Cost-Effectiveness Analysis Of EGFR Mutation Testing And Afatinib Versus Gemcitabine-Cisplatin As First-Line Therapy For Advanced Non-Small-Cell Lung Cancer In China

Figures & data

Figure 1 The schematics of the decision tree (A) and the Markov state transition model (B).

Abbreviations: NSCLC, non-small cell lung cancer; EGFR, epidermal growth factor receptor; M+, mutation-positive; M-, mutation-negative; Markov model.

Table 1 Unit Costs Included In The Model

Variables	Base Case	Range	Distribution	Source
Cost ($)^a
Cost of Afatinib per 40mg^b	48.66	38.93–48.66	Fixed in PSA	[e]
Cost of GemCis per cycle^c	640.56	512.45–768.67	Triangle	[e]
Cost of EGFR testing	316.47	148.34–445.03	Triangle	[e]
Cost of consultation visit and monitoring^d	272.18	217.75–326.62	Triangle	[e]
Cost of pemetrexed maintenance per cycle	2,014.85	1611.88–2417.82	Triangle	[f]
Cost of salvage therapy per cycle	1,238.96	974.92–1523.31	Triangle	[f]
Cost of terminal per cycle	2,583.37	741.72–5099.17	Triangle	[f]
Cost of managing SAEs
Diarrhoea per episode	5.48	4.93–6.03	Triangle	[g]
Rash or acne per episode	1.47	1.32–1.61	Triangle	[g]
Stomatitis or mucositis per episode	4.66	4.19–5.12	Triangle	[g]
Vomiting per episode	142.00	127.80–156.20	Triangle	[g]
Anaemia per episode	98.26	88.43–108.08	Triangle	[g]
Neutropenia per episode	67.26	60.53–73.98	Triangle	[g]
Thrombocytopenia per episode	241.90	217.71–266.09	Triangle	[g]
Liver protected per episode	85.28	76.75–93.80	Triangle	[g]

Notes: ^aCosts are presented in US dollars (2017 average exchange rate, US$ = CYN 6.75). ^bPrice of afatinib was reduced by 30% and was fixed in PSA because it is a brand name drug. ^cCosts of drug were based on weighted average selling price to patient. ^dCosts included the physician visit, the computed tomography-thorax scan, full blood test fee, biochemical test fee, tumor marker tester fee, and live, renal function test fee. ^[e]Costs were sourced from the health system or the National Development and Reform Commission of China. ^[f]Costs charged by previously published studies in China.^15,26,27 [g]Costs based on patient records in local hospitals in China.

Abbreviations: GemCis, gemcitabine plus cisplatin; EGFR, epidermal growth factor receptor; SAEs, serious adverse events; PSA, Probabilistic sensitivity analysis.

Table 2 Utility Values For The Health States And Disutility Values Associated With Adverse Events And Route Of Administration

Variables	Base Case	Range	Distribution	Source
Disease progression
Progression-free	0.804	0.536–0.840	Beta	^Citation29,Citation40
Progressive disease	0.470	0.190–0.560	Beta	^Citation29,Citation40
Utility decrement of SAEs
Diarrhoea	−0.119	0.108–0.132	Beta	^Citation29,Citation41
Rash or acne	−0.099	0.032–0.151	Beta	^Citation29,Citation41
Stomatitis or mucositis	−0.102	0.091–0.112	Beta	^Citation29,Citation41
Vomiting	−0.125	0.048–0.288	Beta	^Citation29,Citation41
Anaemia	−0.191	0.172–0.211	Beta	^Citation29,Citation41
Neutropenia	−0.189	0.171–0.209	Beta	^Citation29,Citation41
Thrombocytopenia	−0.108	0.097–0.119	Beta	^Citation29,Citation41
Route of administration
Intravenous therapy	−0.043	0.004–0.082	Beta	^Citation16
Oral therapy	0.014	0.000–0.037	Beta	^Citation16

Abbreviation: SAEs, serious adverse events.

Table 3 Summary Of The Cost And Outcome Results In Base-Case Analysis

	EGFR Testing/Afatinib	No EGFR Testing/GemCis	Incremental Difference
Total costs (US$)	13,042.55	7973.43	5069.12
Cost for PFS state	8706.63	5397.19	3309.44
Cost for PD state	4295.65	2535.98	1759.67
Cost for Death state	40.27	40.27	0
Total effectiveness (QALYs)	0.39	0.24	0.15
Effectiveness for PFS state	0.30	0.18	0.12
Effectiveness for PD state	0.09	0.06	0.03
ICER (US$/QALY)	33,794.13	–	–

Abbreviations: PFS, progression-free survival; PD, progressive disease; EGFR, epidermal growth factor receptor; QALY, quality-adjusted life-year; ICER, incremental cost-effectiveness ratio; GemCis, gemcitabine plus cisplatin.

Figure 2 One-way sensitivity analyses show the lower and upper values for the cost-effectiveness ratio of the Afatinib strategy to the GemCis strategy for each parameter without PAP (A) and with PAP (B).

Abbreviation: PAP, patient assistance program.

Figure 3 (A) A probabilistic scatter plot of the incremental cost-effectiveness ratio (ICER) between the GemCis and Afatinib strategies for a cohort of 1,000 patients. Each dot represents the ICER for 1 simulation. An ellipse surrounds 95% of the estimates. Dots that are located below the ICER threshold represent cost-effective simulations for the active strategy compared with the control strategy. (B) The cost-effectiveness acceptability curves showing the probabilities of net benefits achieved by the Afatinib strategy compared to the GemCis strategy at different WTP thresholds in advanced NSCLC patients.

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