title: Cost effectiveness of EML4-ALK fusion testing and first-line crizotinib treatment for patients with advanced ALK-positive non-small-cell lung cancer.
abstract: OBJECTIVE
  ALK-targeted therapy with crizotinib offers significant improvement in clinical outcomes for the treatment of EML4-ALK fusion-positive non-small-cell lung cancer (NSCLC). We estimated the cost effectiveness of EML4-ALK fusion testing in combination with targeted first-line crizotinib treatment in Ontario.
  
  
  METHODS
  A cost-effectiveness analysis was conducted using a Markov model from the Canadian Public health (Ontario) perspective and a lifetime horizon in patients with stage IV NSCLC with nonsquamous histology. Transition probabilities and mortality rates were calculated from the Ontario Cancer Registry and Cancer Care Ontario New Drug Funding Program (CCO NDFP). Costs were obtained from the Ontario Case Costing Initiative, CCO NDFP, University Health Network, and literature.
  
  
  RESULTS
  Molecular testing with first-line targeted crizotinib treatment in the population with advanced nonsquamous NSCLC resulted in a gain of 0.011 quality-adjusted life-years (QALYs) compared with standard care. The incremental cost was Canadian $2,725 per patient, and the incremental cost-effectiveness ratio (ICER) was $255,970 per QALY gained. Among patients with known EML4-ALK-positive advanced NSCLC, first-line crizotinib therapy provided 0.379 additional QALYs, cost an additional $95,043 compared with standard care, and produced an ICER of $250,632 per QALY gained. The major driver of cost effectiveness was drug price.
  
  
  CONCLUSIONS
  EML4-ALK fusion testing in stage IV nonsquamous NSCLC with crizotinib treatment for ALK-positive patients is not cost effective in the setting of high drug costs and a low biomarker frequency in the population.
authors.affiliation: Sandjar Djalalov, Jaclyn Beca, and Jeffrey S. Hoch, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital and Cancer Care Ontario; Sandjar Djalalov, Jaclyn Beca, Jeffrey S. Hoch, Murray Krahn, and Natasha B. Leighl, Canadian Centre for Applied Research in Cancer Control; Murray Krahn, Toronto Health Economics and Technology Assessment Collaborative; Ming-Sound Tsao and Natasha B. Leighl, Ontario Cancer Institute and Princess Margaret Cancer Centre, Toronto; and Jean-Claude Cutz, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Sandjar
authors.initials: S
authors.lastname: Djalalov
authors.forename: Jaclyn
authors.initials: J
authors.lastname: Beca
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Hoch
authors.forename: Murray
authors.initials: M
authors.lastname: Krahn
authors.forename: Ming-Sound
authors.initials: MS
authors.lastname: Tsao
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Cutz
authors.forename: Natasha B
authors.initials: NB
authors.lastname: Leighl
mesh_terms: D000970:Antineoplastic Agents / Q000191:economics* / Q000627:therapeutic use; D014408:Biomarkers, Tumor / Q000032:analysis*; D002289:Carcinoma, Non-Small-Cell Lung / Q000737:chemistry / Q000188:drug therapy* / Q000191:economics*; D003362:Cost-Benefit Analysis; D000077547:Crizotinib; D005787:Gene Frequency; D006801:Humans; D007150:Immunohistochemistry / Q000191:economics*; D008175:Lung Neoplasms / Q000737:chemistry / Q000188:drug therapy* / Q000191:economics*; D009367:Neoplasm Staging; D015514:Oncogene Proteins, Fusion / Q000032:analysis* / Q000235:genetics; D009864:Ontario; D011720:Pyrazoles / Q000191:economics* / Q000627:therapeutic use; D011725:Pyridines / Q000191:economics* / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity
chemical_list: D000970:Antineoplastic Agents; D014408:Biomarkers, Tumor; C522504:EML4-ALK fusion protein, human; D015514:Oncogene Proteins, Fusion; D011720:Pyrazoles; D011725:Pyridines; D000077547:Crizotinib