Genomic fusion testing for echinoderm microtubule-associated protein-like 4 (EML4) and anaplastic lymphoma kinase (ALK) genes plus targeted first-line crizotinib is not a cost effective treatment strategy for patients with advanced non-squamous non-small-cell lung cancer (NSCLC), shows a Canadian analysis.
The finding can be explained in part by a low prevalence of EML4–ALK fusion in this population, and more importantly, by the high cost of the tyrosine kinase inhibitor crizotinib, remarks the research team.
“The use of genomic testing facilitates personalized treatment for smaller targeted populations,” write Natasha Leighl (Princess Margaret Hospital, Toronto, Ontario) and co-authors in the Journal of Clinical Oncology.
But they add that introducing it to the larger NSCLC population “as efficiently as possible”, remains a challenge.
While the figures in this cost effectiveness modelling study are specific to the Canadian public healthcare system – which commonly has lower costs than other jurisdictions – the findings indicate that lower drug costs, more targeted molecular testing, or improved effectiveness could make this strategy more economically feasible, say Leighl et al.
EML4–ALK fusion testing using immunohistochemistry confirmed by florescent in situ hybridisation, followed by targeted crizotinib treatment for EML4–ALK-positive NSCLC patients would result in an incremental cost effectiveness ratio (ICER) of CAN$ 255,970 (€ 184,097) per quality-adjusted life–year (QALY) gained, compared with standard care.
Standard care was defined as conventional NSCLC treatment with first-line platinum doublet, second-line pemetrexed and third-line erlotinib, and the direct medical cost of each treatment included drugs costs, administration costs, management of adverse events and usual medical care.
Per average patient with advanced NSCLC, the benefit gained by this pharmacogenomic treatment strategy would be 0.011 QALYs, at an additional cost of CAN$ 2725.
In a separate analysis of NSCLC patients known to be positive for EML4–ALK fusion, treatment with crizotinib versus standard care would produce an ICER of CAN$ 250,632 (€ 180,237). However, the current frequency of EML4–ALK fusion is thought to be 3–7%, remark the researchers.
“Although the acceptability of an ICER value is subjective as well as dependent on jurisdiction, societal values, and total budget, among other things, this estimate is likely not considered cost effective in the current setting”, they conclude.
In the future, targeting fusion testing to light or nonsmoking patients with an epidermal growth factor receptor mutation – mutually exclusive with EML4–ALK rearrangements – may improve cost effectiveness, the team adds.
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