title: Cost-effectiveness of first-line induction and maintenance treatment sequences in non-squamous non-small cell lung cancer (NSCLC) in the U.S.
abstract: OBJECTIVE
  Due to the lack of direct head-to-head trials, there are limited data regarding the comparative effectiveness of induction-maintenance sequences. The objective of this study was to develop a cost-effectiveness model to compare induction-maintenance sequences in the US for the treatment of advanced non-squamous NSCLC.
  
  
  METHODS
  Decision analytic modelling was used to synthesize the treatment effect and baseline risk estimates for nine induction and maintenance treatment sequences, reflecting treatments used in the US. The model was structured using an area-under-the-curve approach and sensitivity analyses were conducted. Model validation was conducted by an independent third party.
  
  
  RESULTS
  All active maintenance therapy-containing regimens, with the exception of gemcitabine+cisplatin (first-line)→erlotinib (maintenance), were more costly than induction-only regimens. Concerning treatments that may be cost effective, the incremental costs per life-year gained were $121,425, $148,994, and $191,270 for gemcitabine+cisplatin→erlotinib versus gemcitabine+cisplatin→best supportive care (BSC), pemetrexed+cisplatin→BSC versus gemcitabine+cisplatin→erlotinib, and for pemetrexed+cisplatin→pemetrexed versus pemetrexed+cisplatin→BSC, respectively. All other regimens were found to be dominated (carboplatin+paclitaxel→BSC; carboplatin+paclitaxel→erlotinib; carboplatin+paclitaxel→pemetrexed; bevacizumab+carboplatin+paclitaxel→bevacizumab) or extendedly dominated (cisplatin+gemcitabine→pemetrexed). Sensitivity analyses demonstrated stability.
  
  
  CONCLUSIONS
  Depending on the specific cost-effectiveness threshold used by a decision maker, the most cost-effective treatment sequence may include the referent comparator gemcitabine+cisplatin and the studied regimens of gemcitabine+cisplatin→erlotinib, pemetrexed+cisplatin→BSC, or pemetrexed+cisplatin→pemetrexed.
authors.affiliation: ICON Health Economics, Oxford, UK.
authors.forename: Gayathri
authors.initials: G
authors.lastname: Kumar
authors.affiliation: ICON Health Economics, Oxford, UK.
authors.forename: Beth
authors.initials: B
authors.lastname: Woods
authors.affiliation: Eli Lilly and Company, DC 5022, Indianapolis, IN 46285, USA. Electronic address: hess_lisa_m@lilly.com.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Hess
authors.affiliation: Eli Lilly and Company, DC 5022, Indianapolis, IN 46285, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Treat
authors.affiliation: Eli Lilly and Company, DC 5022, Indianapolis, IN 46285, USA.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Boye
authors.affiliation: University of Bristol, Bristol, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Bryden
authors.affiliation: Eli Lilly and Company, DC 5022, Indianapolis, IN 46285, USA.
authors.forename: Katherine B
authors.initials: KB
authors.lastname: Winfree
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality; D003362:Cost-Benefit Analysis; D017048:Health Care Costs; D006801:Humans; D060828:Induction Chemotherapy; D008175:Lung Neoplasms / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality; D060046:Maintenance Chemotherapy; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: Comparative effectiveness; Cost effectiveness; First-line therapy; Maintenance therapy; Non-small cell lung cancer