OBJECTIVES: Esophageal cancer (EC) is the eighth most common cancer in the world and the sixth leading cause of cancer-related mortality, with esophageal squamous-cell carcinoma (ESCC) accounting for over 80% of all cases. This study aimed to estimate the cost-effectiveness of nivolumab plus chemotherapy or nivolumab plus ipilimumab compared to chemotherapy alone as first line treatment for advanced or metastatic ESCC using U.S. payer perspective

METHODS: A partitioned-survival model was designed to estimate the cost-effectiveness of nivolumab combination in the overall population of patients with ESCC over a 5-year time horizon. Survival probabilities were derived from reconstructed Kaplan-Meier curves from CheckMate 648 trial results. All cost and utility details were obtained from published literature. Costs, incremental cos-effectiveness ratios (ICERs), and quality-adjusted life-years (QALYs) were calculated. The model's robustness was assessed with a one-way and probabilistic sensitivity analysis (PSA)

RESULTS: In the base-case analysis, nivolumab plus ipilimumab vs chemotherapy alone increased by 0.31 QALYs at an incremental cost of $206,718 while nivolumab plus chemotherapy vs chemotherapy alone increased by 0.22 QALYs at an incremental cost of $131,291. The ICER values for the overall patient population with advanced ESCC was $597,522/QALY for nivolumab plus chemotherapy and $666,832/QALY for nivolumab plus ipilimumab respectively when compared with chemotherapy alone. In the nivolumab-chemotherapy arm, one way sensitivity analysis showed that the cost of nivolumab plus chemotherapy was the major factors influencing the ICER while for nivolumab plus ipilimumab, the utility for progressed disease was the most influential factors. The PSA demonstrated that nivolumab combination therapy could not be cost-effective at the current willingness-to-pay (WTP) threshold of $200,000/QALY

CONCLUSIONS: Nivolumab combination therapy showed higher effectiveness at significantly higher cost compared to chemotherapy alone and is unlikely to be cost-effective as a first-line therapy for patients with advanced or metastatic esophageal squamous cell carcinoma in the U.S.