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Nivolumab in the Treatment of Metastatic Renal Cell Carcinoma

A Cost-Utility Analysis

Raphael, Jacques, MSc, MD*,†; Sun, Zhuolu, MSc; Bjarnason, Georg A., MD; Helou, Joelle, MSc, MD†,§; Sander, Beate, PhD†,∥; Naimark, David M., MSc, MD†,¶

American Journal of Clinical Oncology: December 2018 - Volume 41 - Issue 12 - p 1235–1242
doi: 10.1097/COC.0000000000000451
Original Articles: Genitourinary

Introduction: Nivolumab improves overall survival and health-related quality of life compared with everolimus in metastatic renal cell carcinoma (mRCC). This study assesses the cost-utility of nivolumab from the Canadian health care payer perspective.

Materials and Methods: To evaluate the cost-utility of nivolumab, a Markov cohort model that incorporated data from the phase 3 CheckMate-025 trial and other sources was developed. The incremental cost per quality-adjusted life month (QALM) gained for nivolumab was calculated. A lifetime horizon was used in the base-case with costs and outcomes discounted 3% annually. The probabilities of progression and death from cancer and utility values were captured from the CheckMate-025 trial. Expected costs were based on Ontario fees and other sources. Scenario and sensitivity analyses were conducted to assess uncertainty.

Results: Compared with everolimus, nivolumab provided an additional 4.2 QALM at an incremental cost of $34,153. The resulting incremental cost-effectiveness ratio was $8138/QALM gained. Assuming a willingness to pay (WTP) threshold of $4167/QALM ($50,000/quality-adjusted life-year [QALY]), nivolumab was not cost-effective. In 1-way sensitivity analyses, nivolumab cost, median overall survival, and median treatment duration were sensitive to changes. Furthermore, the results were sensitive to the WTP threshold and nivolumab became a cost-effective strategy with a WTP of $8333/QALM ($100,000/QALY).

Conclusions: Compared with everolimus, nivolumab is unlikely to be cost-effective for the treatment of mRCC from a Canadian health care perspective with its current price assuming a WTP of $50,000/QALY. Although mRCC patients derive a meaningful clinical benefit from nivolumab, considerations should be given to avoid drug wastage and increase the WTP threshold to render this strategy more affordable.

*Department of Oncology, Western University; London Regional Cancer Program, London

Institute of Health Policy, Management and Evaluation, University of Toronto

Department of Medicine, Division of Medical Oncology

Department of Medicine, Division of Nephrology, Sunnybrook Health Sciences Centre

§Princess Margaret Cancer Centre, Radiation Medicine Program

Public Health Ontario, Toronto, ON, Canada

The authors declare no conflicts of interest.

Reprints: Jacques Raphael, MSc, MD, Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON, Canada, M5T 3M6. E-mail: raphaeljack13@hotmail.com.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.