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Cost-Effectiveness of Tumor Genomic Profiling to Guide First-Line Targeted Therapy Selection in Patients With Metastatic Lung Adenocarcinoma

  • Author Footnotes
    ∗ Olivia M. Dong and Pradeep J. Poonnen contributed equally to the article and should be considered first authors.
    Olivia M. Dong
    Footnotes
    ∗ Olivia M. Dong and Pradeep J. Poonnen contributed equally to the article and should be considered first authors.
    Affiliations
    Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA

    Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA
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  • Author Footnotes
    ∗ Olivia M. Dong and Pradeep J. Poonnen contributed equally to the article and should be considered first authors.
    Pradeep J. Poonnen
    Footnotes
    ∗ Olivia M. Dong and Pradeep J. Poonnen contributed equally to the article and should be considered first authors.
    Affiliations
    Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA

    Duke University Medical Center, Durham, NC, USA
    Search for articles by this author
  • David Winski
    Affiliations
    Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA
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  • Shelby D. Reed
    Affiliations
    Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA

    Duke Cancer Institute, Durham, NC, USA

    Duke Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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  • Vishal Vashistha
    Affiliations
    Section of Hematology/Oncology, Raymond G. Murphy New Mexico Veterans Affairs Medical Center, Albuquerque, NM, USA
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  • Jill Bates
    Affiliations
    Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA

    Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Department of Veterans Affairs, National Oncology Program, Durham, NC, USA
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  • Michael J. Kelley
    Affiliations
    Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA

    Duke University Medical Center, Durham, NC, USA

    Duke Cancer Institute, Durham, NC, USA

    Department of Veterans Affairs, National Oncology Program, Durham, NC, USA
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  • Deepak Voora
    Correspondence
    Correspondence: Deepak Voora, MD, Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, 101 Science Dr, DUMC 3382, Durham, NC 27708, USA.
    Affiliations
    Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA

    Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA

    Department of Veterans Affairs, National Oncology Program, Durham, NC, USA
    Search for articles by this author
  • Author Footnotes
    ∗ Olivia M. Dong and Pradeep J. Poonnen contributed equally to the article and should be considered first authors.
Published:November 01, 2021DOI:https://doi.org/10.1016/j.jval.2021.09.017

      Highlights

      • Common tumor profiling approaches in clinical use include comprehensive genomic profiling (CGP), which tests for a broad range of alterations among comprehensive sets of oncogenes, whereas targeted gene panel testing (TGPT) tests for common alterations in selected oncogenes; nevertheless, the optimal approach to tumor profiling in advanced non–small cell lung cancer remains uncertain.
      • From the Centers for Medicare and Medicaid’ perspective, the lifetime cost per quality-adjusted life-years (QALY) gained is $310 735 (TGPT vs no tumor profiling) and $445 545 (CGP vs TGPT) for patients with metastatic lung adenocarcinoma. None of the simulated results generated estimates below the $150 000 per QALY gained willingness-to-pay threshold.
      • Tumor genomic profiling directing selection of first-line cancer-directed targeted therapies does not generate sufficient gains in QALYs to offset the high price of these therapies.

      Abstract

      Objectives

      A cost-effectiveness analysis comparing comprehensive genomic profiling (CGP) of 10 oncogenes, targeted gene panel testing (TGPT) of 4 oncogenes, and no tumor profiling over the lifetime for patients with metastatic lung adenocarcinoma from the Centers for Medicare and Medicaid Services’ perspective was conducted.

      Methods

      A decision analytic model used 10 000 hypothetical Medicare beneficiaries with metastatic lung adenocarcinoma to simulate outcomes associated with CGP (ALK, BRAF, EGFR, ERBB2, MET, NTRK1, NTRK2, NTRK3, RET, ROS1), TGPT (ALK, BRAF, EGFR, ROS1), and no tumor profiling (no genes tested). First-line targeted cancer-directed therapies were assigned if actionable gene variants were detected; otherwise, nontargeted cancer-directed therapies were assigned. Model inputs were derived from randomized trials (progression-free survival, adverse events), the Veterans Health Administration and Medicare (drug costs), published studies (nondrug cancer-related management costs, health state utilities), and published databases (actionable variant prevalences). Costs (2019 US$) and quality-adjusted life-years (QALYs) were discounted at 3% per year. Probabilistic sensitivity analyses used 1000 Monte Carlo simulations.

      Results

      No tumor profiling was the least costly/person ($122 613 vs $184 063 for TGPT and $188 425 for CGP) and yielded the least QALYs/person (0.53 vs 0.73 for TGPT and 0.74 for CGP). The costs per QALY gained and corresponding 95% confidence interval were $310 735 ($278 323-$347 952) for TGPT vs no tumor profiling and $445 545 ($322 297-$572 084) for CGP vs TGPT. All probabilistic sensitivity analysis simulations for both comparisons surpassed the willingness-to-pay threshold ($150 000 per QALY gained).

      Conclusion

      Compared with no tumor profiling in patients with metastatic lung adenocarcinoma, tumor profiling (TGPT, CGP) improves quality-adjusted survival but is not cost-effective.

      Keywords

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