Skip to main content
Download PDF
Download ePub

Nivolumab plus chemotherapy versus chemotherapy alone as first-line treatment for advanced gastric, gastroesophageal junction, and esophageal adenocarcinoma: a cost-effectiveness analysis

Cost Effectiveness and Resource Allocation volume 21, Article number: 65 (2023) Cite this article

Abstract

Background

The aim of the study was to evaluate the cost-effectiveness of nivolumab plus chemotherapy as first-line treatment for patients with advanced gastric, gastroesophageal junction (GEJ), or esophageal adenocarcinoma from the perspective of Chinese and US society.

Methods

To conduct the analysis, a state-transitioned Markov model, which included three mutually exclusive health states (progression-free survival (PFS), progressive disease (PD), and death), was developed. Cycle length was set at 3 weeks and lifetime horizon was set at 10 years. Costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated in the analysis. Willingness-to-pay (WTP) thresholds in the model were set at $37,653.00/QALY in China and $100,000.00/QALY in the US, respectively. Meanwhile, one-way sensitivity analyses and probabilistic sensitivity analyses were conducted to investigate the robustness of the model.

Results

Over a lifetime horizon, the ICERs of nivolumab plus chemotherapy versus chemotherapy alone were $430,185.04/QALY and $944,089.78/QALY in China and the US, respectively. Cost of nivolumab and utility for the PFS state had the most significant impact on ICERs both in the US and China based on the results of the one-way sensitivity analyses. In the probabilistic sensitivity analyses, the proportions of nivolumab plus chemotherapy being cost-effective compared with chemotherapy alone were 0%.

Conclusions

In conclusion, nivolumab plus chemotherapy is unlikely to be a cost-effective treatment option compared with chemotherapy alone in the first-line setting of advanced gastric, GEJ, or esophageal adenocarcinoma.

Introduction

Gastric or gastroesophageal junction (GEJ) cancer is the fifth most common cancer and the fourth leading cause of cancer-related death globally. In 2020, it is estimated that over one million new cases and 769,000 deaths of gastric or GEJ cancer occurred worldwide [1]. Surgery is regarded as the main curative treatment for gastric or GEJ cancer; however, most patients with gastric or GEJ cancer have locally advanced or metastatic disease at the time of diagnosis, and most of patients undergoing gastrectomy will experience disease recurrences [2]. Systemic chemotherapy based on a combination of fluoropyrimidine and platinum is widely used as the first-line therapy for patients with advanced gastric or GEJ cancer, which significantly prolongs overall survival (OS) and improves quality of life (QoL) of these patients [3,4,5]. In 2010, trastuzumab plus chemotherapy was explored to compare with chemotherapy in first-line setting of patients with advanced or metastatic gastric cancer (GC). Trastuzumab plus chemotherapy significantly prolongs OS of patients with HER2-positive metastatic GC and was approved as the standard first-line treatment for these patients [6]. Despite these progresses, the prognosis of patients with advanced gastric or GEJ cancer remains poor, indicating that novel treatment regimens are urgently needed.

In recent years, cancer immunotherapy, which represents a novel method for cancer treatment, has shown promising antitumor effect in a variety of cancers [7, 8]. Nivolumab is a fully human immunoglobulin G4 monoclonal antibody, which binds to the programmed death 1 receptor (PD-1) and restores T-cell immune activity. In previous study, nivolumab substantially prolonged OS compared with placebo in patients with heavily pre-treated advanced or recurrent GC [9]. Recently, the results of CheckMate 649, which aimed to evaluate nivolumab plus chemotherapy versus chemotherapy alone in first-line setting of advanced gastric, GEJ, or esophageal adenocarcinoma, were reported [10]. Nivolumab plus chemotherapy significantly improved OS and progression-free survival (PFS) compared with chemotherapy alone in patients with a PD-L1 CPS of five or more as well as in patients with a PD-L1 CPS of one or more and all randomly assigned patients, which suggested that nivolumab plus chemotherapy as a promising treatment regimen for patients with advanced GEJ, or esophageal adenocarcinoma.

Regardless of the survival benefits achieved by addition of nivolumab, high cost of nivolumab may counterbalance its antitumor effect and lead to substantial financial implications. Recent years, health expenditure on cancer care has been growing rapidly and has become one of the most severe financial burdens for several countries, especially for countries such as China with limited health resources and large amount of population [11, 12]. To solve the problem, cost-effectiveness analysis is widely used in evaluating the economic implication of treatment regimens [13]. The aim of the study was to evaluate the cost-effectiveness of nivolumab with chemotherapy as first-line treatment for patients with advanced GC from the perspective of Chinese and US society.

Materials and methods

Analytic model

A state-transitioned Markov model was developed to evaluate the cost-effectiveness of nivolumab plus chemotherapy compared with chemotherapy alone as first-line treatment for patients with advanced gastric, GEJ, or esophageal adenocarcinoma from a Chinese and US societal perspective (Fig. 1). The model included three mutually exclusive health states (PFS, progressive disease (PD), and death) and integrated efficacy and cost in a hypothetical cohort of patients with advanced gastric, GEJ, or esophageal adenocarcinoma. At the beginning of the model, all patients were assumed to enter the PFS state. Then, these patients can remain in the starting health state or transition to PD or death state at the end of each cycle as described in Fig. 1. Cycle length was set at 3 weeks and lifetime horizon was set at 10 years. Key endpoints of the analysis included costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Willingness-to-pay (WTP) thresholds in the model were set at $37,653.00/QALY (3×per capita GDP of China, 2021) in China and $100,000.00/QALY in the US, respectively. Both costs and health effect were discounted at annual rates of 3%. The model was developed and performed with the Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) and TreeAge software (TreeAge, Williamstown, MA, USA, 2021).

Fig. 1
figure 1

Markov model diagram for patients with advanced gastric, GEJ, or esophageal adenocarcinoma

PFS: progression-free survival; PD: progressive disease

Full size image

Patients and treatment regimens

In the Markov model, the hypothetical cohort of patients was simulated based on the baseline characteristics of the patient in the CheckMate 649 study. Hypothetical eligible criteria were: [1] Aged ≥ 18 years; [2] Histologically confirmed previously untreated, unresectable advanced or metastatic gastric, GEJ, or esophageal adenocarcinoma, regardless of PD-L1 expression. Patients were randomly assigned to nivolumab plus chemotherapy or chemotherapy alone group. Nivolumab was administered as following: 360 mg per 3 weeks or 240 mg per 2 weeks. Chemotherapy regimen was based on investigator’s choice (XELOX [capecitabine 1000 mg/m² twice a day, days 1–14 and oxaliplatin 130 mg/m², day 1, every 3 weeks] or FOLFOX [leucovorin 400 mg/m², day 1, fluorouracil 400 mg/m², day 1 and 1200 mg/m², days 1–2, and oxaliplatin 85 mg/m², day 1, every 2 weeks]). Treatment continued until documented disease progression, unacceptable toxicity, withdrawal of consent, or study end. Nivolumab was given for a maximum of 2 years.

Efficacy, safety, and cost input

Transition parameters and probabilities were estimated based on the clinical data from the CheckMate 649 trial. Survival data in each group were extracted from the Kaplan- Meier survival curves using a plot digitizer software (DigitizeIt, version 2.0, www.digitizeit.de) as individual patient data were not available (Fig. 2). In this analysis, grade 3–4 treatment-related adverse events (AEs) with an incidence of ≥ 5% were derived from the CheckMate 649 trial (Table 1). Meanwhile, utility scores for health states, where 1 is full health and 0 is death, was derived from previous literature [14]. The utility scores for each health state were presented in Table 1.

Fig. 2
figure 2

Modelled survival curves for chemotherapy plus nivolumab and chemotherapy alone group

PFS: progression-free survival; OS: overall survival; CPS: combined positive score

Full size image
Table 1 Key clinical data in the model
Full size table

Costs of drugs, imaging examination and laboratory tests, AE-related treatments, best-supportive care (BSC), and follow-up were calculated in the analysis. The unit prices of drugs in China were retrieved from the national drug prices or our hospital, while in the US, these data were based on the wholesale acquisition costs from the AnalySource database RED BOOK Online (Table 2). The unit cost of imaging examination and laboratory tests, follow-up, AEs-related treatments and BSC were retrieved from the CMS clinical laboratory fee schedule files and previously published literatures (Table 2) [15,16,17,18,19]. To calculate doses of drugs, we used a mean BSA of 2.1 m2 or 1.72 m2 for patients in US and China, respectively [19].

Table 2 Cost parameters input in the model
Full size table

Sensitivity analysis

A series of one-way sensitivity analyses were conducted to investigate the robustness of the model by varying each parameter to its lower and upper bounds. All parameters were assumed to range between ± 20% and the results of the one-way sensitivity analyses were shown as tornado diagrams. In addition, probabilistic sensitivity analyses were also conducted with each key parameter randomly varied within its distribution range simultaneously for 1,000 iterations.

Results

Base case analysis

Table 3 presented the results of the base case analysis. Over a lifetime horizon of 10 years, nivolumab plus chemotherapy group yielded higher effectiveness benefit compared with chemotherapy alone group (1.12 QALYs vs. 0.89 QALYs). The costs of nivolumab plus chemotherapy and chemotherapy alone were $113,897.45 and $14,954.89 in the Chinese societal perspective, while from US societal perspective, the costs of nivolumab plus chemotherapy and chemotherapy alone group were $326,032.70 and $108,892.05, respectively. The ICERs of nivolumab plus chemotherapy versus chemotherapy alone were $430,185.04/QALY and $944,089.78/QALY in China and the US, respectively.

Table 3 Base case results of the model
Full size table

In addition, we also evaluated the pharmacoeconomic profile of nivolumab plus chemotherapy versus chemotherapy alone in patients with a PD-L1 CPS ≥ 5. Effectiveness benefits were 1.25 QALYs vs. 0.87 QALYs for nivolumab plus chemotherapy group and chemotherapy alone group. In this subgroup, the ICERs of nivolumab plus chemotherapy versus chemotherapy alone were $282,889.68/QALY and $649,647.39/QALY in China and the US, respectively.

Sensitivity analysis

Cost of nivolumab and utility for the PFS states had the most significant impacts on results of ICERs both in the US and China based on the results of the one-way sensitivity analysis (Fig. 3). Cost of chemotherapy and utility for the PD state had moderate impact on the results. Cost of AE-related treatment, cost of tests, cost of supportive care, and cost of follow-up had little impact on the results of the model. In the probabilistic sensitivity analyses, the proportions of nivolumab plus chemotherapy being cost-effective compared with chemotherapy alone at the WTP thresholds of $100,000.00/QALY in the US and $37,653.00/QALY in China were 0%.

Fig. 3
figure 3

Tornado diagram for one-way sensitivity analyses. (A) the Chinese payer’s perspective. (B) the US payer’s perspective

PD: progressive disease; PFS: progression-free survival; AEs: adverse events; ICER: incremental cost-effectiveness ratio

Full size image

Discussion

Gastric or GEJ cancer remains one of the most common malignancies worldwide. Patients with advanced gastric cancer have limited treatment options, and the therapeutic effect of current treatment regimens is still not satisfactory. Cancer immunotherapy, which includes immune checkpoint inhibitor, tumor vaccine and adoptive cell therapy, have been widely in a series of cancers and achieved promising antitumor effect. Recently, nivolumab plus chemotherapy have been investigated in the first-line setting of advanced gastric, GEJ, or esophageal adenocarcinoma, which significantly prolonged OS and PFS compared with chemotherapy alone in patients with a PD-L1 CPS of five or more as well as in patients with a PD-L1 CPS of one or more and all randomly assigned patients [10]. However, the price of nivolumab is substantial high. With the widespread use of nivolumab, the dramatic increase in financial burden has become an important issue for doctors, patients and policy makers. Thus, whether its price reflects the drug’s clinical value remain to be determined and an economic evaluation of nivolumab has become urgently needed. In this study, we evaluated the cost-effectiveness of nivolumab plus chemotherapy as first-line treatment for patients with advanced gastric, GEJ, or esophageal adenocarcinoma from the perspective of Chinese and US society. Although nivolumab plus chemotherapy group yielded higher effectiveness benefit compared with chemotherapy alone group (1.12 QALYs vs. 0.89 QALYs), ICERs of nivolumab plus chemotherapy versus chemotherapy alone ($430,185.04/QALY and $944,089.78/QALY in China and the US, respectively) were much higher than the WTP thresholds, suggesting that nivolumab plus chemotherapy is not a cost-effective treatment option compared with chemotherapy alone in the first-line setting of advanced gastric, GEJ, or esophageal adenocarcinoma.

In the one-way sensitivity analyses, the most influencing parameters in the model were cost of nivolumab and utility for the PFS states both in the US and China based on the results of the one-way sensitivity analyses. Recent years, immune checkpoint inhibitors, such as nivolumab and pembrolizumab, have significantly improved survival and quality of life for patients in a series of malignancies. However, not all patients can benefit from the novel treatment, and it is essential to find the most suitable patients with best survival benefits for the immune checkpoint inhibitors. In this analysis, we evaluated the cost-effectiveness of nivolumab plus chemotherapy in patients with a PD-L1 CPS ≥ 5. As expected, ICERs in patients with a PD-L1 CPS ≥ 5 were much lower than those in whole patients. However, these ICERs were also much higher than the WTP thresholds, which suggested that more factors should be considered to select the most suitable patients. In addition, 208 patients enrolled and randomized in CheckMate 649 trial were Chinese. In the subgroup analysis of these patients, nivolumab plus chemotherapy resulted in a more clinically meaningful improvement in median OS (14.3 vs. 10.2 months; HR 0.61 [95% CI: 0.44–0.85]) and median PFS (8.3 vs. 5.6 months; HR 0.57 [95% CI: 0.40–0.80]). Although further exploration may be needed, these results may also influence the pharmacoeconomic profile of combination of chemotherapy and immunotherapy among populations in different regions [20]. On the other hand, the high price of immune checkpoint inhibitors limited their availability, especially in countries with limited healthcare resources. Thus, immune checkpoint inhibitors with low price and high efficacy are urgently needed. Recently, a series of PD-1 inhibitors with lower prices and equal efficacy, such as Toripalimab, Sintilimab, and Camrelizumab were approved in China and was applied to the treatment of a series of cancers, which provides new insights for cancer treatment. Taken esophageal cancer as an example, several studies have demonstrated that pembrolizumab plus chemotherapy is not a cost-effective option for advanced esophageal cancer in the US and China, regardless of PD-L1 expression status [17, 21, 22]. However, sintilimab plus chemotherapy, toripalimab plus chemotherapy and camrelizumab plus chemotherapy were likely to have a cost-effectiveness advantage over chemotherapy alone for previously untreated advanced or metastatic ESCC in China [23,24,25,26]. Thus, with the widely application of these drugs, PD-1 inhibitors may become a more cost-effective treatment option in the first-line setting of advanced gastric, GEJ, or esophageal adenocarcinoma.

Several limitations in the analysis should be addressed. First, the cost of grade 1–2 AEs were not included, which may undermine the robustness of the study. Fortunately, the results of the one-way sensitivity analyses demonstrated the economic results were not sensitive to AEs-related parameters. Second, as a trial-based model, the model survival originated from the published data of CheckMate 649 trial. CheckMate 649 trial is a multicenter, randomized, phase III clinical trial comparing nivolumab plus chemotherapy versus chemotherapy alone in advanced gastric, GEJ, or esophageal adenocarcinoma. Although large and well-designed. it might not fully reflect the natural disease course in the real-world. Third, the study merely investigated the cost-effectiveness of nivolumab plus chemotherapy versus chemotherapy alone. Other competing treatment regimens were not included as the absence of head-to-head trials. Fourth, utility scores in the study were derived from previously published literature as the HRQoL data for patients were unavailable in the CheckMate 649 trial, which might lead to bias in the model outcomes.

In conclusion, nivolumab plus chemotherapy is unlikely to be a cost-effective treatment option compared with chemotherapy alone in the first-line setting of advanced gastric, GEJ, or esophageal adenocarcinoma, based on the efficacy reported in the CheckMate 649 study and the current prices of these drugs.

Data Availability

The data generated in the current study are available from the corresponding author on reasonable request.

References

  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and Mortality Worldwide for 36 cancers in 185 countries. Cancer J Clin. 2021;71(3):209–49.

    Article  Google Scholar 

  2. Joshi SS, Badgwell BD. Current treatment and recent progress in gastric cancer. Cancer J Clin. 2021;71(3):264–79.

    Article  Google Scholar 

  3. Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2016;27:v38–v49.

    Article  CAS  PubMed  Google Scholar 

  4. Wang F-H, Zhang X-T, Li Y-F, Tang L, Qu X-J, Ying J-E, et al. The chinese society of clinical oncology (CSCO): clinical guidelines for the diagnosis and treatment of gastric cancer, 2021. Cancer Commun. 2021;41(8):747–95.

    Article  Google Scholar 

  5. Japanese Gastric Cancer A. Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer. 2021;24(1):1–21.

  6. Bang Y-J, Van Cutsem E, Feyereislova A, Chung HC, Shen L, Sawaki A, et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. The Lancet. 2010;376(9742):687–97.

    Article  CAS  Google Scholar 

  7. Kumar A, Swain CA, Shevde LA. Informing the new developments and future of cancer immunotherapy future of cancer immunotherapy. Cancer Metast Rev. 2021;40(2):549–62.

    Article  CAS  Google Scholar 

  8. Esfahani K, Roudaia L, Buhlaiga N, Del Rincon SV, Papneja N, Miller WH. A review of Cancer Immunotherapy: from the past, to the Present, to the future. Curr Oncol. 2020;27(12):87–97.

    Article  Google Scholar 

  9. Kang Y-K, Boku N, Satoh T, Ryu M-H, Chao Y, Kato K, et al. Nivolumab in patients with advanced gastric or gastro-oesophageal junction cancer refractory to, or intolerant of, at least two previous chemotherapy regimens (ONO-4538-12, ATTRACTION-2): a randomised, double-blind, placebo-controlled, phase 3 trial. The Lancet. 2017;390(10111):2461–71.

    Article  CAS  Google Scholar 

  10. Janjigian YY, Shitara K, Moehler M, Garrido M, Salman P, Shen L, et al. First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial. The Lancet. 2021;398(10294):27–40.

    Article  CAS  Google Scholar 

  11. Dieleman JL, Templin T, Sadat N, Reidy P, Chapin A, Foreman K, et al. National spending on health by source for 184 countries between 2013 and 2040. The Lancet. 2016;387(10037):2521–35.

    Article  Google Scholar 

  12. Dieleman JL, Campbell M, Chapin A, Eldrenkamp E, Fan VY, Haakenstad A, et al. Future and potential spending on health 2015–40: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. The Lancet. 2017;389(10083):2005–30.

    Article  Google Scholar 

  13. Neumann PJ, Kim DD, Trikalinos TA, Sculpher MJ, Salomon JA, Prosser LA, et al. Future directions for cost-effectiveness analyses in Health and Medicine. Med Decis Making. 2018;38(7):767–77.

    Article  PubMed  Google Scholar 

  14. Cao X, Cai H, Li N, Zheng B, Zheng Z, Liu M. First-line nivolumab plus ipilimumab or chemotherapy versus chemotherapy alone for advanced esophageal cancer: a cost-effectiveness analysis. Ther Adv Med Oncol. 2022;14:17588359221122733.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Zhang PF, Xie D, Li Q. Cost-effectiveness analysis of nivolumab in the second-line treatment for advanced esophageal squamous cell carcinoma. Future Oncol. 2020;16(17):1189–98.

    Article  CAS  PubMed  Google Scholar 

  16. Li SN, Peng LB, Tan CQ, Zeng XH, Wan XM, Luo X et al. Cost-effectiveness of ramucirumab plus paclitaxel as a second-line therapy for advanced gastric or gastro-oesophageal cancer in China. PLoS ONE. 2020;15(5).

  17. Zhu YW, Liu K, Ding D, Zhou YY, Peng LB. Pembrolizumab Plus Chemotherapy as First-Line treatment for Advanced Esophageal Cancer: a cost-effectiveness analysis. Adv Therapy. 2022;39(6):2614–29.

    Article  Google Scholar 

  18. Ramamurthy C, Handorf EA, Correa AF, Beck JR, Geynisman DM. Cost-effectiveness of abiraterone versus docetaxel in the treatment of metastatic hormone naïve prostate cancer. Urologic Oncology: Seminars and Original Investigations. 2019;37(10):688–95.

    Article  PubMed  Google Scholar 

  19. Zhang PF, Xie D, Li Q. Adding Enzalutamide to First-Line treatment for metastatic hormone-sensitive prostate Cancer: a cost-effectiveness analysis. Front Public Health. 2021;9.

  20. Liu TS, Bai YX, Lin XY, Li W, Wang JF, Zhang XC, et al. First-line nivolumab plus chemotherapy vs chemotherapy in patients with advanced gastric, gastroesophageal junction and esophageal adenocarcinoma: CheckMate 649 chinese subgroup analysis. Int J Cancer. 2023;152(4):749–60.

    Article  CAS  PubMed  Google Scholar 

  21. Zheng Z, Lin J, Zhu H, Cai H. Cost-effectiveness analysis of Pembrolizumab plus Chemotherapy vs. Chemotherapy alone as first-line treatment in patients with esophageal squamous cell carcinoma and PD-L1 CPS of 10 or more. Front Public Health. 2022;10.

  22. Ye Z-M, Xu Z, Wang H-L, Wang Y-Y, Chen Z-C, Zhou Q, et al. Cost-effectiveness analysis of pembrolizumab plus chemotherapy versus chemotherapy as the first-line treatment for advanced esophageal cancer. Cancer Med. 2023;12(5):6182–9.

    Article  CAS  PubMed  Google Scholar 

  23. Liu L, Wang L, Chen L, Ding Y, Zhang Q, Shu Y. Cost-effectiveness of sintilimab plus chemotherapy versus chemotherapy alone as first-line treatment of locally advanced or metastatic oesophageal squamous cell carcinoma. Front Immunol. 2023;14.

  24. Ye Z-M, Xu Z, Zeng F-Y, Tang Z-Q, Zhou Q. Cost-effectiveness analysis of Sintilimab Combined with Chemotherapy Versus Chemotherapy alone as the First-Line treatment for Advanced Esophageal Cancer. Front Pharmacol. 2022;13.

  25. Fang R, Wang S, Liu Y, Xu J. Cost-effectiveness analysis of Toripalimab Plus Paclitaxel and Cisplatin as First-Line treatment for Advanced or metastatic esophageal squamous cell carcinoma. Adv Therapy. 2023;40(3):1019–30.

    Article  CAS  Google Scholar 

  26. Gong J, Shang J, Su D, Qian X, Liu G, Sun Z. Cost-effectiveness of camrelizumab plus chemotherapy versus chemotherapy alone as first-line therapy in advanced or metastatic esophageal squamous cell carcinoma. Expert Rev PharmacoEcon Outcomes Res. 2023;23(6):709–17.

    Article  PubMed  Google Scholar 

Download references

Funding

This work was funded by the National Natural and Scientific Foundation of China (NO. 81572988) and Science & Technology Department of Sichuan Province Funding Project (NO. 2018SZ0117).

Author information

Author notes

  1. Peng-Fei Zhang and Xuan-Qiong Shi these authors contributed equally to this work.

Authors and Affiliations

  1. Gastric Cancer Center, Division of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China

    Peng-Fei Zhang & Xuan-Qiong Shi

  2. Med-X Center for Informatics, Sichuan University, Chengdu, China

    Peng-Fei Zhang & Qiu Li

  3. Laboratory of Human Diseases and Immunotherapies, West China Hospital, Sichuan University, Chengdu, China

    Peng-Fei Zhang

  4. Institute of Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China

    Peng-Fei Zhang

  5. Division of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China

    Qiu Li

Authors
  1. Peng-Fei Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xuan-Qiong Shi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Qiu Li
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

PFZ and QL designed the study; PFZ, and XQS collected and analyzed data; PFZ, XQS drafted the manuscript. All authors reviewed the manuscript draft and approved the final manuscript.

Corresponding author

Correspondence to Qiu Li.

Ethics declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that there is no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, PF., Shi, XQ. & Li, Q. Nivolumab plus chemotherapy versus chemotherapy alone as first-line treatment for advanced gastric, gastroesophageal junction, and esophageal adenocarcinoma: a cost-effectiveness analysis. Cost Eff Resour Alloc 21, 65 (2023). https://doi.org/10.1186/s12962-023-00476-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12962-023-00476-2

Keywords

Cost Effectiveness and Resource Allocation

ISSN: 1478-7547

Contact us