Cost-Utility Analysis of Genomic Profiling in Directing Targeted Therapy in Advanced NSCLC in Thailand

Background Sequential next-generation sequencing (NGS) testing has demonstrated cost-effectiveness in guiding targeted therapy with tyrosine kinase inhibitors (TKIs) for advanced non-small cell lung cancer (aNSCLC) in developed countries. However, its cost-effectiveness in developing countries remains uncertain. Objective The aim was to conduct a cost-utility analysis comparing sequential NGS testing with the current approach of single epidermal growth factor receptor (EGFR) testing combined with first-line targeted therapy, as implemented under Thailand's Universal Health Coverage scheme for aNSCLC. Method Hybrid decision tree and Markov models were developed to estimate the lifetime costs and quality-adjusted life years (QALYs) associated with each strategy. The models simulate cohorts of aNSCLC patients who receive platinum-based chemotherapy or TKIs based on identified gene alterations. Patients enter the model at 60 years of age. The incremental cost-effectiveness ratio (ICER) was computed from a societal perspective. The analysis employed a lifetime horizon and discounted costs and outcomes at a rate of 3%. Furthermore, uncertainty and scenario analyses were conducted. Findings A sequential NGS testing strategy could identify an additional 19% of patients with biomarker-positive findings who subsequently received biomarker-driven targeted therapy compared to a single EGFR testing strategy. The number needed to screen to identify a single gene mutation and administer first-line TKI was six for the sequential NGS testing strategy. Compared to the single EGFR testing, the ICER of the sequential NGS testing strategy was 1,851,150 THB/QALY (US$51,335). At a willingness-to-pay threshold of 160,000 THB/QALY (US$4437), the single EGFR testing strategy demonstrated 100% cost-effectiveness. In contrast, the sequential NGS testing was not deemed cost-effective. The sensitivity of the ICER was influenced by the overall survival rates associated with anaplastic lymphoma kinase (ALK) inhibitors and platinum-based chemotherapy. Interpretation Sequential NGS testing identified a greater number of patients with aNSCLC eligible for targeted therapies, resulting in improved survival rates and enhanced QALYs compared to single EGFR testing. However, in the context of Thailand, sequential NGS testing was not cost-effective. The single EGFR testing strategy emerged as the most cost-effective option for guiding first-line targeted therapy.