6.2.3. Atezolizumab for Patients Who Have Progressed within 12 Months of Neoadjuvant or Adjuvant Platinum-Containing Chemotherapy Regardless of PD-L1 Expression

As pembrolizumab and atezolizumab are the only ICIs evaluated in randomized controlled trial for this bladder cancer treatment setting, Slater et al., performed a cost-effective evaluation comparative study [80]. The analysis compared a >2-year follow-up for pembrolizumab's KEYNOTE-045 trial with the data from atezolizumab's IMvigor211 trial. The study found because atezolizumab was less effective at extending the lives of patients, it use would increase costs by \$26,458 in the U.S. for the same QALY-gained with pembrolizumab. Pembrolizumab had a cost-effective ratio of \$93,481/QALY-gained. Thus, at a willingness-to-pay threshold of \$100,000, the increased costs for using atezolizumab make it non cost-effective option for treating bladder cancer for this indication. The Scottish Medicines Consortium also determined that atezolizumab was not cost-effective for use within its healthcare system [85]. The primary reason was the small numerical increase in median OS compared with chemotherapy.

#### 6.2.4. Atezolizumab for Patients Who Are Cisplatin-Ineligible

NICE's ERG performed an analysis of the cost-effectiveness of atezolizumab for cisplatin-ineligible patients. NICE recommended atezolizumab as an option for untreated advanced or metastatic bladder cancer in patients who are ineligible for cisplatin-containing chemotherapy [86]. However, the ERG did note that although atezolizumab appears to be an effective treatment, it is difficult to establish the size of the clinical benefit compared with current treatments. Clinicians invited to comment during the review commented that atezolizumab therapy was not favorable over current treatments. The ERG further notes that they are awaiting data from the IMvigor130 trial. The trial has shown that the addition of atezolizumab to chemotherapy was associated with a significant prolongation of PFS and able to improve OS particularly in patients with a relative high PD-L1 expression status. NICE has not updated its findings or recommendation. We believe atezolizumab is likely cost-effective in this setting for patients with high PD-L1 status.
