus everolimus. A theoretical durable response in 10%, 15% or 20% of patients treated with nivolumab reduced the ICER to $86,660/QALY, $64,809/QALY or $48,493/QALY, respectively, compared with everolimus. Conclusion(s): Our analysis shows that any durable response changes the ICER dramatically and improves the likelihood that a drug will be considered cost effective. Therefore, we must thrive to understand the long term benefit of immunotherapy in different cancers.