Cost-Effectiveness of Perioperative Immune Checkpoint Therapy for NSCLC in Japan, the United States, and Brazil

Introduction: Immune checkpoint inhibitors (ICIs) are increasingly being used to treat lung cancer perioperatively. Although ICI use has led to long-term improvements in patient outcomes, its high costs have increased medical expenses. We evaluated the cost-effectiveness of perioperative ICI therapy for NSCLC in Japan, the USA, and Brazil. Methods: Hazard ratios of disease-free survival and overall survival for neoadjuvant or adjuvant chemotherapy and neoadjuvant, adjuvant, or neoadjuvant plus adjuvant therapy with ICI were estimated from landmark phase III trials using a network meta-analysis. A partitioned survival model was used to estimate quality-adjusted life-years and life-years. Drug and hospitalization costs were included using standard regimens as of April 2023, discounted at 2% annually. Results: The incremental cost-effectiveness ratio (ICER) per quality-adjusted life-years for neoadjuvant chemotherapy compared with no perioperative treatment was ¥714,940 ($4468) in Japan. That for neoadjuvant therapy by ICI compared with neoadjuvant chemotherapy was ¥5,285,770 ($33,036). The ICERs for other regimens were not calculated because of their dominance. In the USA and Brazil, the ICERs for neoadjuvant chemotherapy were $32,726 and $29,320, respectively, whereas those for neoadjuvant therapy with ICI were $228,467 and $92,573, respectively. Conclusions: The ICER threshold in Japan is generally ¥5 million and ¥7.5 million for essential drugs such as anticancer agents. The ICER of neoadjuvant chemotherapy was lower than the former threshold, whereas that of neoadjuvant nivolumab was lower than only the latter threshold. Therefore, neoadjuvant chemotherapy is cost-effective in Japan, the USA, and Brazil, whereas neoadjuvant nivolumab is only cost-effective in Japan.