Cost-effectiveness of nivolumab in squamous and non-squamous non-small cell lung cancer in Canada and Sweden: an update with 5-year data

Figures & data

Figure 1. Tornado diagram for squamous (a) and non-squamous (b) NSCLC in Canada. Lower and upper limits of the OWSA shown in parentheses; all costs shown in CAN$. Abbreviations. ICER, incremental cost-effectiveness ratio; PF, progression-free; PD, progressed disease.

Table 1. Cost and utility inputs in the models.

Parameter	Value in Canada (CAN$)	Value in Sweden (SEK)
Resource use progression-free (every 4 weeks)^a [34,35]	995.74	2,457.75
Resource use progressed disease (every 4 weeks)^a [34,35]	1147.59	5075.12
Resource use end-of-life costs [36,37]	21,974.54	76,927.00
Drug acquisition costs (per vial/pack) [29]
Nivolumab, 100-mg vial [31]	1955.42	13,067.50
Docetaxel, 20-mg vial [30]	231.20	136.50
Erlotinib, 150 mg [33]	47.47	669.97
Cisplatin, 100 mg [32]	19.00	208.00
Carboplatin, 150 mg [32]	18.80	126.50
Gemcitabine, 1000 mg [46]	62.00	446.00
Vinorelbine, 50 mg	34.02	404.00
Drug administration costs (per 4 weeks) [34,35]
Nivolumab	105.15	5193.00
Docetaxel, cisplatin, carboplatin, gemcitabine, vinorelbine	75.00	5193.00
Erlotinib	–	–
Drug monitoring costs (per 4 weeks) [35]
Nivolumab	–	381.71
Docetaxel [47]	3.98	352.45
Erlotinib, cisplatin, carboplatin, gemcitabine, vinorelbine	3.98	265.00
Treatment-related AE costs [14,38]
Squamous NSCLC patients
Nivolumab	83.39	28.41
Docetaxel	4492.46	14,585.89
Non-squamous NSCLC patients
Nivolumab	151.14	46.48
Docetaxel	3575.77	13,379.85
Health state utilities
Squamous NSCLC patients
Progression-free^b	0.745	0.810
Progressed disease^b	0.695	0.777
Non-squamous NSCLC patients
Progression-free^b	0.754	0.819
Progressed disease^b	0.698	0.785

^aDetailed resource use and unit costs inputs provided in Supplementary material Table S3.

^bEstimated from CheckMate 017 and CheckMate 057 (data on file, Bristol Myers Squibb).

Abbreviations. AE, adverse event; NSCLC, non-small cell lung cancer.

Table 2. Base-case results for the squamous (a) and non-squamous (b) NSCLC populations in Canada (CAN$).

(a)	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Nivolumab vs. docetaxel	96,451	0.85	0.69	112,921	140,753
Cost breakdown		Nivolumab		Docetaxel
Disease management		43,503		34,179
Treatment acquisition		99,696		10,816
Treatment administration		1117		429
Monitoring		0		16
Subsequent treatment		3491		1505
AE		83		4492
Total costs		147,890		51,439
Total QALYs		1.29		0.60
Total LYs		1.77		0.91
(b)	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Nivolumab vs. docetaxel	93,146	0.67	0.54	139,530	173,804
Cost breakdown		Nivolumab		Docetaxel
Disease management		45,605		38,102
Treatment acquisition		98,037		10,408
Treatment administration		1098		422
Monitoring		0		15
Subsequent treatment		2797		2021
AE		151		3576
Total costs		147,689		54,543
Total QALYs		1.36		0.83
Total LYs		1.87		1.21

Abbreviations. AE, adverse event; Inc., incremental; LY, life-year; LYG, life-year gained; NSCLC, non-small cell lung cancer; QALY, quality-adjusted life-year.

Table 3. Base-case results for the squamous (a) and non-squamous (b) NSCLC populations in Sweden (SEK).

(a)	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Nivolumab vs. docetaxel	535,333	1.28	0.94	417,693	568,895
Cost breakdown		Nivolumab		Docetaxel
Disease management		157,316		127,614
Treatment acquisition		477,339		6427
Treatment administration		78,952		29,921
Monitoring		2837		1470
Subsequent treatment		20,005		21,128
AE		28		14,586
Total costs		736,478		201,146
Total QALYs		1.66		0.72
Total LYs		2.31		1.03
(b)	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Nivolumab vs. docetaxel	499,737	1.03	0.75	483,531	662,991
Cost breakdown		Nivolumab		Docetaxel
Disease management		169,331		141,171
Treatment acquisition		454,649		6146
Treatment administration		75,199		29,227
Monitoring		2698		1348
Subsequent treatment		26,791		37,704
AE		46		13,380
Total costs		728,714		228,977
Total QALYs		1.70		0.95
Total LYs		2.33		1.29

Abbreviations. AE, adverse event; Inc., incremental; LY, life-year; LYG, life-year gained; NSCLC, non-small cell lung cancer; QALY, quality-adjusted life-year.

Figure 2. CEAC for squamous (a) and non-squamous (b) NSCLC in Canada. Abbreviations. CEAC, cost-effectiveness acceptability curve; QALY, quality-adjusted life-year; WTP, willingness to pay.

Figure 3. Tornado diagram for squamous (a) and non-squamous (b) NSCLC in Sweden. Lower and upper limits of the OWSA shown in parentheses; all costs shown in SEK. Abbreviations. ICER, incremental cost-effectiveness ratio; PF, progression-free; PD, progressed disease.

Figure 4. CEAC for squamous (a) and non-squamous (b) NSCLC in Sweden. Abbreviations. CEAC, cost-effectiveness acceptability curve; QALY, quality-adjusted life-year; WTP, willingness to pay.

Table 4. Scenario analyses results for the squamous (a) and non-squamous (b) NSCLC populations in Canada (CAN$).

(a) Nivolumab vs. docetaxel	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Base case (10-year time horizon, 5% discount rate without 2-year stopping rule)	96,451	0.85	0.69	112,921	140,753
Scenario 1 (10-year time horizon, 1.5% discount rate without 2-year stopping rule)	101,747	0.96	0.76	105,887	133,011
Scenario 2 (10-year time horizon, 5% discount rate with 2-year stopping rule)	69,549	0.85	0.69	81,426	101,495
Scenario 3 (10-year time horizon, 1.5% discount rate with 2-year stopping rule)	71,681	0.96	0.76	74,597	93,706
Scenario 4 (15-year time horizon, 5% discount rate without 2-year stopping rule)	98,562	1.00	0.80	98,165	123,536
Scenario 5 (20-year time horizon, 5% discount rate without 2-year stopping rule)	99,799	1.10	0.87	91,133	115,190
Scenario 6 (using a dose of 240 mg every 2 weeks for nivolumab)	95,297	0.85	0.69	111,570	139,069
Scenario 7 (using utility estimates from Chouaid et al 2013[44])	96,451	0.85	0.68	112,921	141,701
Scenario 8 (nivolumab acquisition cost 20% lower)	76,512	0.85	0.69	89,577	111,656
Scenario 9 (nivolumab acquisition cost 20% higher)	116,391	0.85	0.69	136,265	169,851
(b) Nivolumab vs. docetaxel	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Base case (10-year time horizon, 5% discount rate without 2-year stopping rule)	93,146	0.67	0.54	139,530	173,804
Scenario 1 (10-year time horizon, 1.5% discount rate without 2-year stopping rule)	98,585	0.76	0.61	129,381	162,514
Scenario 2 (10-year time horizon, 5% discount rate with 2-year stopping rule)	64,582	0.67	0.54	96,743	120,507
Scenario 3 (10-year time horizon, 1.5% discount rate with 2-year stopping rule)	66,709	0.76	0.61	87,548	109,968
Scenario 4 (15-year time horizon, 5% discount rate without 2-year stopping rule)	94,821	0.79	0.63	119,578	150,245
Scenario 5 (20-year time horizon, 5% discount rate without 2-year stopping rule)	95,993	0.88	0.69	109,439	138,168
Scenario 6 (using a dose of 240 mg every 2 weeks for nivolumab)	91,718	0.67	0.54	137,391	171,141
Scenario 7 (using utility estimates from Chouaid et al 2013 [44])	93,146	0.67	0.51	139,530	181,284
Scenario 8 (nivolumab acquisition cost 20% lower)	73,539	0.67	0.54	110,159	137,218
Scenario 9 (nivolumab acquisition cost 20% higher)	112,753	0.67	0.54	168,901	210,390

Abbreviations. Inc., incremental; LY, life-year; LYG, life-year gained; NSCLC, non-small cell lung cancer; QALY, quality-adjusted life-year.

Table 5. Scenario analyses results for the squamous (a) and non-squamous (b) NSCLC populations in Sweden (SEK).

(a) Nivolumab vs. docetaxel	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Base case (15-year time horizon with 2-year stopping rule)	535,333	1.28	0.94	417,693	568,895
Scenario 1 (15-year time horizon without 2-year stopping rule)	756,081	1.28	0.94	589,931	803,482
Scenario 2 (20-year time horizon with 2-year stopping rule)	539,099	1.49	1.04	362,063	516,575
Scenario 3 (using a dose of 480 mg every 4 weeks for nivolumab)	510,861	1.28	0.94	398,599	542,889
Scenario 4 (using utility estimates from Chouaid et al. 2013 [44]	535,333	1.28	0.87	417,693	617,793
Scenario 5 (nivolumab acquisition cost 20% lower)	439,865	1.28	0.94	343,204	467,441
Scenario 6 (nivolumab acquisition cost 20% higher)	630,800	1.28	0.94	492,181	670,348
(b) Nivolumab vs. docetaxel	Inc. costs	Inc. LYs	Inc. QALYs	Inc. cost per LYG	Inc. cost per QALY
Base case (15-year time horizon with 2-year stopping rule)	499,737	1.03	0.75	483,531	662,991
Scenario 1 (15-year time horizon without 2-year stopping rule)	732,823	1.03	0.75	709,058	972,222
Scenario 2 (20-year time horizon with 2-year stopping rule)	503,847	1.23	0.85	411,247	593,316
Scenario 3 (using a dose of 480 mg every 4 weeks for nivolumab)	477,978	1.03	0.75	462,477	634,124
Scenario 4 (using utility estimates from Chouaid et al. 2013 [44]	499,737	1.03	0.67	483,531	746,035
Scenario 5 (nivolumab acquisition cost 20% lower)	408,807	1.03	0.75	395,550	542,357
Scenario 6 (nivolumab acquisition cost 20% higher)	590,667	1.03	0.75	571,512	783,626

Abbreviations. Inc., incremental; LY, life-year; LYG, life-year gained; NSCLC, non-small cell lung cancer; QALY, quality-adjusted life-year.

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Data availability statement

The analysis reported in this study uses patient-level data from the CheckMate 017 and CheckMate 057 trial. The patient-level data are not publicly available, but the results of the trial have been reported in a number of publications. The trial results supporting the findings of this analysis are presented graphically within the article. The survival analysis was implemented in R using the flexsurv package.