OBJECTIVES : Despite the efficacy of TKI inhibitors in EGFR mutation-positive non-small-cell lung cancer, resistance eventually develops. For afatinib, this is most commonly due to the T790M mutation. Osimertinib showed clinical activity in the treatment of T790M-positive disease following progression on first-line treatment with first and second-generation TKIs. Recently, osimertinib improved progression-free survival first-line, but no overall survival, versus first-generation TKIs (erlotinib and gefitinib) in Asian patients. In this evaluation, we compare first-line treatment with afatinib versus first-line treatment with osimertinib in a Chinese setting.

METHODS : We constructed a partitioned survival analysis in excel using reconstructed survival data, predominantly from FLAURA, and a network meta-analysis. We assumed that 76% and 78% of patients progressing on afatinib and osimertinib, respectively, would be eligible and receive subsequent therapy. Furthermore, we assumed that 65.4% of patients eligible for subsequent therapy, after progressing on afatinib, would receive treatment with osimertinib due to acquired T790M. Costs were estimated by using Chinese hospital data and literature. The primary outcome was the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed.

RESULTS : Mean progression-free survival was 17.2 vs 24.0 months, mean total time on targeted therapy was 25.6 vs 24 months and mean overall survival was 50.1 vs 46.9 months for afatinib vs osimertinib. Afatinib achieved additional 0.013 quality-adjusted life-years (QALYs) with ¥153,318 lower costs in comparison with osimertinib. Discounted at 5%, the QALYs increased by 0.16 and cost decreased by ¥151,132.68. The model was most sensitive to variance in the parametric survival inputs and percentage of patients eligible for subsequent treatment.

CONCLUSIONS : First-line treatment with afatinib increase patient benefit and reduce cost compared with first-line osimertinib for patients with EGFR mutation-positive NSCLC in China.