Osimertinib versus platinum-pemetrexed in patients with previously treated EGFR T790M advanced non-small cell lung cancer: An updated AURA3 trial-based cost-effectiveness analysis

Abstract

Background: A recently overall survival (OS) analysis from the AURA3 trial indicated that osimertinib improves median OS versus platinum-pemetrexed for patients with previously treated epidermal growth factor receptor (EGFR) T790M advanced non-small cell lung cancer (NSCLC). Here, we assessed the cost-effectiveness of second-line osimertinib versus platinum-pemetrexed, from the perspectives of the United States payer and the Chinese health care system.

Methods: A Markov model was constructed to compare the costs and health outcomes of osimertinib versus platinum-pemetrexed in second-line treatment of EGFR T790M advanced NSCLC. Life years (LYs), quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) were calculated. One-way and probabilistic sensitivity analyses assessed the robustness of the model. Cost-effectiveness was examined in the intention-to-treat (ITT) population and central nervous system (CNS) metastases population.

Results: In the United States, compared with platinum-pemetrexed, osimertinib yielded additional effectiveness of 0.43 QALYs and -0.12 QALYs, with incremental costs of $67,588 and $16,465 in the ITT population and CNS metastases population, respectively. The ICERs of osimertinib over platinum-pemetrexed were $159,126/QALY and $-130,830/QALY, respectively. The probability of osimertinib being cost-effective was 37% and 5.76%, respectively, at the willingness-to-pay (WTP) threshold of $150,000/QALY. In China, osimertinib showed incremental effectiveness of 0.34 QALYs and -0.14 QALYs, with incremental costs of $1,663 and $-505, resulting in ICERs of $4,950/QALY and $3,754/QALY in the ITT population and CNS metastases population, respectively. At the WTP threshold of $37,489/QALY, there was a 100% and 26% likelihood that osimertinib was cost-effective in the ITT population and CNS metastases population.

Conclusion: In the United States, second-line osimertinib treatment for EGFR T790M advanced NSCLC is not cost-effective compared to platinum-pemetrexed under the current WTP threshold. When the osimertinib price reduces, the economic outcome may become favorable. In China, assuming a WTP threshold of $37,489/QALY, osimertinib is the dominant treatment strategy compared with platinum-pemetrexed in the ITT population and provides cost savings for CNS metastases patients.

Keywords: EGFR; cost-effectiveness; non-small-cell lung cancer; osimertinib; platinum-pemetrexed.

Figure 1

Three-state Markov model Structure. NSCLC, Non-Small Cell Lung Cancer; EGFR, epidermal growth factor receptor; TKI, tyrosine kinase inhibitor.

Figure 2

Tornado diagrams of one-way sensitivity analyses with greatest influence variables. The diagram shows the association of variables with the ICER of osimertinib versus platinum-pemetrexed in the second-line treatment of EGFR T790M positive advanced NSCLC in intention-to-treat population, from (A) the United States payer and (B) Chinese health care system perspectives. The vertical black line represents the base-case result of $159,126 per QALY and $4,950 per QALY in the United States and Chinese context, respectively. *ICER lower than 0. ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-years; PP, platinum-pemetrexed; BSA, body surface area; PFS, progression-free survival; PD, progressive disease.

Figure 3

Cost-effectiveness acceptability curves for the osimertinib and platinum-pemetrexed groups in intention-to-treat population generated from the probabilistic sensitivity analysis (10,000 iterations) from (A) the United States payer and (B) Chinese health care system perspectives. The blue and red vertical dotted line in (A) represent the $100,000 and $150,000 per QALY willingness-to-pay thresholds. The blue, black and red vertical dotted line in (B) represent the $19,003, $37,489 and $85,176 per QALY willingness-to-pay thresholds. QALY, quality-adjusted life-years.