Economic Analysis of Exclusionary EGFR Test Versus Up-Front NGS for Lung Adenocarcinoma in High EGFR Mutation Prevalence Areas

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Szu-Chun Yang Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan;

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Yi-Chen Yeh Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei;
College of Medicine, National Yang Ming Chiao Tung University, Taipei;

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Yi-Lin Chen Molecular Diagnosis Laboratory, Department of Pathology, National Cheng Kung University Hospital, Tainan;
Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan; and

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Chao-Hua Chiu College of Medicine, National Yang Ming Chiao Tung University, Taipei;
Division of Thoracic Oncology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

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Background: This study sought to determine whether exclusionary EGFR mutation testing followed by next-generation sequencing (NGS) is a cost-efficient and timely strategy in areas with high prevalence rates of EGFR mutation. Methods: We developed a decision tree model to compare exclusionary EGFR testing followed by NGS and up-front NGS. Patients entered the model upon diagnosis of metastatic lung adenocarcinoma. Gene alterations with FDA-approved targeted therapies included EGFR, ALK, ROS1, BRAF, RET, MET, NTRK, and KRAS. Model outcomes were testing-related costs; time-to-test results; monetary loss, taking both costs and time into consideration; and percentage of patients who could be treated by FDA-approved therapies. Stacked 1-way and 3-way sensitivity analyses were performed. Results: Exclusionary EGFR testing incurred testing-related costs of US $1,387 per patient, a savings of US $1,091 compared with the costs of up-front NGS. The time-to-test results for exclusionary EGFR testing and up-front NGS were 13.0 and 13.6 days, respectively. Exclusionary EGFR testing resulted in a savings of US $1,116 in terms of net monetary loss, without a reduction of patients identified with FDA-approved therapies. The EGFR mutation rate and NGS cost had the greatest impact on minimizing monetary loss. Given that the tissue-based NGS turnaround time was shortened to 7 days, up-front NGS testing would become the best strategy if its price could be reduced to US $568 in Taiwan. Conclusions: In areas with high prevalence rates of EGFR mutation, exclusionary EGFR testing followed by NGS, rather than up-front NGS, is currently a cost-efficient strategy for metastatic lung adenocarcinoma.

Submitted August 4, 2021; final revision received December 8, 2021; accepted for publication December 8, 2021. Published online April 6, 2022.

Author contributions: Study design: Chiu. Data curation: Yeh, Chen. Model development and data analysis: Yang. Data interpretation: Yang, Chiu. Funding acquisition: Yang, Chiu. Investigation: Yang, Chiu. Project administration: Chiu. Manuscript preparation: All authors.

Disclosures: Dr. Chiu has disclosed receiving honoraria from AstraZeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Chugai Pharmaceutical, Eli Lilly, Merck Sharp & Dohme, Novartis, Ono Pharmaceutical, Pfizer, Roche, and Takeda, and serving on the advisory board for Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, Merck Sharp & Dohme, Novartis, and Roche. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This work was supported by Taipei Veterans General Hospital (V110C-106) and the Ministry of Science and Technology (110-2314-B-006-100-MY2).

Correspondence: Chao-Hua Chiu, MD, Division of Thoracic Oncology, Department of Chest Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. Email: jhchiou@vghtpe.gov.tw

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