Efficacy Offsets High Costs for Immunotherapy in US, But Not Overseas

It is no secret that cancer treatment can become extremely expensive in the United States, as well as in other countries around the world. As new immunotherapy agents become more widely used in the cancer space, getting a better idea of the price tag associated with them is crucial.

Results from the Keynote-045 study showed that Keytruda (pembrolizumab) had better overall survival rates and less toxicity compared with chemotherapy in the second line setting of advanced bladder cancer. As a result, the drug was approved in both the United States and the European Union in 2017 for the treatment of patients with locally advanced or metastatic urothelial carcinoma.

These promising study results and approvals make affordability all the more important, as patients and providers seek to determine if the agent is, indeed, worth the price.

“Recently, immune-modulating drugs have been introduced to the second line setting of advanced bladder cancer,” the study authors wrote in an abstract presented at the 2018 Genitourinary Cancers Symposium. “The high cost of immunotherapy necessitates an assessment of its value by considering both efficacy and cost.”

Therefore, researchers from Israel, the United Kingdom (UK) and Canada sought to determine the cost-effectiveness of Keytruda for the second-line treatment of patients with advanced bladder cancer. Drug costs were compared between the US, UK, Canada and Australia.

The researchers developed their own Markov model, a statistical tool that evaluates decision-making regarding risk that is continuous over time, to compare the cost and effectiveness of Keytruda versus chemotherapy in this patient setting. Outcomes were measured in two ways: life-years (LYs) and quality-adjusted life-years (QALYs).

“These are common outputs of cost-effectiveness analyses to examine the efficacy of the intervention,” lead author Michal Sarfaty, from the Institute of Oncology at the Davidoff Cancer Center in Petach Tikva, Israel, explained in an interview with CURE. “QALY expresses both the quality and quantity of life lived. One QALY equals to a year in perfect health. A year in less than perfect health equals to less than one QALY.”

On average, Keytruda measured up to have a 0.36 QALY-gain compared to chemotherapy. The incremental cost-effectiveness ratios (ICERs) — defined by the difference in cost between two interventions – varied among countries, with the US having the highest difference ($122,557/QALY) followed by Australia ($99,966/QALY), Canada ($93,648/QALY) and the UK ($91,997/QALY).

As the differences in cost varied from country to country, so did the patients’ willingness to pay (WTP) per QALY. In the US, these costs were around $100,000 to $150,000; whereas in the UK it was only 20,000 to 50,000 pounds (about $25,000 to $65,000 in US dollars); 20,000 to 100,000 CAD for Canada (about $16,000 to $80,000 in US dollars); and 40,000 to 75,000 AUD in Australia (about $32,000 to $60,000 US dollars).

While costs of treatment may be higher in the United States, patients were also more willing to pay for Keytruda, making it more cost-effective than it may be considered in other countries.

“The reason Americans are willing to pay more for their health care mostly involves differences in the health care structure and regulation, namely the fact that Medicare is not allowed by law to negotiate drug prices, but probably also cultural aspects and others,” said Sarfaty.

And while this study only looked at Keytruda in particular, Sarfaty noted that future research should look at all of the immunotherapy agents that are approved to treat metastatic bladder cancer.