Atezolizumab for non-small cell lung cancer: Is it cost-effective? A comprehensive systematic review and meta-analysis

Michelle Gunawan; Khansa Iffa Puti Alya; Aisya Permatasiwi; Divana Zahra

doi:10.22146/inajbcs.v57i3.Suplement.24303

Michelle Gunawan Hematology and Oncology Division, Internal Medicine Department, dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia
Khansa Iffa Puti Alya Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
Aisya Permatasiwi Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
Divana Zahra Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia

DOI: https://doi.org/10.22146/inajbcs.v57i3.Suplement.24303

Keywords: Atezolizumab, Cancer Policy, Cost-Effectiveness Analysis, Non Small Cell Lung Cancer

Abstract

Atezolizumab is an established therapeutic option throughout the treatment continuum of non-small cell lung cancer (NSCLC). However, existing evidence on its cost-effectiveness remains conflicting. This study aims to comprehensively evaluate the cost-effectiveness of atezolizumab in treating any stage of NSCLC. This study was conducted in accordance with the PRISMA 2020 guidelines. Six databases were searched through July 2025 using MeSH terms and PICOS criteria to retrieve economic evaluations of atezolizumab for NSCLC. Data on study characteristics and economic outcomes were extracted, and all costs were converted to 2022 USD. Net monetary benefit (NMB) was calculated and pooled using random-effects meta-analysis. Study quality was appraised using the CHEERS 2022 checklist. Seventeen eligible studies were included, all of which met CHEERS standards. Across varying willingness-to-pay (WTP) thresholds, 66.7% reported atezolizumab as cost-effective in the adjuvant setting, 16.7% in first-line, and 100% in second-line therapy. Nevertheless, the meta-analysis yielded negative pooled NMBs for both first- and second-line use in advanced NSCLC, and an inconclusive cost-effectiveness for adjuvant therapy. Threshold analysis indicated that atezolizumab was not cost-effective at WTP values of $50,000- 100,000 per quality-adjusted life year (QALY), with uncertainty persisting even at $150,000. Variations in WTP thresholds, PD-L1 expression, drug pricing policies and patient assistance programs (PAP) influenced outcomes. The use of different modeling approaches—primarily Markov and partitioned survival models— may have contributed to result inconsistency. The limited number of studies, combined with the absence of empirical standard errors, reduced the reliability of pooled estimates, while high heterogeneity and high-income country settings further limited generalizability. Overall, atezolizumab appears unlikely to be cost-effective for advanced NSCLC, with inconclusive evidence for adjuvant use. These findings offer critical input for policy-making in oncology and highlight the need for further analyses and broader data sources to improve global relevance.