In the Journals

EML4-ALK fusion testing, targeted crizotinib treatment not cost-effective in NSCLC

EML4-ALK fusion testing to identify patients with advanced non–small cell lung cancer eligible for first-line, targeted treatment with crizotinib may not be cost-effective, according to study results.

Researchers in Ontario used a Markov model to compare the cost-effectiveness of two treatment approaches for patients with stage IV nonsquamous NSCLC. One approach consisted of molecular screening and targeted treatment with crizotinib (Xalkori, Pfizer). The other approach consisted of standard care, which included platinum doublet (cisplatin and gemcitabine) as first-line therapy, second-line pemetrexed (Alimta, Eli Lilly) and third-line erlotinib (Tarceva; Genentech, Astellas Pharma).

Overall, researchers found molecular testing led to an increase of 0.011 quality-adjusted life-years and a $2,725 (Canadian dollars) increase in costs. Fusion testing accounted for $60 of those costs.

Researchers then calculated an incremental cost-effectiveness ratio of $255,970 per quality-adjusted life-year gained with molecular testing compared with standard care.

Among EML4-ALK fusion-positive patients, first-line crizotinib treatment led to a 0.379 increase in quality-adjusted life-years. However, treatment was associated with a $95,043 increase in costs compared with standard care and an incremental cost-effectiveness ratio of $250,632 per quality-adjusted life-year gained.


Ronan J. Kelly

“Lower drug costs, more targeted molecular testing, or improved effectiveness would be required to make this strategy more economically feasible,” the researchers wrote. “The results of our study are preliminary, because they are based on noncomparative data; thus, future head-to-head clinical trials will provide valuable insight into the optimal treatment of advanced NSCLC.”

Drug cost is the underlying problem, Ronan J. Kelly, MD, MBA, of the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, and colleagues wrote in an accompanying editorial.

Cost could be calculated according to the prolongation of life associated with the drug, they wrote. For instance, drugs with a 6-month benefit may cost $50,000 to $60,000 per year, whereas drugs with a 2-month benefit should cost less than $30,000 yearly.

“The debate as to how we can continue to pay for each breakthrough medication without bankrupting patients or society while continuing to incentivize research and development needs to take center stage,” Kelly and colleagues wrote. “Multiplex assays may be one solution to lower screening costs, and next-generation sequencing has the potential to raise the frequency of actionable biomarkers to higher thresholds so that screening costs will not continue to play such a dominant role in the cost-effectiveness analysis. But the elephant in the room is that society cannot continue to pay $10,000 per month for each new molecularly targeted drug.”

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Disclosure: The researchers report consultant/advisory roles with and honoraria/research funding from Novartis and Pfizer.