Cost-Effectiveness Analysis of Nivolumab Versus Docetaxel for the Treatment of Advanced Nonsquamous NSCLC Including PD-L1 Testing in the United States

OBJECTIVES: Nivolumab (NIV) is an FDA-approved immunotherapy for the treatment of advanced nonsquamous non-small cell lung cancer (NSCLC), with results from the Checkmate-057 trial showing NIV to have a superior efficacy and safety profile compared to docetaxel (DOC). This study aimed to examine the cost-effectiveness of NIV versus DOC for nonsquamous NSCLC and programmed death ligand 1 (PD-L1) test implications in the United States (US).

METHODS: A Markov model with three health states (progression-free, progressive disease, death) from Checkmate-057 data compared NIV, DOC, and a PD-L1 test-based strategy using TreeAge Pro. Patients tested with PD-L1+ tumors (≥1% or 10%) received NIV, whereas those tested negative received DOC. The model adopted a willingness-to-pay (WTP) threshold of $150,000/QALY from a US healthcare perspective. A lifetime horizon with a monthly cycle length was used with a 3% discount on costs and utilities derived from published resources and utility weights from a beta distribution. Uncertainty was evaluated through one-way sensitivity analyses (OWSA)and probabilistic sensitivity analyses (PSA).

RESULTS: In the base model, NIV treatment was expected to generate 0.91 QALYs at a cost of $70,283, and DOC treatment was expected to generate 0.67 QALYs at a cost of $56,752, which resulted in an ICER of $55,322/QALY. The resulting ICER was $86,192/ QALY in the ≥ 1% PD-L1 test-based model and $95,426/QALY in the ≥ 10% PD-L1 test-based model, compared to DOC. All the OWSAs resulted in an ICER < $150,000/QALY, and the PSA revealed that NIV had an ICER < $150,000/QALY in 100% of iterations.

CONCLUSIONS: From a US healthcare perspective, NIV could be considered cost-effective for the treatment of nonsquamous NSCLC compared with DOC at a WTP threshold of $150,000/ QALY. PD-L1 testing and selecting patients for NIV based on test positivity thresholds have also demonstrated cost-effectiveness compared to DOC.