Cost-effectiveness of first-line induction and maintenance treatment sequences in non-squamous non-small cell lung cancer (NSCLC) in the U.S.

Objectives: Due to the lack of direct head-to-head trials, there are limited data regarding the comparative effectiveness of induction-maintenance sequences. The objective of this study was to develop a cost-effectiveness model to compare induction-maintenance sequences in the US for the treatment of advanced non-squamous NSCLC. Materials and methods: Decision analytic modelling was used to synthesize the treatment effect and baseline risk estimates for nine induction and maintenance treatment sequences, reflecting treatments used in the US. The model was structured using an area-under-the-curve approach and sensitivity analyses were conducted. Model validation was conducted by an independent third party. Results: All active maintenance therapy-containing regimens, with the exception of gemcitabine + cisplatin (first-line) → erlotinib (maintenance), were more costly than induction-only regimens. Concerning treatments that may be cost effective, the incremental costs per life-year gained were $121,425, $148,994, and $191,270 for gemcitabine + cisplatin → erlotinib versus gemcitabine + cisplatin → best supportive care (BSC), pemetrexed + cisplatin → BSC versus gemcitabine + cisplatin → erlotinib, and for pemetrexed + cisplatin → pemetrexed versus pemetrexed + cisplatin → BSC, respectively. All other regimens were found to be dominated (carboplatin + paclitaxel → BSC; carboplatin + paclitaxel → erlotinib; carboplatin + paclitaxel → pemetrexed; bevacizumab + carboplatin + paclitaxel → bevacizumab) or extendedly dominated (cisplatin + gemcitabine → pemetrexed). Sensitivity analyses demonstrated stability. Conclusions: Depending on the specific cost-effectiveness threshold used by a decision maker, the most cost-effective treatment sequence may include the referent comparator gemcitabine + cisplatin and the studied regimens of gemcitabine + cisplatin → erlotinib, pemetrexed + cisplatin → BSC, or pemetrexed + cisplatin → pemetrexed.