Kate Young

Evaluating the broad societal value of pembrolizumab in women’s cancer in Brazil

Our study analyzes the cost-effectiveness of pembrolizumab in early-stage triple-negative breast cancer (eTNBC) and persistent, recurrent, or metastatic cervical cancer (CC) referred to here as "women's cancer" in a Brazilian setting. We incorporate the value elements described in the third Special Task Force Report by the Professional Society for Health Economics and Outcomes Research and additional novel elements considered relevant to women's cancer. We analyzed the incremental cost-effectiveness ratio (ICER) of pembrolizumab-based therapy in treating eTNBC and CC over a lifetime across the three perspectives: traditional payer perspective (TPP), traditional societal perspective (TSP), and broad societal perspective (BSP). Existing analyses previously used for health technology assessment included a four health state Markov model for eTNBC and a three health state Markov model for CC. These models were expanded to include productivity for the TSP along with caregiver burden, insurance value, value of hope, real option value, severity of disease, out-of-pocket expenses, and fertility treatment costs for the BSP. Data sources included the corresponding clinical trials and a targeted literature review. A single standard of care (SoC) comparator, using indication prevalence weighting and market share, was used to formulate the overall ICER. Probabilistic sensitivity analysis and scenario analyses were conducted. Pembrolizumab-based therapy generated an ICER over three times less with the BSP (R$45,180), compared with TPP (R$139,083) and TSP (R$141,152). The largest driver of results was the inclusion of insurance value, which substantially impacted quality-adjusted life years (QALYs). However, results excluding insurance value still generated an ICER of R$74,291, R$64,792 less than the TPP. Probabilistic results were consistent with the deterministic analysis. A broader analysis perspective significantly increased the estimated value of treating women's cancers compared with the TPP, indicating the perspective used by health technology bodies likely does not capture the full societal value of therapeutics.

Cost effectiveness of pembrolizumab plus lenvatinib compared with chemotherapy for treating previously treated advanced endometrial cancer in Sweden

Pembrolizumab plus lenvatinib was recently approved for the treatment of advanced or recurrent endometrial carcinoma in women with disease progression on or following prior treatment with a platinum‑containing therapy in any setting, and who are not candidates for curative surgery or radiation (KEYNOTE-775/Study-309; NCT03517449). The objective was to assess the cost effectiveness of pembrolizumab plus lenvatinib compared with chemotherapy from a Swedish healthcare perspective. A lifetime partitioned-survival model with three health states (progression free, progressed disease, death) was constructed. Chemotherapy was represented by paclitaxel or doxorubicin. Overall survival, progression-free survival, time on treatment, and utility data were obtained from KEYNOTE-775 (database lock: March 1, 2022). Costs (in 2020 Swedish Krona [SEK]) included drug acquisition and administration, health state, end of life, adverse event management, subsequent treatment, and societal (scenario analysis). Outcomes were calculated as quality-adjusted life-years (QALY) and life-years. Model results were presented as incremental cost-effectiveness ratios for all-comers, patients with proficient mismatch repair tumors, and deficient mismatch repair tumors. Deterministic and probabilistic sensitivity analyses were conducted. Pembrolizumab plus lenvatinib is a cost-effective treatment when compared with chemotherapy, with estimated deterministic and probabilistic incremental cost-effectiveness ratios of SEK 795,712 and 819,757 per QALY gained. Pembrolizumab plus lenvatinib was associated with a large incremental QALY and life-year gain per person versus chemotherapy over the model time horizon (1.49 and 1.76). Time-to-event data were incomplete and semiparametric and parametric curves were utilized for lifetime extrapolation. Willingness-to-pay thresholds, costs, and utility weights vary by country, which would vary the treatment's cost effectiveness in different countries. This partitioned survival analysis suggests that pembrolizumab plus lenvatinib is cost effective compared with chemotherapy in Sweden for women with advanced or recurrent endometrial carcinoma following previous systemic therapy. Results were robust to mismatch repair status and to changes in parameters/assumptions.

The broad societal value of pembrolizumab for women’s cancer in Canada

The impact of women's cancers is multifaceted, with broad societal and economic consequences. Health technology assessments often rely solely on costs and outcomes directly relevant to the healthcare system. Our study incorporates the additional and novel value elements across three perspectives for pembrolizumab in four women's cancers in a Canadian setting. We analyzed the net monetary benefit (NMB) of pembrolizumab-based treatments of early-stage triple-negative breast cancer, metastatic triple-negative breast cancer, microsatellite instability-high endometrial cancer, and cervical cancer from three perspectives: traditional payer perspective (TPP), traditional societal perspective (TSP), and broad societal perspective (BSP). Indications and comparators were modeled independently, combined, and weighted by prevalence. Pembrolizumab-based therapy generated an NMB over four times greater with the BSP (Canadian dollars, CAD$925,078), compared with TPP (CAD$226,090) and TSP (CAD$222,556). The largest driver of results was the inclusion of insurance value. Results excluding insurance value still generated an NMB of CAD$484,384, more than twice the TPP. Broadening the perspective to include additional value elements considerably increased the overall value of treatment of women's cancer compared with the TPP, indicating that the perspective used by health technology bodies may not fully capture the societal value of therapeutics.