OBJECTIVES: To study the cost-effectiveness of nivolumab versus surveillance in Sweden for the adjuvant treatment of patients with muscle invasive urothelial carcinoma (UC) with high risk of recurrence and tumor cell PD-L1 expression ≥ 1% who have undergone radical resection.
METHODS: A three state (disease-free, recurrent, death) Markov model was built and run for a lifetime from a healthcare payer perspective to estimate life-years (LYs), quality adjusted LYs (QALYs) and incremental cost-utility ratios (ICURs). Patient characteristics, efficacy (disease-free survival) and safety (adverse event frequencies), and EQ-5D-3L health state utilities were derived from the CheckMate 274 study. Aggregate costs and QALYs associated with the recurrent state were modelled as one-offs based on local shares of first-line therapies used to treat metastatic UC. Costs and long-term health outcomes associated with metastatic UC treatments were based on published duration of therapy and survival data or prior health technology appraisals reporting their total estimated costs and QALYs. An annual discount rate of 3.0% was applied to costs and QALYs. In addition to base-case ICURs, results from probabilistic and one-way deterministic sensitivity analyses and scenario analyses were obtained to examine the robustness of the results.
RESULTS: Treatment with nivolumab treatment led to improvement in LYs and QALYs and higher costs (9.70, 6.25, and SEK 1,247,051, respectively) versus surveillance (6.54, 4.26, and SEK 716,044, respectively). This resulted in an ICUR of SEK 266,834/QALY gained. All tested scenarios and varied inputs in the deterministic sensitivity analyses resulted in <15% and <25% change from the base-case ICUR, respectively. Probabilistic sensitivity analyses resulted in an average ICUR of SEK 274,961/QALY, with nivolumab having a 98% probability of being cost-effective at a willingness-to-pay threshold of SEK 1,000,000/QALY gained.
CONCLUSIONS: Nivolumab is estimated to be a life-extending and cost-effective adjuvant treatment for muscle-invasive UC in Sweden.
