The cost watchdog for the National Health Service in England and Wales has given the green light for doctors to prescribe Eli Lilly’s Alimta for the treatment of patients with non-small cell lung cancer.

More specifically, the National Institute for Health and Clinical Excellence has published a Final Appraisal Determination endorsing the use of Alimta (pemetrexed) in combination with cisplatin on the NHS as a first-line treatment of locally advanced or metastatic NSCLC on the condition that the tumour has been confirmed as adenocarcinoma or large-cell carcinoma.

Around 80% of lung cancers are the NSCLC type, of which the main forms are squamous cell carcinoma (45%), adenocarcinoma (45%) and large cell carcinoma (10%). The prognosis for patients with NSCLC is poor with an expected survival of around six months from diagnosis, and just 20% are still alive a year after diagnosis.

The current standard of care for NSCLC on the NHS is Eli Lilly’s chemotherapy Gemzar
(gemcitabine), which currently holds around 85% of the UK market, followed by vinorelbine in second place with 11% market share (although the Institute points out that this could be over-inflated because it could include its use in other indications).

Clinical trials of Alimta, which works by interfering with the folate-dependent metabolic processes essential for cancer cell replication and survival, have shown that together with cisplatin it offers the advantages of increased survival in the adenocarcinoma and large-cell carcinoma subpopulations and lower toxicity – in particular lower incidences of febrile neutropenia and alopecia – compared to gemcitabine/cisplatin, benefits with NICE ruled were “clinically-significant” especially when taking into account the overall low survival rates for NSCLC.

In terms of expense, a 500-mg vial of Alimta costs £800 (excluding VAT), which equates to a cost per patient, based on an average of four treatment cycles, of around £6,400. An exploratory analysis by NICE’s Expert Review Group suggested that allowing for six cycles of chemotherapy the ICER (incremental cost-effectiveness ratio) for pemetrexed/cisplatin compared with gemcitabine/cisplatin was £23,598 per QALY gained for adenocarcinoma and large-cell carcinoma patients. Furthermore, when the number of cycles was cut to four the ICER dropped to £17,162 per QALY gained, and so the Committee concluded that pemetrexed/cisplatin is “a cost-effective use of NHS resources based on the evidence available”.

The decision marks a stark turnaround from its position in 2007 when the Institute originally rejected Alimta as a treatment for NSCLC on grounds that there was no evidence that the drug was more clinically or cost effective than other treatments.