Nivolumab plus ipilimumab and pembrolizumab are the most cost-effective front-line treatment options for patients with newly diagnosed advanced melanoma and unknown BRAF status, according to a study published in JAMA Oncology (2020. doi:10.1001/jamadermatol.2020.2398).
“The effectiveness of immune checkpoint inhibitors… and BRAF and MEK inhibitors has improved advanced melanoma recovery. However, it is unknown whether these novel therapies are cost-effective for newly diagnosed advanced melanoma with unknown BRAF status,” explained Bin Wu, PhD, Medical Decision and Economic Group, Ren Ji Hospital, Department of Pharmacy, Shanghai Jiaotong University School of Medicine, China, and Lizheng Shi, PhD, MsPharm, MA, Department of Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana.
In order to compare the cost-utility of these novel agents and their combinations with or without BRAF testing guidance for these patients, Dr Wu and Dr Shi conducted an analysis based on long-term survival data.
A decision-analytic model was adopted to project the outcomes of 8 strategies containing different immune checkpoint inhibitors and BRAF and MEK inhibitors. Key clinical data from the CheckMate 067, KEYNOTE-006, COMBI-d, and COMBI-v trials were used along with cost and health-preference data. Costs were estimated from the US payer perspective.
The main outcomes and measures were costs, quality-adjusted life-years (QALYs), incremental cost-utility ratio (ICUR), and incremental net health benefits.
The strategy consisting of nivolumab plus ipilimumab without patient selection based on BRAF status yielded the most significant health outcome. Additionally, the nivolumab strategy was the least expensive option.
The nivolumab, pembrolizumab, and nivolumab plus ipilimumab strategies showed the ordered ICURs were $8593 (SD, $592,995)/QALY for pembrolizumab vs nivolumab and $125,593 (SD, $5,751,223)/QALY for nivolumab plus ipilimumab vs pembrolizumab.
“For newly diagnosed advanced melanoma with unknown BRAF pathogenic variant status, nivolumab plus ipilimumab and pembrolizumab strategies are likely to be the most cost-effective options,” Dr Wu and Dr Shi concluded.
“BRAF and MEK inhibitors might be productively placed in a second-line setting after BRAF pathogenic variant is confirmed,” they added.—Janelle Bradley
