On 16 May 2018, the NICE released Technology appraisal guidance [TA520] and recommended atezolizumab as an option for treating locally advanced or metastatic non-small cell lung cancer (NSCLC) in adults who have had chemotherapy (and targeted treatment if they have an EGFR- or ALK‑positive tumour), only if:
- atezolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses and
- the company provides atezolizumab with the discount agreed in the patient access scheme.
This recommendation is not intended to affect treatment with atezolizumab that was started in the NHS before this guidance was published. Patients having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Treatments for NSCLC after chemotherapy include docetaxel alone, pembrolizumab (for tumours expressing the PD‑L1 protein) and nintedanib plus docetaxel for adenocarcinoma.
The OAK clinical trial evidence shows that patients having atezolizumab live longer than those having docetaxel alone. There is no evidence directly comparing atezolizumab with pembrolizumab. But indirect analyses show that for patients with PD‑L1‑positive disease, there may be no difference in survival benefit for atezolizumab compared with pembrolizumab.
Atezolizumab meets NICE's criteria to be considered a life-extending treatment at the end-of-life compared with docetaxel alone, but not compared with pembrolizumab.
The most plausible cost-effectiveness estimates for atezolizumab, compared with docetaxel (for PD‑L1‑negative disease) and with pembrolizumab (for PD‑L1‑positive disease), are within the range NICE considers an acceptable use of NHS resources. Therefore, it can be recommended after chemotherapy for locally advanced or metastatic NSCLC.
The appraisal committee recalled its earlier conclusion that because the company's full trial population data did not include the appropriate comparator for patients with PD‑L1‑positive disease, it preferred the company's subgroup analyses by PD‑L1 status. It concluded that the most plausible incremental cost-effectiveness ratio (ICER) for atezolizumab compared with pembrolizumab for PD‑L1‑positive disease was within the range usually considered a cost-effective use of NHS resources. For PD‑L1‑negative disease the appraisal committee noted that atezolizumab met NICE's end-of-life criteria compared with docetaxel. It concluded that the most plausible ICER for atezolizumab compared with docetaxel was also within the range usually considered a cost-effective use of NHS resources. The appraisal committee recalled its conclusion that a 2‑year stopping rule for treatment with atezolizumab is preferred because the best length of treatment with immunotherapies is uncertain. The full committee discussion about this guidance, you can find here.