Cost-effectiveness and safety comparison of tremelimumab-durvalumab (STRIDE) versus atezolizumab-bevacizumab in unresectable hepatocellular carcinoma.

6 Background: Tremelimumab plus durvalumab (STRIDE regimen) and atezolizumab plus bevacizumab are approved first-line therapies for unresectable hepatocellular carcinoma (uHCC). Both improve survival versus sorafenib, but comparative data on cost-effectiveness and safety are limited. We analyzed survival outcomes, toxicity, and economic estimates for these two regimens. Methods: We conducted a literature-based comparative analysis using published data. Primary endpoints included overall survival (OS), progression-free survival (PFS), grade ≥3 adverse events (AEs), and incremental cost-effectiveness ratios (ICERs) from a U.S. payer perspective. We then compared the cost analysis of the drug pricing at our institution. Results: In the HIMALAYA trial, the STRIDE regimen demonstrated a median OS of 16.4 months vs 13.8 months with sorafenib (HR 0.78; 95% CI, 0.66–0.92). An updated analysis reported that 25.2% of participants were alive at 4 years. IMbrave150 reported OS of 19.2 months with atezolizumab-bevacizumab vs 13.4 months for sorafenib (HR 0.66; 95% CI, 0.52–0.85). Median PFS was 3.8 months for STRIDE and 6.8 months for atezolizumab-bevacizumab. Safety: Grade ≥3 treatment-related AEs occurred in 46.9% (STRIDE) and 56.5% (atezolizumab-bevacizumab). In STRIDE Grade 3/4 immune-mediated AEs were noted in 12.6% of patients compared to 2.4 % of patients with sorafenib. In the updated safety results, IMbrave150 reported a 27 % grade 3/4 immune-related AEs with the most common being immune-related hepatitis. Grade 3/4 bleeding and hypertension were reported in 18% and 26% of patients respectively. Cost analysis: The ICER of STRIDE was $19,239/QALY compared with sorafenib. Atezolizumab-bevacizumab had an ICER of $169,223/QALY vs sorafenib. Our institutional cost analysis confirmed similar results. For a one-year average, the cost of the STRIDE regimen was approximately $192,152 and the IMBrave150 regimen was $305,269 (weight = 80 kg) excluding infusion room cost. Conclusions: Atezolizumab-bevacizumab shows slightly longer OS compared to the STRIDE regimen, although no head-to-head comparison is available between these regimens. The STRIDE regimen confirms greater cost-effectiveness and better side effect profile in the U.S. setting. The AE profile was different with more bleeding and hypertension noted with the IMbrave 150 regimen and higher immune-related AEs in the STRIDE regimen. Treatment selection should consider individual risk factors, safety profile, and economic impact.