Cost-effectiveness analysis of four sampling and genomic testing strategies for patients with advanced non-small-cell lung cancer in Australia.

Molecular testing informs therapy selection for patients with non-small-cell lung cancer (NSCLC) providing access to better treatments. However, the costs and benefits of alternative specimens and testing options are unknown. We modelled the cost-effectiveness of four molecular testing strategies involving combinations of biopsy (tissue aspirate versus liquid), sample (formalin-fixed paraffin-embedded cell block, cytology smears or cell-free DNA) and molecular test (single-gene, small panel or large panel). Outcomes included health system costs, life years and quality-adjusted life years (QALYs) from 5,000 Monte Carlo simulations. One-way and probabilistic sensitivity analyses and budget impact analyses were also undertaken. Over 5 years, the predicted mean costs per person (for combined tissue acquisition, testing and subsequent treatment) ranged from AU$87,915 for standard care to AU$98,712 for cytology smears and large panel sequencing. Outcomes were lowest for single-gene or small gene panel strategies (1.70-1.75 QALYs) and highest for the large-panel strategies (1.82-1.88 QALYs). Compared with standard care, the incremental cost per QALY gained ranged from $59,983 (95% uncertainty interval (UI): AU$48,598, $79,664) to AU$70,840 (95% UI: AU$57,697, AU$87,937). Findings were most sensitive to quality-of-life estimates and targeted therapy costs but not to biopsy, sampling or molecular testing costs. The budget impact of these new diagnostics is not inconsequential with costs up to 64% higher than those for current standard care. For people with advanced NSCLC, alternative sampling and comprehensive genomic testing combinations are potentially cost-effective in Australia.