title: Cost effectiveness of personalized therapy for first-line treatment of stage IV and recurrent incurable adenocarcinoma of the lung.
abstract: OBJECTIVE
  Patients with epidermal growth factor receptor (EGFR) mutation-positive stage IV adenocarcinoma have improved survival with tyrosine kinase inhibitor (TKI) treatments, but the cost effectiveness of personalized first-line therapy using EGFR mutation testing is unknown.
  
  
  METHODS
  We created a decision analytic model comparing the costs and effects of platinum combination chemotherapy with personalized therapy in which patients with EGFR mutation-positive tumors were treated with erlotinib. We used two testing strategies: testing only those with tissue available and performing a repeat biopsy if tissue was not available versus three nontargeted chemotherapy regimens (ie, carboplatin and paclitaxel; carboplatin and pemetrexed; and carboplatin, pemetrexed, and bevacizumab).
  
  
  RESULTS
  Compared with a carboplatin plus paclitaxel regimen, targeted therapy based on testing available tissue yielded an incremental cost-effectiveness ratio (ICER) of $110,644 per quality-adjusted life year (QALY), and the rebiopsy strategy yielded an ICER of $122,219 per QALY. Probabilistic sensitivity analysis revealed substantial uncertainty around these point estimates. With a willingness to pay of $100,000 per QALY, the testing strategy was cost effective 58% of the time, and the rebiopsy strategy was cost effective 54% of the time. Personalized therapy with an EGFR TKI was more favorable when the nontargeted chemotherapy regimen was more expensive. Compared with carboplatin, pemetrexed, and bevacizumab, ICERs were $25,547 per QALY for the testing strategy and $44,036 per QALY for the rebiopsy strategy.
  
  
  CONCLUSIONS
  Although specific clinical circumstances should guide therapy, our cost-effectiveness analysis supports the strategy of testing for EGFR mutations in patients with stage IV or recurrent adenocarcinoma of the lung, rebiopsying patients if insufficient tissue is available for testing, and treating patients with EGFR mutations with erlotinib as first-line therapy.
authors.affiliation: University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. eaf@mail.med.upenn.edu
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Handorf
authors.forename: Sean
authors.initials: S
authors.lastname: McElligott
authors.forename: Anil
authors.initials: A
authors.lastname: Vachani
authors.forename: Corey J
authors.initials: CJ
authors.lastname: Langer
authors.forename: Mirar
authors.initials: M
authors.lastname: Bristol Demeter
authors.forename: Katrina
authors.initials: K
authors.lastname: Armstrong
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy* / Q000191:economics*; D000077192:Adenocarcinoma of Lung; D000368:Aged; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000191:economics; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000191:economics / Q000627:therapeutic use; D000068258:Bevacizumab; D016190:Carboplatin / Q000008:administration & dosage / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D066246:ErbB Receptors / Q000037:antagonists & inhibitors / Q000235:genetics; D005820:Genetic Testing / Q000191:economics; D005971:Glutamates / Q000008:administration & dosage / Q000191:economics; D006147:Guanine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000191:economics; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy* / Q000191:economics*; D008297:Male; D058990:Molecular Targeted Therapy / Q000191:economics / Q000379:methods; D009154:Mutation; D009367:Neoplasm Staging; D017239:Paclitaxel / Q000008:administration & dosage / Q000191:economics; D000068437:Pemetrexed; D057285:Precision Medicine / Q000191:economics* / Q000379:methods*; D047428:Protein Kinase Inhibitors / Q000191:economics / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D014481:United States
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D005971:Glutamates; D047428:Protein Kinase Inhibitors; D000068437:Pemetrexed; D000068258:Bevacizumab; D006147:Guanine; D016190:Carboplatin; D066246:ErbB Receptors; D017239:Paclitaxel