EML4-ALK Fusion Testing and Crizotinib Are Not Cost-Effective in NSCLC
Studies with the tyrosine kinase inhibitor crizotinib (Xalkori) have shown significant improvement in clinical outcomes for the treatment of echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase (EML4-ALK) fusion-positive non–small-cell lung cancer (NSCLC), but researchers recently questioned its cost-effectiveness. In the study, researchers evaluated the cost-effectiveness of EML4-ALK fusion testing and first-line therapy with crizotinib for patients with advanced ALK-fusion–positive NSCLC, from the perspective of the Canadian public healthcare system (Djalalov S, et al. J Clin Oncol. 2014;32:1012-1019).
Researchers used a Markov model to compare the cost-effectiveness of 2 treatment approaches for patients with stage IV nonsquamous NSCLC. The first approach consisted of molecular screening and targeted therapy with crizotinib. The second approach consisted of standard of care, which included platinum doublet (cisplatin and gemcitabine) as first-line therapy, second-line pemetrexed (Alimta), and third-line erlotinib (Tarceva). The transition probabilities and mortality rates included in the model were calculated from the Ontario Cancer Registry and the Cancer Care Ontario New Drug Funding Program (CCO NDFP). The costs were obtained from the Ontario Case Costing Initiative, CCO NDFP, University Health Network, and from literature.
Overall, the results showed that targeted crizotinib therapy using EML4-ALK fusion testing resulted in 0.011 quality-adjusted life-years (QALYs), but cost $2725 (Canadian dollars) more per patient. Fusion testing accounted for $60 of those costs. Researchers then calculated an incremental cost-effectiveness ratio (ICER) of $255,970 per QALY gained compared with standard of care with no testing and no crizotinib treatment. Among EML4-ALK fusion-positive patients, first-line crizotinib resulted in 0.379 QALYs; cost an additional $95,043; and produced an ICER of $250,632 per QALY gained compared with standard of care. The major driver of crizotinib’s cost-effectiveness was drug price.
For this strategy to be more economically feasible, the researchers concluded that lower drug costs, more targeted molecular therapy, or improved effectiveness would be required. They noted that the results are preliminary, because they are based on noncomparative data; therefore, future head-to-head clinical trials will provide better insight into the optimal treatment of advanced NSCLC, which accounts for 85% of all lung cancers.