Trastuzumab-Deruxtecan Reimbursement: A Careful Evaluation of Cost-Effectiveness for Advanced Gastric Cancer

Zorginstituut Nederland advises against routine trastuzumab-deruxtecan reimbursement for adults with HER2-positive gastric or gastro-oesophageal junction adenocarcinoma after two or more prior therapies, unless price negotiations secure at least a 62 percent reduction. The drug meets scientific standards and offers added clinical value, yet its cost-effectiveness remains unacceptable under current pricing.

Pricing Thresholds for Third-Line Gastric Cancer Therapy

The DESTINY-Gastric01 trial demonstrated a 17.8-week survival gain over chemotherapy, meeting PASKWIL criteria for meaningful benefit. Even so, the incremental cost-effectiveness ratio stands at €239,946 per QALY—far above the €80,000 reference value. Annual budget impact is projected at roughly €866,000 for twelve patients in year three, highlighting the economic tension.

Clinical Evidence and Dutch Practice Alignment

Data from DESTINY-Gastric01, supplemented by the TAGS trial and Dutch claims, confirm that trastuzumab-deruxtecan at 6.4 mg/kg every three weeks outperforms standard options such as irinotecan. While the population reflects Dutch practice, uncertainties in long-term outcomes and quality-of-life data led to a GRADE downgrade. Both TAS-102 and irinotecan remain usual care in the third line.

Negotiation Levers for Oncology Market Access

Should negotiations achieve the required price cut, trastuzumab-deruxtecan reimbursement could become viable within the Dutch basic package. The small patient population limits immediate budget pressure, yet expanding indications and existing breast-cancer use underscore the need for strong price-volume agreements. Shared decision-making will stay critical given higher rates of serious adverse events.