Cost-Effectiveness of Pembrolizumab Monotherapy for High Programmed Death Ligand 1 Advanced or Metastatic Non-small Cell Lung Cancer Depends on Long-Term Survivors.

backgroundPembrolizumab shows effectiveness in treating metastatic non-small cell lung cancer (metNSCLC), with a subgroup of patients experiencing long-term survival (LTS) benefits. The existence of a LTS subgroup may influence the cost-effectiveness of pembrolizumab monotherapy compared with platinum-based chemotherapy. This study aims to assess the potential implications of such a subgroup on the cost-effectiveness for patients with non-squamous metNSCLC and PD-L1 ≥ 50% who are ineligible for targeted therapies.

methodsThis study used a decision analytic model based on Dutch real-world data (2008-2014). Two strategies were simulated: (1) a chemotherapy strategy: patients receive chemotherapy in the first-, second-, and third-line; and (2) a pembrolizumab strategy: patients receive first-line pembrolizumab followed by chemotherapy for those progressing to second- and third-lines. The pembrolizumab strategy is evaluated with and without the assumption that there is a LTS subgroup. The LTS subgroup is assumed to be free from metNSCLC-related progression after treatment. Costs (2022 €), including drug costs, other direct medical costs, family costs, and healthcare costs in life years gained, are considered from first-line treatment to death. Effects are measured in quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) is assessed using an €80,000/QALY threshold. Threshold analyses are performed on the size and mortality rate of the LTS subgroup and on the price of pembrolizumab.

resultsQALYs per patient were 0.65 for chemotherapy, 1.24 for pembrolizumab without LTS, and 3.52 for pembrolizumab with LTS. Average costs per patient were €58,800 for chemotherapy, €154,600 for pembrolizumab without LTS, and €178,600 for pembrolizumab with LTS. Pembrolizumab without LTS was not cost-effective compared with chemotherapy (ICER €167,600/QALY), but pembrolizumab with LTS (30% of simulated population) was cost effective (ICER of €43,100/QALY). Threshold analyses showed that a LTS subgroup size of at least 10% or halving the price of pembrolizumab was needed for pembrolizumab to be cost-effective.

conclusionsPembrolizumab is a cost-effective first-line treatment for patients with metNSCLC and PD-L1 ≥ 50% in the Netherlands when at least 10% of patients are long-term survivors. Without long-term survivors, this treatment is not cost-effective. Therefore, it is crucial to consider long-term survivors in assessing the cost-effectiveness of immunotherapy in metNSCLC.