Details regarding cost-effectiveness studies of melanoma

Reference, Country, YearComparisonMethodologyaCostsQALYsICERWTPConclusionsCriticisms
Barzey et al., USA, 2013 [37]Ipi vs. BSC for recurrent/metastatic diseaseMarkov; accounted for toxicity and administration costs$168,602 ipi, $21,886 BSC1.76 ipi, 0.62 BSCRelative to BSC, ipi $128,656/QALY$146,000/QALYIpi CE using given WTP threshold, not so at more accepted cutoffs- Overall modeling horizon of complete lifetime, causing errors in survival extrapolation and thus costs- Lack of accountability for hospice/palliative care and death costs- BSC arm (without chemotherapy) provides little meaningful clinical comparison
Curl et al., USA, 2014 [38]Dac vs. vem vs. vem + ipi for unresected/metastatic BRAF mutant diseaseDeterministic expected-value model; accounted for toxicity, administration, and follow-up costs$8391 dac, $156,831 vem, $254,695 vem + ipi0.30 dac, 0.72 vem, 1.34 vem + ipiRelative to dac, vem $353,993/QALY, vem + ipi $158,139/QALYNo specific amount usedVem or vem + ipi not CE in this setting- Overall modeling horizon of complete lifetime, causing errors in survival extrapolation and thus costs- Assumed effect of vem + ipi is seamlessly additive- Lack of accountability for hospice/palliative care and death costs; unclear methodology for toxicity costs
Bohensky et al., Australia, 2016 [39]Nivo vs. ipi for unresected/metastatic BRAF WT diseaseMarkov; accounted for toxicity, administration, and end-of-life costs$178,612 nivo, $138,987 ipi2.5 nivo, 1.2 ipiRelative to ipi, nivo $30,475/QALY$35,000/QALYNivo is more CE than ipi in this setting- Overall modeling horizon of 10 years, causing errors in survival extrapolation and thus costs- Used data from second-line ipi and extrapolated to first-line ipi- Assumed patients weigh same as mean Australian body weight in trial (dosed accordingly); duration of therapy assumed to be same as the mean amount on trial
Oh et al., USA, 2017 [40]Nivo vs. ipi vs. nivo+ipi for unresected/metastatic diseaseMarkov; accounted for toxicity, administration, follow-up, and end-of-life costs$169,320 nivo, $213,763 ipi, $228,352 both4.24 nivo, 3.68 ipi, 4.37 bothRelative to nivo, ipi was dominated; relative to ipi, both $21,143/QALY; relative to nivo, both $454,092/QALY$100,000/QALYNivo (single-agent) is most CE in this setting; PD-L1 status changes cost-effectiveness negligibly- Overall modeling horizon of 14.5 years, causing errors in survival extrapolation and thus costs- Owing to no overall survival data, survival figures were dependent on progression-free survival values only- Did not account for 2nd or 3rd line therapies
Wang et al., USA, 2017 [41]Pembro vs. ipi for unresected/metastatic diseasePS; accounted for toxicity, administration, follow-up, and end-of-life costs$303,505 pembro, $239,826 ipi3.45 pembro, 2.67 ipiRelative to ipi, pembro $81,091/QALY$100,000/QALYPembro is more CE than ipi in this setting- Overall modeling horizon of 20 years, causing errors in survival extrapolation and thus costs- Assumed no systemic therapy of any kind following progression- Pembro planned for maximum of 24 months in model (instead of until progression)
Miguel et al., Portugal, 2017 [42]Pembro vs. ipi for unresected/metastatic diseasePS; accounted for toxicity, administration, and end-of-life costs€156,268 ($191,924) pembro, €110,034 ($135,140) ipi3.31 pembro, 2.33 ipiRelative to ipi, pembro €47,221 ($57,988)/QALY€50,000 ($61,407)/QALYPembro is more CE than ipi in this setting- Overall modeling horizon of 40 years, when exceedingly low numbers of patients still alive, causing errors in survival extrapolation and thus costs- Only grade ≥ 3 toxicities accounted for, as a one-time cost- Pembro planned for maximum of 24 months in model (instead of until progression)
Kohn et al., USA, 2017 [43]Dac vs. nivo vs. ipi vs. nivo+ipi vs. pembro (q2w) vs. pembro (q3w) for unresected/metastatic diseaseMarkov with built-in transition to 2nd and 3rd line therapies; accounted for toxicity, administration, and end-of-life costs$146,775 dac, $172,219 nivo, $152,403 ipi, $206,435 nivo+ipi, $164,871 q2w pembro, $127,626 q3w pembro0.26 dac, 0.54 nivo, 0.34 ipi, 0.56 nivo+ipi, 0.43 q2w pembro, 0.38 q3w pembroRelative to q3w pembro, dac, ipi, and q2w pembro were dominated; nivo $66,800/QALY; nivo+ipi $319,723/QALY$100,000/QALYNivo or q3w pembro (followed by 2nd line ipi) is most CE in this setting- Overall modeling horizon of complete lifetime, causing errors in survival extrapolation and thus costs- No prospective data for several arms (e.g. pembro followed by 2nd line ipi)- Did not use immunotherapy dosing by body weight; although ongoing trials may not utilize weight-based dosing, previous trials (i.e., major sources of extracted data) have done so
Meng et al., England, 2018 [44]Dac vs. ipi vs. nivo for unresected/metastatic BRAF WT; ipi vs. dab vs. vem vs. nivo for BRAF mutant diseaseMarkov; accounted for toxicity, administration, and end-of-life costsBRAF WT: dac £25,228 ($35,542), ipi £57,158 ($80,532), nivo £97,898 ($137,931); BRAF mutant: ipi £56,621 ($79,775), dab £71,511 ($100,754), vem £74,001 ($104,262), nivo £88,228 ($124,307)1.23 dac, 2.54 (avg) ipi, 1.69 dab, 1.70 vem, 4.29 (avg) nivoBRAF WT: relative to dac, ipi £22,589 ($31,825)/QALY, nivo £24,483 ($34,493)/QALY; BRAF mutant: relative to ipi, dab and vem dominated; nivo £17,362 ($24,460)/QALY£50,000 ($70,462)/QALYNivo is most CE in these settings- Overall modeling horizon of complete lifetime, causing errors in survival extrapolation and thus costs- Model sensitive to treatment duration, but nonuniform comparison of continuing nivo for 2 years versus dac and vem until progression- Unclear description of cost summary with 2nd line of therapy

QALY quality-adjusted life year, ICER incremental cost-effectiveness ratio, WTP willingness to pay (threshold); ipi, ipilimumab, BSC best supportive care, CE cost-effective; dac, dacarbazine; vem, vemurafenib; nivo, nivolumab, WT wild-type; pembro, pembrolizumab, PS partitioned survival, dab dabrafenib; avg., average

aAll studies but one (Kohn et al) consisted of three basic health states (progression-free (stable), progressive disease, and death); all studies performed sensitivity analyses in addition to the base case