In the CheckMate 025 study (NCT01668784), nivolumab improved overall survival (OS) versus everolimus in previously treated patients with advanced renal cell carcinoma (N Engl J Med 2015;373:1803–13). We evaluated the cost-effectiveness of nivolumab versus everolimus for the treatment of these patients from a Swedish healthcare system perspective.
Cost-effectiveness was assessed using a partitioned survival model consisting of three health states: progression-free survival (PFS), disease progression, and death. The proportion of patients in each state was calculated based on PFS and OS distributions from CheckMate 025. Average cost per state was estimated, and in combination with adverse events, subsequent treatment utilization, and drug costs, total model costs were calculated. Because CheckMate 025 allowed for treatment beyond progression, treatment costs were based on time to discontinuation (TTD) rather than PFS, reflecting a more conservative approach. Quality-adjusted life-years (QALYs) were calculated using quality of life assessments on EQ-5D and represented the effectiveness portion of the model. A lifetime perspective was applied (ie, 25 years) with costs and outcomes discounted by 3% annually. Sensitivity analyses were conducted to assess uncertainty.
Nivolumab resulted in greater total costs versus everolimus (SEK 1,551,386 vs 904,120), driven by differences in drug costs (SEK 939,416 vs 294,050). Effectiveness (QALYs) was also greater for nivolumab (2.9 vs 2.2). The incremental cost-effectiveness ratio (ICER) was SEK 943,346 per QALY. Applying nivolumab costs based on PFS (vs TTD) to the model decreased costs to SEK 483,875 and reduced the ICER to SEK 705,215.
These analyses demonstrate that although treatment with nivolumab is associated with higher costs, nivolumab was cost-effective at established thresholds when accounting for treatment costs that continued through progression. We believe that this model structure could serve as a template for assessing cost-effectiveness in other European Union countries.
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Legal entity responsible for the study
S. Johal: Employment: Parexel Access Consulting Consulting: PAREXEL Access Consulting - Received a consultancy fee to support analysis. K.M. Johannesen: Employee of BMS. B. Malcolm: Employment: Bristol-Myers Squibb and Novartis Stock Ownership: Bristol-Myers Squibb Research Funding received from working on numerous publications with Novartis Travel: Bristol-Myers Squibb and Novartis. J. Doan: Employment: Bristol-Myers Squibb Stock Ownership: Bristol-Myers Squibb.