Many countries with national healthcare systems or payers such as insurance companies use cost-effectiveness analyses to decide whether to cover new medicines, balancing treatment costs with potential health benefits. That strategy often limits access to new, targeted therapies, even when these drugs prove highly effective and become part of standard-of-care therapy for many patients.

A new study from Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine examined the cost-effectiveness of durvalumab, a targeted immunotherapy for lung cancer that is known to extend lifespan. The findings show that the drug exceeded official cost-effectiveness thresholds for all four analyzed countries: the United States, Brazil, Singapore, and Spain.

The study could help guide drug-pricing strategies to reduce financial burdens and increase the number of patients who benefit from treatment.

“Cost-effectiveness analyses can help establish a value-based price for discussions with payers,” including insurance companies and national health care systems, said senior author Gilberto Lopes, MD, chief of medical oncology and medical director for international affairs at Sylvester.

Cost-effectiveness analyses can also inform biopharma companies about barriers to access, resulting in pricing-structure changes for targeted drugs in different countries, he added.

That’s a key aim of the Access to Oncology Medicines (ATOM) Coalition, a global initiative chaired by Lopes to improve access to oncology treatments in low-income countries.

Effective but unavailable

Since its approval for lung cancer in 2018, durvalumab has become part of the standard of care for the disease. The drug is used as a maintenance therapy, usually for a year, after primary chemotherapy for unresectable (inoperable), locally advanced non-small cell lung cancer (NSCLC).

The drug extends lifespan by more than 18 months compared to placebo, according to an analysis of five years of data from the PACIFIC clinical trial.

Despite its effectiveness, durvalumab access is limited in some settings. In Brazil, for instance, the drug was approved in 2020 but remains unreimbursed by its public health system.

In this new study, International Cost-Effectiveness Analysis of Durvalumab in Stage III Non–Small Cell Lung Cancer, published in the Journal of the American Medical Association Open Access, the researchers developed a model to assess durvalumab’s treatment costs and health benefits in lung cancer patients over a 10-year period. To calculate treatment costs, the researchers collected a wide range of data, including drug pricing in different countries, administration costs, adverse events, and follow-up care. In the U.S., the cost of treatment with durvalumab was $114,394.

“To evaluate the cost-effectiveness of durvalumab vs placebo as maintenance therapy in patients with unresectable stage III NSCLC from four international payer perspectives (US, Brazil, Singapore, and Spain),” wrote the investigators. “In this economic evaluation, a Markov model was designed to compare the lifetime cost-effectiveness of maintenance durvalumab for unresectable stage III NSCLC with that of placebo, using five-year outcomes data from the PACIFIC randomized placebo-controlled trial.

Gilberto Lopes, MD, chief of medical oncology and medical director for international affairs at the Sylvester Comprehensive Cancer Center says “Cost-effectiveness analyses can help establish a value-based price for discussions with payers,” including insurance companies and national health care systems. [Sylvester Comprehensive Cancer Center]
“Individual patient data were extracted from the PACIFIC, KEYNOTE-189, ADAURA, ALEX, and REVEL randomized clinical trials to develop a decision-analytic model to determine the cost-effectiveness of durvalumab compared with placebo maintenance therapy over a 10-year time horizon. Direct costs, adverse events, and patient characteristics were based on country-specific payer perspectives and demographic characteristics. The study was conducted from June 1, 2022, through December 27, 2023.

“Life-years, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs) were estimated at country-specific willingness-to-pay thresholds ([data reported in U.S.$] U.S.: $150,000 per QALY; Brazil: $22,251 per QALY; Singapore: $55,288 per QALY, and Spain: $107,069 per QALY). One-way and probabilistic sensitivity analyses were performed to account for parameters of uncertainty. A cost-threshold analysis was also performed.

“The U.S. base-case model found that treatment with durvalumab was associated with an increased cost of $114,394 and improved effectiveness of 0.50 QALYs compared with placebo, leading to an ICER of $228,788 per QALY. Incremental cost-effectiveness ratios, according to base-case models, were $141,146 for Brazil, $153,461 for Singapore, and $125,193 for Spain. Durvalumab price adjustments to the PACIFIC data improved cost-effectiveness in Singapore, with an ICER of $45 164. The model was most sensitive to the utility of durvalumab.

“In this cost-effectiveness analysis of durvalumab as maintenance therapy for unresectable stage III NSCLC, the therapy was found to be cost-prohibitive from the perspective of various international payers according to country-specific willingness-to-pay thresholds per QALY. The findings of the study suggest that discounted durvalumab acquisition costs, as possible in Singapore, might improve cost-effectiveness globally.”

To quantify health benefits, the researchers used a measurement commonly used in economic evaluations called quality-adjusted life years (QALYs). This data combines lifespan gains with information on quality of life. The researchers then generated a single metric called an incremental cost-effectiveness ratio. The researchers found that the cost-effectiveness ratio in the U.S. for durvalumab was $228,788 per QALY.

Though Medicaid and Medicare typically pay for the drug, this cost-effectiveness ratio exceeds the agencies’ threshold target of $150,000. The cost-effectiveness ratios also exceed health system thresholds in the other analyzed countries. Overall, the study authors concluded that durvalumab treatment for lung cancer remains globally “cost prohibitive.”

The researchers went on to show how reduced industry pricing can improve cost-effectiveness. This analysis used discounted prices in Singapore that are available through an industry pricing program. The program brought the cost-effectiveness ratio down from $153,461 per QALY to $45,164—below the official threshold in Singapore.

Increasing access

“The overall goal of these types of studies is to shed an academic, and hopefully neutral light on all these numbers,” said study first author Samuel Kareff, MD, Sylvester’s chief hematology and oncology clinical fellow. The study’s strengths include accounting for multiple lines of therapy and using biomarker-guided treatments in its model (durvalumab targets PD-L1, which is typically screened for prior to treatment). Limitations of the study include its narrow global coverage and the lack of analyses in poorer countries where access is more restrictive, Kareff explained.

He noted that drug companies face the challenge of recouping their massive drug-development costs while ensuring patients are served. Cost-effectiveness analyses can help, he said.

In May, Bristol Myers Squibb released its 10-year strategy to improve access to treatments for patients in low- and middle-income countries, including a collaboration with the ATOM Coalition to increase access to another targeted immunotherapy, nivolumab.

“As the pace of innovation increases and more targeted therapies become available, we unfortunately expect treatment costs to increase as well,” Kareff pointed out.

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