Cost-effectiveness of nivolumab and ipilimumab versus pembrolizumab and axitinib in advanced renal cell carcinoma with intermediate or poor prognostic risk: a Brazilian private healthcare system perspective
Creators: name: Dhanji, Nishit
name: Decimoni, Tassia Cristina
name: Dyer, Matthew T. D.
name: May, Jessica R.
name: van de Wetering, Gijs
name: Petersohn, Svenja
name: Nickel, Katharina
name: Silva, Amanda
name: Muniz, David Q. B.
name: Oliveira, Ana Paula Casagrande D.
Publisher: name: Taylor & Francis
Year: 2023
Subjects: subject: Medicine
subject: Ecology
subject: FOS: Biological sciences
subject: Biological Sciences not elsewhere classified
subject: Cancer
subject: Science Policy

description: Nivolumab plus ipilimumab (NIVO + IPI) and pembrolizumab plus axitinib (PEM + AXI) have demonstrated significant clinical benefits as first-line (1 L) treatments for intermediate/poor-risk advanced renal cell carcinoma (aRCC) patients. This study aimed to assess the cost-effectiveness of NIVO + IPI versus PEM + AXI from a Brazilian private healthcare system perspective, utilizing a novel approach to estimate comparative efficacy between the treatments. A three-state partitioned survival model (progression-free, progressed, and death) was developed to estimate costs, life-years (LYs), quality-adjusted LYs (QALYs), and the incremental cost-utility ratio (ICUR) over a 40-year time horizon. In the absence of head-to-head comparisons between NIVO + IPI and PEM + AXI, clinical data for NIVO + IPI was obtained from CheckMate 214 (NCT02231749) and for PEM + AXI from KEYNOTE-426 (NCT02853331). A matching-adjusted indirect comparison was conducted to account for the imbalance of treatment effect modifiers between the trials. Patient characteristics, resource use, health state utilities, and costs were based on Brazilian-specific sources. Costs and health outcomes were both discounted by 5% annually in line with Brazilian guidelines. The robustness of the results was evaluated through extensive sensitivity analysis and scenario analyses. When comparing the <i>matched</i> versus <i>unmatched</i> OS, PFS, and TTD curves there was no noteworthy difference. NIVO + IPI was associated with cost savings (R$ 350,232), higher LYs (5.54 vs. 4.61), and QALYs (4.74 vs. 3.76) versus PEM + AXI, resulting in NIVO + IPI dominating PEM + AXI. Key model drivers were the treatment duration for PEM, NIVO, and AXI. NIVO + IPI remained dominant in all scenario analyses, which indicated that model results were robust to alternative modelling inputs or assumptions. This analysis shows that NIVO + IPI is estimated to be a life-extending and potentially cost-saving 1 L treatment option when compared with PEM + AXI for intermediate/poor-risk a RCC patients in the Brazilian private healthcare system. Nivolumab plus ipilimumab (NIVO+IPI) and pembrolizumab plus axitinib (PEM+AXI) are currently the two most prescribed therapies in the Brazilian private healthcare market for the first-line (1L) treatment of intermediate/poor-risk advanced renal cell carcinoma (RCC) patients. Given that financial resources are limited, economic evaluations are needed to enable Brazilian payers to make informed decisions. In order to provide robust evidence on the relative costs and benefits of 1L RCC treatments in the Brazilian private healthcare system, the cost-effectiveness of NIVO+IPI versus PEM+AXI was evaluated using a three-state model. This model simulates the patient's journey, where a patient can remain free of disease progression, experience disease progression, or die. To reflect the Brazilian situation, patient characteristics, healthcare resource use and costs, and quality-of life data in the model were based on Brazilian sources. NIVO+IPI and PEM+AXI have not been compared “head-to-head” in a clinical trial, therefore treatment efficacy was estimated using a matching-adjusted indirect comparison, a method that uses patient-level data from one trial (Checkmate 214) to match summary patient characteristics from the comparator trial (KEYNOTE-426), thus enabling a robust comparison. Model results showed that NIVO+IPI was associated with cost savings (R$ 350,232), higher life-years (5.54 vs 4.61), and quality-adjusted life-years (4.74 vs 3.76) versus PEM+AXI, resulting in NIVO+IPI being less costly and providing more clinical benefits than PEM+AXI. By showing that NIVO+IPI is a life-extending and cost-saving 1L treatment option when compared with PEM+AXI for intermediate/poor-risk aRCC patients, this study can help Brazilian payers make value-based choices on their resource allocation.