Pembrolizumab and lenvatinib versus carboplatin and paclitaxel as first-line therapy for advanced or recurrent endometrial cancer: A Markov analysis

Gynecol Oncol. 2021 Aug;162(2):249-255. doi: 10.1016/j.ygyno.2021.05.038. Epub 2021 Jun 6.


Objective: To determine the cost effectiveness of pembrolizumab/lenvatinib (P/L) versus standard-of-care carboplatin/paclitaxel (C/T) as first-line systemic therapy for patients with advanced/recurrent endometrial cancer.

Methods: We designed a Markov model to simulate treatment outcomes for advanced/recurrent endometrial cancer patients whose tumors are either microsatellite stable (MSS) or have high microsatellite instability (MSI-high). We adopted a healthcare sector perspective for the analysis. Model inputs for costs, health utility, and clinical estimates were obtained from the literature including data from GOG0209 and KEYNOTE-146. Primary outcomes included costs of care, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). The time-horizon was three years and the discount rate was 3% annually.

Results: In a MSS cohort, compared to C/T, first-line treatment with P/L increased treatment costs by $212,670 and decreased QALYs by 0.28 per patient. In a MSI-high cohort, compared to C/T, P/L increased costs by $313,487 and increased QALYs by 0.11 per patient, representing an ICER of $2,849,882 per QALY. Sensitivity analyses found that the price of the new drugs was the most important determinant of the ICER and that the price of the new drugs would need to decrease by 85% to $2817 per cycle to reach a $150,000/QALY threshold.

Conclusion: In the MSS model, we found that first-line therapy for advanced or recurrent endometrial cancer with P/L increased costs and worsened outcomes compared to C/T. In the MSI-high model, P/L improved survival and QALYs compared to C/T but was not cost-effective at the current cost of the drugs.

Keywords: Advanced and recurrent endometrial cancer; Cost-effectiveness; Immunotherapy.

Publication types

  • Comparative Study

MeSH terms

  • Antibodies, Monoclonal, Humanized / economics
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Antineoplastic Combined Chemotherapy Protocols / economics*
  • Antineoplastic Combined Chemotherapy Protocols / therapeutic use
  • Carboplatin / economics
  • Carboplatin / therapeutic use
  • Cost-Benefit Analysis / methods
  • Cost-Benefit Analysis / statistics & numerical data*
  • Decision Trees
  • Drug Costs*
  • Endometrial Neoplasms / drug therapy*
  • Endometrial Neoplasms / economics
  • Endometrial Neoplasms / genetics
  • Endometrial Neoplasms / mortality
  • Female
  • Humans
  • Markov Chains
  • Microsatellite Instability
  • Neoplasm Recurrence, Local / drug therapy*
  • Neoplasm Recurrence, Local / economics
  • Neoplasm Recurrence, Local / genetics
  • Neoplasm Recurrence, Local / mortality
  • Neoplasm Staging
  • Paclitaxel / economics
  • Paclitaxel / therapeutic use
  • Phenylurea Compounds / economics
  • Phenylurea Compounds / therapeutic use
  • Progression-Free Survival
  • Quality of Life
  • Quality-Adjusted Life Years
  • Quinolines / economics
  • Quinolines / therapeutic use


  • Antibodies, Monoclonal, Humanized
  • Phenylurea Compounds
  • Quinolines
  • Carboplatin
  • pembrolizumab
  • lenvatinib
  • Paclitaxel