Mechanism(s) To Increase Cost-effectiveness and Sequencing in aRCC

Price reduction is one mechanism that increases drug cost-effectiveness. A sensitivity analysis showed that nivolumab was likely to be only 3.10% cost-effective at full cost, but 74.30% cost-effective at 85% of the full cost and 100% cost-effective at 60% of the full cost. When quality of life (QoL) was not factored into the model, corresponding cost-effectiveness was 4.90%, 76.00%, and 100%.

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“Because our study shows that the results are sensitive to the price of nivolumab, a reduction in price by negotiation regarding the tradeoffs between the drug price and coverage may be an appropriate and effective method to improve the cost-effectiveness,” the authors wrote.

In a similar cost-effectiveness analysis of nivolumab in the treatment of non-squamous non-small cell lung cancer (NSCLC), Swiss researchers showed that a cost reduction of 33% with nivolumab given to patients with only PD-L1+ tumors or a cost reduction of 45% with nivolumab given to all patients resulted in ICERs below or near the WTP and increased its cost-effectiveness.3 Reducing the dose and treatment time decreased the ICER partly below the WTP threshold, increasing cost-effectiveness.3

The Swiss study also showed that although providing nivolumab to patients with PD-L1 expression of at least 1% or at least 10% resulted in higher mean costs, the approach was more cost effective than treating all patients with nivolumab. “PD-L1 testing should be considered in patients with non-squamous NSCLC who are candidates for PD-L1 checkpoint inhibitor therapy,” the authors concluded.

The National Institute for Health and Care Excellence (NICE), which assesses new drugs and treatment as they become available, first rejected nivolumab as insufficiently cost-effective for patients with aRCC in the United Kingdom. When the drug manufacturer offered to discount nivolumab, this decision was reversed.

Patients with aRCC now have 3 new options after progression on prior anti-angiogenic therapy: nivolumab, cabozantinib, and the combination of lenvatinib and everolimus. As treatment options increase, patient-reported outcomes and cost-effective analyses will play a key role in determining how these drugs are sequenced in clinical practice.4

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A network meta-analysis suggests that patients with poor prognosis may be more effectively treated with cabozantinib while patients with good performance status may be better off with nivolumab. While a cost-effective analysis of cabozantinib is not available, it is available at a monthly cost of about $13,000.5