Cost-Effectiveness Analysis of Adjuvant Therapy for BRAF-Mutant Resected Stage III Melanoma in Medicare Patients

Background Adjuvant therapy for stage III melanoma improves several measures of patient survival. However, decisions regarding inclusion of adjuvant therapies in the formularies of public payers necessarily consider the cost-effectiveness of those treatments. The objective of this study is to evaluate the cost-effectiveness of four recently approved adjuvant therapies for BRAF-mutant stage III melanoma in the Medicare patient population. Methods In this cost-effectiveness analysis, a Markov microsimulation model was used to simulate the healthcare trajectory of patients randomized to receive either first-line targeted therapy (dabrafenib-trametinib) or immunotherapy (ipilimumab, nivolumab, or pembrolizumab). The base case was a 65-year-old Medicare patient with BRAF V600E-mutant resected stage III melanoma. Possible health states included recurrence-free survival, adverse events, local recurrence, distant metastases, and death. Transition probabilities were determined from published clinical trials. Costs were estimated from reimbursement rates reported by CMS and the Red Book drug price database. Primary outcomes were costs (US$), life years, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model robustness was evaluated using one-way and probabilistic sensitivity analyses. Results Dabrafenib-trametinib provided 1.83 QALYs over no treatment and 0.23 QALYs over the most effective immunotherapy, pembrolizumab. Dabrafenib-trametinib was associated with an ICER of $95,758/QALY over no treatment and $285,863/QALY over pembrolizumab. Pembrolizumab yielded an ICER of $68,396/QALY over no treatment and dominated other immunotherapies. Conclusions Pembrolizumab is cost-effective at a conventional willingness-to-pay (WTP) threshold, but dabrafenib-trametinib is not. Though dabrafenib-trametinib offers incremental QALYs, optimization of drug pricing is necessary to ensure dabrafenib-trametinib is accessible at an acceptable WTP threshold.