Abstract 667P
Background
The therapeutic landscape for metastatic renal cell carcinoma (mRCC) has been revolutionized by recent randomized controlled trials of recent US Food and Drug Administration approved immune checkpoint inhibitors (ICI) combinations that demonstrated improved patient outcomes, but the optimal treatment sequence in patients with mRCC remains unclear. To inform policy makers about the value of these treatments, we developed a Markov model to compare the cost effectiveness of different strategies for sequencing novel agents for the treatment of mRCC.
Methods
A Markov model was developed in TreeAge to compare the lifetime cost and effectiveness of NCCN recommended first-line therapies for mRCC followed by the most common second-line therapy for each combination (Table). Health outcomes were obtained from published literature and measured in life-years and quality-adjusted life-years (QALYs). Drug costs were obtained from CMS 2021 Fee Schedule and Red Book Online in 2021 US dollars. Survival data were extrapolated by fitting Weibull curves. Model robustness was addressed in univariable and probabilistic analyses. A willingness-to-pay (WTP) threshold of US$150,000 per QALY was used.
Results
Nivolumab plus ipilimumab followed by cabozantinib was the only treatment that met the cost-effectiveness threshold at $101,331/QALY. All other regimens were dominated. Table: 667P
| First Line Therapy | Second Line Therapy | Total | Incremental | ICER (US$/QALY) | |||
| Cost (USD) | LY | QALY | Cost (USD) | QALY | |||
| NIV + IPI | CAB | $617,379 | 7.82 | 6.09 | --- | --- | Baseline |
| NIV + CAB | LEN + EVE | $861,349 | 6.79 | 4.86 | $243,970 | -1.24 | Dominated |
| PEM + AXI | CAB | $628,557 | 3.91 | 2.67 | $3,264 | -3.42 | Dominated |
| PEM+ LEN | CAB | $686,925 | 4.87 | 3.36 | $25,464 | -2.73 | Dominated |
NIV=nivolumab, IPI=ipilimumab, CAB=cabozantinib, LEN=lenvatinib, EVE=everolimus, PEM=pembrolizumab, AXI=axitinib.
Conclusions
Nivolumab plus ipilimumab followed by cabozantinib is the most cost-effective treatment strategy for mRCC with a WTP of $150,000/QALY.
Clinical trial identification
Editorial acknowledgement
Legal entity responsible for the study
Jad Chahoud.
Funding
Has not received any funding.
Disclosure
B.J. Manley: Non-Financial Interests, Personal, Member: NCCN Kidney cancer Panel; Financial Interests, Personal, Advisory Board: Merck. J. Chahoud: Financial Interests, Personal, Advisory Board: Exelixsis; Financial Interests, Personal, Advisory Board: Pfizer. All other authors have declared no conflicts of interest.