Cost-effectiveness of precision diagnostic testing for precision medicine approaches against non-small-cell lung cancer: a systematic review

Precision diagnostic testing (PDT) employs appropriate biomarkers to identify cancer patients that may optimally respond to precision medicine (PM) approaches, such as treatments with targeted agents and immuno-oncology drugs. To date, there are no published systematic appraisals evaluating the cost effectiveness of PDT in non-small-cell lung cancer (NSCLC). In order to address this gap, we conducted Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) searches for the years 2009-2019. Consolidated Health Economic Evaluation Reporting Standards were employed to screen, assess and extract data. Employing base costs, life years gained or quality-adjusted-life-years, as well as willingness-to-pay (WTP) threshold for each country, net monetary benefit was calculated to determine cost-effectiveness of each intervention. Thirty-seven studies (50%) were included for analysis; a further thirty-seven (50%) were excluded, having failed population-, intervention-, comparator-, outcomes-, and study-design criteria. Within the thirty-seven studies included, we defined sixty-four scenarios. Eleven scenarios compared PDT-guided PM to non-guided therapy [epidermal growth factor receptor (EGFR), n=5; programmed death-ligand 1 (PD-L1), n=6). Twenty-eight scenarios compared PDT-guided PM to chemotherapy alone [anaplastic lymphoma kinase, n=3; EGFR, n=17; PD-L1, n=8]. Twenty-five scenarios compared PDT-guided PM to chemotherapy alone, while varying the PDT approach. Thirty-four scenarios (53%) were cost-effective, twenty-eight (44%) were not cost-effective, and two were marginal, dependent on their country's WTP threshold. When PDT-guided therapy was compared to a therapy-for-all patients approach, all scenarios (100%) proved cost-effective. Seven of thirty-seven studies had been structured appropriately to assess PDT-PM cost-effectiveness. Within these seven studies, all evaluated scenarios were cost-effective. However, 81% of studies had been poorly designed. Our systematic analysis implies that more robust health economic evaluation could help identify additional approaches towards PDT cost-effectiveness, underpinning value-based care and enhanced outcomes for patients with NSCLC.