Nodal observation is the most cost-effective option for managing patients with sentinel lymph node-positive melanoma compared with completion lymph node dissection, completion lymph node dissection plus pembrolizumab, or pembrolizumab alone, according to a recent study in the Annals of Surgical Oncology (Ann Surg Oncol. 2020. doi:10.1245/s10434-020-09137-7.)
“Survival for positive sentinel lymph node… patients does not differ between completion lymph node dissection… and nodal observation,” explained Hayley Standage, BS, Oregon Health and Science University, Portland, Oregon and colleagues.
“However, treating these patients with… [completion lymph node dissection] and checkpoint inhibitors, such as pembrolizumab, improves outcomes,” they continued.
Standage and colleagues aimed to evaluate the cost-effectiveness of these measures, along with that of completion lymph node dissection with pembrolizumab.
Nodal observation patients experienced fewer lymphedema cases compared with the other patient cohorts, but also experienced more recurrence of melanoma. Completion lymp node dissection alone was more expensive than observation and had lower quality-adjusted life years (QALYs). The addition of pembrolizumab to completion lymph node dissection did have less recurrences and mortality than the other cohorts, but still was more expensive and had less QALYs than nodal observation.
Interestingly, when the authors looked at pembrolizumab therapy alone, they found the highest QALYs, but the cost was $1.2 million for each QALY. In order for pembrolizumab alone to be cost effective compared to nodal observation, the drug cost would need to be less than $14,404 per patient, according to the study results.
In order to ascertain this data, the authors designed a simulated treatment protocol for a theoretical population of 1,000 patients with sentinel lymph node-positive melanoma with a Markov model including a 5-year follow-up time frame. Cost-effectiveness was defined as an incremental ratio among therapies being below a willingness-to-pay level of $100,000 per QALY.
Despite better outcomes with respect to recurrence and mortality, completion lymph node dissection plus pembrolizumab carries an important quality-of-life concern and pemrbolizumab’s current cost of therapy is high, decreasing their cost-effectiveness. At this time, the authors support that nodal observation alone is the most cost-effective treatment for sentinel lymph node-positive melanoma.—Jennifer Spector
