Costs of Extended Use of the Immune Check Point Inhibitors in 1st-line Non-Small Cell Lung Cancer

Abstract

Aim: Cost-effectiveness in the health care system has been extensively investigated. Reports, however, on costs and the impact of extended use of the immune check point inhibitors (ICI) are rare. Pembrolizumab (Pembro) improved the 5-year overall survival in1st-line advanced/metastatic non-small cell lung cancer a/m-NSCLC. ICI are rather expensive, and costs are bound to increase with prolonged therapy. We purposed to focus on cost of extended ICI use beyond their indications in a/m-NSCLC. Methods: The 2020 annual posted drug costs were calculated in US$. Except for the one-year adjuvant Durv, used for curative intent, ICI costs were calculated for 2-years and beyond. Adverse events-treatment costs and generic chemo-drugs were not included. Results: ICI costs ranged from $103,400 to $168,948 with $148,431 mean. Adjuvant Durv one-year costs were $148,013. The 2-year Pembro costs in PD-L1 > 50% were $334,652, multiplying to >$836,630 after 5 years. Addition of 4 Peme cycles improved outcome regardless of PD-L1 at costs of $360,912. Costs of the 2-year Atezolizumab/Bevacizumab (Atezo/Bev) and one-year Peme were $722,977. Use of Biosimilar (Bio) saved $77,120. Atezo-Peme without Bev reduced costs to $422,725. Costs of Ipilimumab/Nivolumab (Ipi/Nivo) were $544,696. Adding 2 Peme cycles increased costs to $557,826. Extended for 6 months, the 2-year-costs of the 3 ICI combinations increased by 25% of the maintenance ICI. As compared with Pembro-Peme, the 2-year costs of Atezo/Bio-Bev-Peme were 2.00 higher, Atezo-Bio-Bev-Peme 1.79, Atezo-Pem 1.17, Ipi/Nivo 1.51 and Ipi/Nivo-Peme 1.55. The ratios would further separate with extended use beyond 2 years. Conclusions: ICI costs are determined by duration of therapy more than by the posted annual price. Costs of extended use call for guidance on therapy duration and emphasize the need for cost constraint-policies.