Hoag Family Cancer Institute, Newport Beach, CA
David Joseph Benjamin , Arash Rezazadeh
Background: Since the approval of sunitinib for the treatment of advanced renal cell carcinoma (RCC), the first-line treatment landscape has drastically altered with combination tyrosine kinase inhibitor (TKI) plus immunotherapy (IO) regimens. Despite improvements in survival, it remains unclear if these therapies are cost prohibitive for patients or hospitals compared to prior standard of care sunitinib. Methods: Approved TKI plus IO therapies were identified using the US FDA Oncology Announcements website and confirmed with NCCN Guidelines (Version 3.2023). Cost per unit was identified using public data (Lexicomp or manufacturer’s website). We calculated total cost of each treatment regimen using the cost per unit for each therapy and the median duration on treatment as reported in each combination therapy's clinical trial publication. Results: Average PFS benefit from combination TKI plus IO therapies was 8.1 months (range 4-14.7) in comparison with sunitinib. Average cost of TKI plus IO therapy was $443,839.32 compared with $199,541.44 for sunitinib therapy. Conclusions: Average increase in cost of TKI plus IO therapy compared to sunitinib was $244,297.88. For every month of PFS benefit with TKI plus IO combination therapy, there was on average $30,160.23 cost added per month. These increased costs may be prohibitive for many patients and hospitals, particularly in low- and middle-income countries (LMICs).
Drug(s) Name(s) | Trial Name | Median Duration of Treatment (months) | Cost per Unit | Cycle Length | Cost of Treatment | PFS Benefit (months) |
---|---|---|---|---|---|---|
Sunitinib | N/A | 11.0 | $890.81 (50 mg tablet) | 4 weeks on, 2 weeks off | $199,541.44 | 6 |
Axitinib plus avelumab | Javelin Renal 101 | 8.6 avelumab, 9.0 axitinib | $6,314.70 (avelumab 600 mg); $711.04 (axitinib BID) | Avelumab 10 mg/kg every 2 weeks; Axitinib 5 mg PO BID | $113,664.60 + $194,824.96 = $308,489.56 | 5.4 |
Axitinib plus pembrolizumab | KEYNOTE-426 | 10.4 | $711.04 (axitinib BID); $10,474.08 (pembrolizumab) | Pembrolizumab 200 mg every 3 weeks; Axitinib 5 mg PO BID | $224,688.64 + $157,111.2 = $381,799.84 | 4 |
Lenvatinib plus pembrolizumab | CLEAR | 17.0 | $426.26 (Lenvatinib 20 mg); $10,474.08 (pembrolizumab) | Pembrolizumab 200 mg every 3 weeks; Lenvatinib 20 mg daily | $220,376.42 + $251,377.92 = $471,754.34 | 14.7 |
Cabozantinib plus nivolumab | CheckMate 9ER | 13.3 | $8,463.84 (nivolumab); $931.50 (cabozantinib 40 mg tablet) | Nivolumab 240 mg every 2 weeks; cabozantinib 40 mg daily | $236,987.52 + $376,326 = $613,313.52 | 8.3 |
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