OBJECTIVES: To assess the cost-effectiveness of pembrolizumab with chemotherapy (with or without bevacizumab) versus chemotherapy (with or without bevacizumab) in PD-L1-positive (CPS≥1) patients with persistent, recurrent, or metastatic cervical cancer, from the French healthcare perspective.

METHODS: A three-state semi-Markov model (pre-progression, post-progression and death) was adapted to French settings to estimate the cost-effectiveness of pembrolizumab + chemotherapy ± bevacizumab versus chemotherapy ± bevacizumab. Clinical and quality of life data were obtained from patient-level data of the phase 3 study KEYNOTE-826 interim analysis. Progression-free survival, time to progression, post-progression survival and time on treatment were extrapolated over a 7-year time horizon based on piecewise models. EQ-5D-5L data estimated by a regression model were converted to French population-based utilities using the French value set. Only direct medical costs were considered, based on public sources. Costs and health outcomes were discounted at 2.5% per year. Incremental cost-effectiveness ratio (ICER) was calculated as cost per quality-adjusted life year (QALY) gained. Deterministic and probabilistic sensitivity analyses and scenarios analyses were conducted to assess robustness of results.

RESULTS: Pembrolizumab plus chemotherapy ± bevacizumab generates an incremental cost of €111,341 and 2.35 incremental QALYs per patient compared to chemotherapy ± bevacizumab, resulting in an ICER of €168,076/QALY. Results were mostly sensitive to methods of extrapolation and treatment duration, with an ICER varying from €134,644/QALY (-20%), to €197 473/QALY (+17%). A scenario using a partitioned survival model produces an ICER of €193 482/QALY. Exploratory subgroups analyses relative to the use of bevacizumab are associated with ICERs from €158 738/QALY in patients receiving bevacizumab to €214 450 /QALY in patients not receiving bevacizumab. Pembrolizumab plus chemotherapy ± bevacizumab has more than 80% probability of being cost-effective below the willingness-to-pay threshold of €250,000/QALY.

CONCLUSIONS: Combining pembrolizumab with chemotherapy, regardless of the use of bevacizumab, improves life expectancy and appears cost-effective versus chemotherapy.