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Cost-Effectiveness Analysis of a New Second-Line Treatment Regimen for Advanced Intrahepatic Cholangiocarcinoma: Biomarker-Driven Targeted Therapy of Pemigatinib Versus 5-FU Chemotherapy

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Abstract

Background and Objectives

The National Comprehensive Cancer Network recommends a second-line treatment of pemigatinib for patients with intrahepatic cholangiocarcinoma with fibroblast growth factor receptor 2 (FGFR2) fusions/rearrangements and modified FOLFOX (mFOLFOX) for those without FGFR2 alterations. However, these regimens are not yet covered by Taiwa’s National Health Insurance. This cost-effectiveness analysis evaluated the cost-effectiveness of the pemigatinib/mFOLFOX regimen as the second-line treatment for advanced intrahepatic cholangiocarcinoma based on FGFR2 status in comparison with the regimen of fluorouracil chemotherapy and provided a cost-effectiveness analysis-based reference price for pemigatinib.

Methods

A three-state partitioned survival model with a 5-year time horizon was constructed for patients with advanced intrahepatic cholangiocarcinoma who did not respond to first-line therapy. Overall and progression-free survival functions of pemigatinib, mFOLFOX, and fluorouracil were estimated from the FIGHT-202, ABC-06, and NIFTY trials, respectively. The utility of health states and disutility of adverse events were obtained from the literature. The genetic testing fee and price of pemigatinib were set as the market price. Other costs related to advanced intrahepatic cholangiocarcinoma were calculated using National Health Insurance claims data. The willingness-to-pay threshold was three times the gross domestic product per capita in 2021 (NT$2,889,684). A 3% discount rate was applied to quality-adjusted life-years and costs. Scenario analyses included a gradual price reduction of pemigatinib, alternative survival models, application of a National Health Insurance payment conversion factor to non-medication costs, and consideration of life-years as effectiveness. A deterministic sensitivity analysis, probabilistic sensitivity analysis, and a value of information analysis were performed.

Results

The new regimen provided an incremental 0.13 quality-adjusted life-years, with incremental costs of NT$459,697, yielding an incremental cost-effectiveness ratio of NT$3,411,098 per quality-adjusted life-year and an incremental net monetary benefit of − NT$70,268. The new regimen was found to be 53.2% cost effective in the probabilistic sensitivity analysis. The expected value of uncertainty measured by the expected value of perfect information was NT$80,695/person. In scenario analyses, the incremental net monetary benefit was positive when the price of pemigatinib was reduced by 40% or more. When applying a conversion factor to non-medical costs, the probability of the new regimen being cost effective was slightly increased from 53.2 to 56.5% compared with the base-case analysis. The utility and the cost of the new regimen were the main drivers of uncertainty.

Conclusions

Although the new second-line genetic-based and biomarker-driven regimen of pemigatinib/mFOLFOX appears not cost effective for patients with advanced intrahepatic cholangiocarcinoma in the base-case analysis, our analysis suggests it is highly likely to be cost effective in the case of a 40% price reduction on pemigatinib.

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Authors and Affiliations

  1. Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, 112304, Taipei, Taiwan

    Chen-Han Chueh, Yi-Wen Tsai, Zi-Rong Chen & Ming-Neng Shiu

  2. Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan

    Ming-Neng Shiu

  3. Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan

    Yu-Wen Wen

  4. Department of Oncology, Taipei Veterans General Hospital, 112201, Taipei, Taiwan

    Nai-Jung Chiang

  5. School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan

    Nai-Jung Chiang

Authors
  1. Chen-Han Chueh
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Corresponding authors

Correspondence to Yi-Wen Tsai or Nai-Jung Chiang.

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Funding

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of Interest/Competing Interests

Nai-Jung Chiang has received payment for lectures from Eli Lilly and Company, TTY Biopharm Company Limited, Ono Pharmaceutical Co., Ltd., Bristol Myers Squibb, PharmaEngine, Inc., and Roche. Chen-Han Chueh, Zi-Rong Chen, Ming-Neng Shiu, Yu-Wen Wen, and Yi-Wen Tsai have no conflicts of interest that are directly relevant to the content of this article.

Ethics Approval

The Institutional Review Board of National Yang Ming Chiao Tung  University, Taiwan approved this study (YM111012E).

Availability of Data and Material

The data that support the findings of this study are available from the Ministry of Health and Welfare, Taiwan, but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available.

Consent to Participate

The Institutional Review Board of National Yang Ming Chiao Tung University (IRB) agreed to waive the consent to participate for this research because this research is low risk. Furthermore, the possible risk to the research subjects is no more than that of those who did not participate in the research, and the exemption from obtaining prior consent does not affect the rights and interests of the research subjects.

Consent to Publish

Consent to publish is not required because the IRB agreed that this research did not require consent to participate.

Code Availability

The code supporting the findings of this study is available from the corresponding authors upon request.

Authors’ Contributions

Conceptualization: Y-WW, Y-WT, N-JC; data curation: Z-RC; formal analysis: C-HC, Z-RC; methodology: M-NS, Y-WW, Y-WT; project administration: M-NS, Y-WT, N-JC; resources: Y-WT; software: C-HC, Z-RC; supervision: M-NS, Y-WW, Y-WT, N-JC; validation: C-HC; visualization: C-HC, Z-RC; writing, original draft: C-HC, Z-RC, Y-WT; writing, review and editing: C-HC, M-NS, Y-WW, Y-WT, N-JC. All authors read and approved the final manuscript.

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Chueh, CH., Tsai, YW., Chen, ZR. et al. Cost-Effectiveness Analysis of a New Second-Line Treatment Regimen for Advanced Intrahepatic Cholangiocarcinoma: Biomarker-Driven Targeted Therapy of Pemigatinib Versus 5-FU Chemotherapy. PharmacoEconomics 41, 307–319 (2023). https://doi.org/10.1007/s40273-022-01227-6

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