# Annals of Lung Cancer

ISSN: 2643-5713

### Article Outline

RESEARCH ARTICLE | VOLUME 1 | ISSUE 1 | DOI: 10.36959/571/717 OPEN ACCESS

# Survival and Values of the Immune Check Point Inhibitors in Non-Small-Cell Lung Cancer

Helmy M Guirgis

• Helmy M Guirgis 1*
• Hematology-Oncology Section, Department of Medicine, University of California, Irvine, California, USA

Guirgis HM (2017) Survival and Values of the Immune Check Point Inhibitors in Non-Small-Cell Lung Cancer. Ann Lung Cancer 1(1):30-34.

Accepted: September 26, 2017 | Published Online: September 28, 2017

# Survival and Values of the Immune Check Point Inhibitors in Non-Small-Cell Lung Cancer

## Abstract

The efficacy and safety of the Immune Check Point Inhibitors (ICPI) have been well documented. Their costs and values have received lesser attention.

### Objectives

Design a grading system to measure survival and weigh values of the ICPI in 2nd-line Non-Small-Cell Lung Cancer (NSCLC).

## Methodology

### Costs of the ICPI

The estimated median 4-week costs of the ICPI in our study were $10,077. The 4-week costs of Nivo 3.0 mg/Kg q 2 weeks was$10,021 and the 240 mg $11,914. Administered q 3 weeks, costs of Atezo 1,200 mg was$11,493, Pembro 2.0 mg/Kg $8,027 and 200 mg$11,509. At 10 mg/Kg, Pembro the 4-week costs were $40,135 and Nivo$33,063.

### Nivolumab in squamous vs. non-squamous NSCLC (Table 2)

Nivolumab OS/gr in the squamous histology were 96/B, HR 0.59, C/LYG $488,524 and RV 0.20. In non-squamous, the OS/gr was slightly lower at 84/C at a higher HR of 0.73. The C/LYG was$558,326 and RV 0.18. Summary of the impact of PD-L1 on OS/gr and values:

1. In subset analyses of non-squamous, PD-L1 > 10% enrichment markedly improved Nivo OS/gr from 84/C to 264/A and RV from 0.18 to 0.56 (Table 2).

2. Atezo OS/gr in squamous and non-squamous was 87/C and RV 0.16. The results improved in PD-L1 > 1.0 or tumor infiltrating immune cells to 162/A and RV 0.30 (Table 3).

3. Enrichment of PD-L1 improved Pembro 2.0 mg/Kg OS/gr from 57/C to 201/A and RV from 0.15 to 0.53 (Table 3).

## Discussion

The American Society of Clinical Oncology (ASCO) reported frameworks to assess the value of anticancer treatment in 2013 [17]. The Magnitude of Clinical Benefit Scale was also put forward by the European Society of Clinical Oncology (ESMO) [18]. The benefits were given a score, numerical weights and points to reflect the impact of treatment on survival and response rates. Both societies used similar sets of level one data to develop their models [19]. The progress in the development of anticancer drugs came, not surprisingly, at high costs. The continued rise of drug costs, diminishing or stagnant values and widening gap in communication of cost issues between physicians and patients [20-21] prompted the present investigation. Our focus was to highlight the survival data and values of the ICPI class of drugs using Doc and Ramu as comparators.

### The grading of overall survival

There is growing recognition that OS gains by anticancer drugs of < 2 months is of questionable clinical significance. Grade D was therefore assigned to < 45 days and A to > 135 days. Based on subset analysis of major clinical studies, the PD-L1 enrichment resulted in an increase of the OS to > 260 days, an unprecedented survival in an incurable 2nd-line NSCLC. If such trend continues to improve, the grading range of OS needs to change.

### Rationale behind the C/LYG

The cost-effectiveness methodology [22,23] are widely used to measure differences in cost vs. differences in outcome between 2 entities. However, the costs and values between the ICPI members, Doc and Ramu varied widely. In addition, cost and values differences between Nivo, Atezo and Pembro were non-significant. The costs of the incremental OS gains over control at the one-year milestone were therefore adopted as the basis of our calculation. Regardless of the method used, the results and conclusions would be the same.

### Results

Nivolumab (Nivo) in non-squamous NSCLC demonstrated OS/gr 84/C and C/LYG $558,326. In >10% Programmed Death Receptor-Ligand1 (PD-L1), the OS/gr improved to 264/A and C/LYG$177,645. Using Atezolizumab (Atezo), irrespective of PD-L1, the OS/gr were 87/C and C/LYG $618,244. The results improved in enriched PD-L1 to 162/A and$332,020 respectively. Pembrolizumab (Pembro) in PD-L1 > 1.0%, the OS/gr were 57/C and C/LYG $659,059. The results improved in > 50% PD-L1 to 201/A and$186,897. Enrichment of PD-L1 increased the relative values of Nivo from 0.19 to 0.56, Atezo from 0.16 to 0.30 and Pembro from 0.15 to 0.53.

### Conclusions

Simplified methodology to grade survival and weigh values of the ICPI was proposed. In 2nd-line non-squamous NSCLC, irrespective of PD-L1 positivity, the OS/gr and values of Nivo, Atezo and Pembro were marginal. The unprecedented OS and the enhanced values with PD-L1 enrichment tend to justify their costs. The consistency of the results could give credence to our conclusions. The available cost comparative data precluded favoring one ICPI over another.