Cost-effectiveness of nivolumab and ipilimumab versus pembrolizumab and axitinib in advanced renal cell carcinoma with intermediate or poor prognostic risk: a Brazilian private healthcare system perspective

Figures & data

Figure 1. Model structure. Abbreviations. PF, progression-free state; PD, progressed disease state.

Table 1. Treatment effect modifiers assessed in CheckMate 214 trial’s intermediate/poor-risk population.

	Unmatched checkmate 214 both treatment arms (%)	P-value interaction with Treatment	KEYNOTE-426 both treatment arms (%)	Matched checkmate 214 base case (%)	Matched checkmate 214 scenario (%)
Sarcomatoid features*	13.22†	0.048	18.17** [16]	18.17	–
Age <65	61.87†	0.028	62.49**[16]	62.49	–
Metastases lymph	48.05 [12]	0.224	49.83 [30]	49.83	49.83
IMDC intermediate-risk	78.75 [12]	–	81.76 [30]	81.76	81.76
IMDC poor-risk	21.25 [12]	0.151	18.24 [30]	–	18.24
Sex male	72.61 [12]	0.159	72.94**[16]	72.94	–
Metastases lung	69.78 [12]	0.309	73.65 [30]	–	73.65
Metastases bone	20.43** [12]	0.590	27.03 [30]	–	27.03
Metastases liver	20.90 [12]	0.728	16.89 [30]	–	16.89

*In KN-426 this was only tested in 67% of subjects; the percentage presents the proportion of positive/total number of tests.

**Information for KN-426 was only available for the ITT population, a similar proportion was assumed in the intermediate-poor population compared to the ITT. ​ † Based on individual patient-level data.

Table 2. Drug acquisition costs for 1 L treatments (source: CMED 2022).

Drug	Dose per tablet/vial	Units per package	Cost per package
NIVO	40 mg	1	R$ 4,111.53
	100 mg	1	R$ 10,278.81
AXI	1 mg	180	R$ 14,441.73
	5 mg	60	R$ 24,060.04
IPI	50 mg	1	R$ 21,708.48
	200 mg	1	R$ 86,834.06
PEM	100 mg	1	R$ 18,501.91

Abbreviations. NIVO, nivolumab; AXI, axitinib; IPI, ipilimumab; PEM, pembrolizumab; mg, milligram; CMED, Câmara de Regulação do Mercado de Medicamentos.

Table 3. Follow-up visit and laboratory test unit costs.

Resource	Unit cost	Source
Medical visit	R$ 224.90	CBHPM, 2018
Abdomen CT + Pelvis CT + Thorax CT	R$ 2,701.72
Brain MRI	R$ 1,854.18
Skeletal scintigraphy	R$ 632.68
Full blood count + Renal function + Liver Function	R$ 173.21
Nurse or pharmacist visit	R$ 150.00	COFEN, 2021
Terminal care − 30-day hospital admission	R$ 26,622.66	Rol ANS 2019 Report #242

CT: computerized tomography; MRI: Magnetic resonance imaging; CBHPM: Classificação Brasileira Hierarquizada de Procedimentos Médicos; COFEN: Conselho Federal de Enfermagem.

Figure 2. KM data for KEYNOTE-426 and matched and unmatched CheckMate 214; top: OS, middle: PFS, bottom: TTD.

Figure 3. Survival models used in the base case, fit the adjusted NIVO + IPI data and the PEM + AXI data from KEYNOTE-426; top: OS, middle: PFS, bottom: TTD.

Table 4. Base case results.

	Total costs	Total QALYs	Total LYs	Incremental costs	Incremental QALYs	Incremental LYs	Incremental cost per QALY
PEM + AXI	R$1,478,290	3.76	4.61	–	–	–	–
NIVO + IPI	R$1,128,058	4.74	5.54	- R$350,232	0.98	0.93	Dominant

NIVO + IPI: nivolumab plus ipilimumab; PEM + AXI: pembrolizumab plus axinitib; QALYs: quality-adjusted life-years; LY, life-years.

PF: progression-free state; PD: progressed disease state.

Figure 4. Deterministic sensitivity analysis for NIVO + IPI vs PEM + AXI: incremental costs.

Figure 5. Deterministic sensitivity analysis for NIVO + IPI vs PEM + AXI: incremental QALYs.

Figure 6. Scatter plot of incremental costs and QALYs of NIVO + IPI vs. PEM + AXI.

Figure 7. Cost-effectiveness acceptability curve.