Cost-utility analysis of atezolizumab combined with bevacizumab for unresectable hepatocellular carcinoma in Thailand

Abstract

Background: Clinical trials have proven the efficacy and safety of atezolizumab combined with bevacizumab (A+B) in treating unresectable hepatocellular carcinoma (uHCC). This study aimed to assess the cost-utility of A+B compared to best supportive care (BSC) among uHCC patients in Thailand.

Methods: We conducted a cost-utility analysis from a societal perspective. We used a three-state Markov model to estimate relevant costs and health outcomes over the lifetime horizon. Local cost and utility data from Thai patients were applied. All costs were adjusted to 2023 values using the consumer price index. We reported results as incremental cost-effectiveness ratios (ICERs) in United States dollars ($) per quality-adjusted life year (QALY) gained. We discounted future costs and outcomes at 3% per annum. We then performed one-way sensitivity analysis and probabilistic sensitivity analysis to assess parameter uncertainty. The budget impact was conducted to estimate the financial burden from the governmental perspective over a five-year period.

Results: Compared to BSC, A+B provided a better health benefit with 0.8309 QALY gained at an incremental lifetime cost of $45,357. The ICER was $54,589 per QALY gained. The result was sensitive to the hazard ratios for the overall survival and progression-free survival of A+B. At the current Thai willingness-to-pay (WTP) threshold of $4,678 per QALY gained, the ICER of A+B remained above the threshold. The projected budgetary requirements for implementing A+B in the respective first and fifth years would range from 8.2 to 27.9 million USD.

Conclusion: Although A+B yielded the highest clinical benefit compared with BSC for the treatment of uHCC patients, A+B is not cost-effective in Thailand at the current price and poses budgetary challenges.

Fig 1. Markov model structure with the three health states.

Fig 2

Predicted overall survival of patients who received atezolizumab plus bevacizumab (A+B) and best supportive care (BSC). Abbreviation: A+B, atezolizumab plus bevacizumab; BSC, best supportive care.

Fig 3

Cost-effectiveness acceptability curve. Abbreviation: A+B, atezolizumab plus bevacizumab; QALY, quality-adjusted life year; USD, the United States dollar.

Fig 4. One-way sensitivity analysis on changes in base case ICER for atezolizumab plus bevacizumab (A+B) versus best supportive care (BSC).

Abbreviation: AB, atezolizumab plus bevacizumab; BSC, best supportive care; CI, confidence interval; ICER, incremental cost-effectiveness ratio; HR, hazard ratio; PFS, progression free survival; OS, overall survival.

Fig 5. Five-year budget estimation.

Abbreviation: USD, the United States dollar.