Cost-effectiveness Analysis of Nivolumab for Treatment of Platinum-Resistant Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck


Abstract

Background: The CheckMate 141 trial found that nivolumab improved survival for patients with recurrent or metastatic head and neck cancer (HNC). Despite the improved survival, nivolumab is much more expensive than standard therapies. This study assesses the cost-effectiveness of nivolumab for the treatment of HNC.

Methods: We constructed a Markov model to simulate treatment with nivolumab or standard single-agent therapy for patients with recurrent or metastatic platinum-refractory HNC. Transition probabilities, including disease progression, survival, and probability of toxicity, were derived from clinical trial data, while costs (in 2017 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios (ICERs), expressed as dollar per quality-adjusted life-year (QALY), were calculated, with values of less than $100 000/QALY considered cost-effective from a health care payer perspective. We conducted one-way and probabilistic sensitivity analyses to assess model uncertainty.

Results: Our base case model found that treatment with nivolumab increased overall cost by $117 800 and improved effectiveness by 0.400 QALYs compared with standard therapy, leading to an ICER of $294 400/QALY. The model was most sensitive to the cost of nivolumab, though nivolumab only became cost-effective if the cost per cycle decreased from $13 432 to $3931. The model was not particularly sensitive to assumptions about survival. If one assumed that all patients alive at the end of the CheckMate 141 trial were cured of their disease, nivolumab was still not cost-effective (ICER $244 600/QALY).

Conclusion: While nivolumab improves overall survival, at its current cost it would not be considered a cost-effective treatment option for patients with HNC.

Figures

Figure 1.
Figure 1.
State transition diagram. The three main health states are represented by ovals and include “stable disease,” “cancer progression,” and “death.” Arrows represent possible transitions from one health state to the next. Patients may experience toxicity and remain in their same state after a decrement in utility and additional cost.
Figure 2.
Figure 2.
Model validation. This figure shows the cost-effectiveness model validation results. The top panel (plot) shows how our model (smooth curves) predicts survival compared with the CheckMate 141 trial (superimposed). The bottom panel (table) shows how our model predicts overall survival, progression-free survival, grade 3–4 toxicity, and grade 5 toxicity compared with the CheckMate 141 trial.
Figure 3.
Figure 3.
One-way sensitivity analyses. These plots represent the cost-effectiveness of nivolumab as measured with the increasing incremental cost-effectiveness ratio (ICER). The dashed line represents the willingness-to-pay threshold of $100,000 and the shaded region below the dashed line represents ICERs where nivolumab would be considered cost-effective. The top plot (A) demonstrates how the cost-effectiveness of nivolumab varies by the cost of nivolumab. The bottom plot (B) demonstrates how the cost-effectiveness of nivolumab varies with assumptions about the risk of death for nivolumab compared with standard therapy. QALY = quality-adjusted life-year.
Figure 4.
Figure 4.
Cost-effectiveness acceptability curve. This plot shows the results of a probabilistic sensitivity analysis comparing the cost-effectiveness of nivolumab with standard therapy for recurrent/metastatic squamous cell carcinoma of the head and neck. QALY = quality-adjusted life-year.
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