Atezolizumab versus Pembrolizumab for First-line Treatment in Non-small-cell Lung Cancer with High PD-L1 Expression: A Network Meta-analysis and Cost-effectiveness Analysis from Chinese Perspectives

Abstract Background: Atezolizumab and pembrolizumab have been approved for treating metastatic non-small-cell lung cancer (NSCLC) patients with high programmed cell death - ligand 1(PD-L1) expression in the first-line setting. This study aimed to compare the cost-effectiveness of the two ICI monotherapies in this patient population, from the perspective of Chinese payer's. Material and Methods: Using network meta-analysis and partitioned survival model, we conducted cost-effectiveness analysis for atezolizumab and pembrolizumab for the first-line treatment of NSCLC. Clinical information was gathered from phase 3 randomized clinical trials. Costs and health state utilities data were derived from previous literature or calculated from perspectives of payers in China. Uncertainty of the model was explored by performing one-way sensitivity analysis and probabilistic sensitivity analysis. Scenario analysis was conducted to investigate the influence of drug assistance projects on the cost-effectiveness of certain group of people. Results: In base case analysis, atezolizumab improved 0.18 quality-adjusted life-years (QALYs), accompany with a decreased overall cost of $100, resulting in its dominance of pembrolizumab. The scenario analysis showed that with the drug assistance projects, the use of atezolizumab increased cost of $9,564 compared with pembrolizumab, which led to an incremental cost-effectiveness ratio (ICER) of $54,475 per QALY. Conclusion: In this economic evaluation comparing two ICI monotherapies for high PD-L1 expression metastatic NSCLC patients, atezolizumab was the dominant treatment strategy compared with pembrolizumab. In scenario analysis, we explored the influence of drug assistance projects for ICIs and found that atezolizumab was not cost-effective compared with pembrolizumab at a willingness-to-pay (WTP) threshold of $38,431 per QALY.