Two clinician-researchers are suggesting that more emphasis should be placed on maximizing the cost-benefit assessment of a precision medicine approach to testing and treating metastatic non–small-cell lung cancer (NSCLC), particularly with patient survival and the duration of treatment increasing appreciably (Graham DM, Leighl NB. Front Oncol. 2014;4:258).
Donna M. Graham, MD, a clinical research fellow, Centre for Cancer Research and Cell Biology, Queen’s University, Belfast, United Kingdom, and Natasha B. Leighl, MD, MMSc, of the Princess Margaret Cancer Centre, Toronto, Ontario, Canada, focused on epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) and crizotinib (Xalkori); the latter targets the EML4-ALK fusion gene.
They acknowledge that “these targeted therapies have dramatically changed the diagnosis and treatment of NSCLC.” However, they also note that the monthly cost (in Canadian dollars) for the EGFR TKI erlotinib (Tarceva) is $2847, and for crizotinib it is $10,400, plus additional expenses associated with these treatments.
“These medications have made a great difference for many of our patients. But it’s critical that we try and do better with respect to negotiating lower prices of the drugs for our patients,” Dr Graham told Value-Based Cancer Care in a telephone interview.
Dr Graham and Dr Leighl showed that the cost-effectiveness of EGFR mutation testing and EGFR TKI treatment for patients with EGFR-mutated advanced NSCLC vary greatly, depending on the determination of costs. For example, lower cost-effectiveness figures were found in studies using the low-end negotiated costs (Brown T, et al. Health Technol Assess. 2013;17:1-278) or when some medications were donated (Zhou C, et al. Lancet Oncol. 2011;12:735-742).
One study found that drug cost was the biggest driver of increased cost associated with EGFR mutation testing and treating EGFR-positive patients with erlotinib, despite the higher costs associated with the molecular testing required to stratify patients to these therapies (Bajaj PS, et al. J Med Econ. 2014;12:1-9). The cost of testing for mutation did not exceed $0.019 per member per month; however, that was offset by the reduced treatment of chemotherapy-related adverse events. Conversely, the overall treatment expenditures accounted for $0.013 per member per month, with long-term treatment making the greatest contribution to cost.
“So these cost-effectiveness studies may be more complex to interpret, with longer survival and treatment duration,” Dr Graham said.
The researchers also examined the overall cost-effectiveness of crizotinib therapy, including testing with immunohistochemistry (IHC) and/or fluorescence in situ hybridization (FISH). The main Canadian study on this topic, which Dr Leighl helped conduct (Djalalov S, et al. J Clin Oncol. 2014;32: 1012-1019), showed that the incremental cost-effectiveness ratio for using crizotinib first line in EML4-ALK fusion–positive tumors was $255,970 (Canadian dollars) per quality-adjusted life-year gained. This is “in excess of commonly accepted cost-effectiveness thresholds,” the pair noted.
Dr Graham and Dr Leighl concluded that these expensive medications must be used judiciously, stating that “collaboration with payers and manufacturers is a key to ensure that cost of treatment is not prohibitive for patients and permitting further advances in lung cancer therapy.”