Cost-Effectiveness of Neoadjuvant and Adjuvant Pembrolizumab for Locally Advanced Head and Neck Cancer in Switzerland

The pembrolizumab Swiss HNSCC cost analysis shows that adding neoadjuvant and adjuvant pembrolizumab to standard multimodal regimens produces meaningful survival gains at an incremental cost well below common Swiss willingness-to-pay benchmarks. Over a lifetime horizon the regimen adds 1.42 quality-adjusted life-years while raising total expenditure by only CHF 20,178 per patient, yielding an incremental cost-effectiveness ratio of CHF 14,227 per quality-adjusted life-year gained. Probabilistic results indicate a 96 percent likelihood of cost-effectiveness at a CHF 100,000 threshold, supporting adoption within the Swiss statutory health insurance framework.

Survival Gains and Pembrolizumab Swiss HNSCC Cost

A four-state Markov cohort structure was calibrated to Swiss unit costs and Belgian EQ-5D-5L tariffs to translate KEYNOTE-689 event-free survival curves into lifetime outcomes. Cause-specific hazards were fitted separately for each transition from the event-free state, with the Gompertz-generalised gamma combination selected for its conservative long-term projections that remained consistent with the observed 3.2-year median follow-up. Resource-use estimates were elicited directly from Swiss clinicians and combined with national tariff schedules, ensuring that both drug acquisition and downstream salvage costs reflected local practice patterns.

Robust Sensitivity Across Scenarios

Deterministic variation of the most influential parameters, principally the transition rate from locoregional recurrence to incurable progression and the cost of initial surgery plus radiotherapy, produced incremental cost-effectiveness ratios ranging only from CHF 11,928 to CHF 15,056 per quality-adjusted life-year. Scenario analyses that altered time horizon, discount rates, or relative dose intensity confirmed that all plausible configurations remained below CHF 23,292 per quality-adjusted life-year. These bounded results indicate that the economic advantage is driven primarily by delayed progression rather than by assumptions about terminal-care intensity. The pembrolizumab Swiss HNSCC cost profile therefore holds steady even when key inputs fluctuate within realistic clinical ranges.

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Global Equity and Reimbursement Implications

Swiss findings demonstrate that pembrolizumab-based perioperative therapy can be positioned as a high-value intervention when health technology assessment bodies apply thresholds near CHF 100,000, yet the same price point creates immediate affordability obstacles in low- and middle-income countries where head and neck squamous cell carcinoma incidence is elevated and radiotherapy or surgical capacity is constrained. India alone accounts for nearly 30% of global HNSCC cases, and across Southeast Asia and sub-Saharan Africa, patients frequently present with locally advanced disease due to delayed diagnosis and constrained healthcare infrastructure.

The ICER of CHF 14,227 (approximately USD 16,000) per QALY gained substantially exceeds the cost-effectiveness thresholds commonly applied in LMICs — typically one to three times GDP per capita. For countries such as India (GDP per capita ~USD 2,500) or Nigeria (~USD 2,200), even a fraction of this incremental cost would challenge affordability. Pembrolizumab’s list price remains a significant barrier; while voluntary licensing agreements and biosimilar development may improve access over time, current pricing structures place immunotherapy out of reach for most publicly funded LMIC health systems.

Several factors could improve the value proposition in LMIC contexts. The higher baseline risk and younger age at presentation in many LMIC populations may amplify absolute survival benefits, potentially improving cost-effectiveness if modelled with local epidemiological data. Price reductions through tiered pricing, compulsory licensing, or procurement through pooled mechanisms such as the Pan-American Health Organization’s Strategic Fund could meaningfully alter the economic equation. Additionally, the model’s finding that PD-L1 CPS ≥1 selection enriches for responders suggests that biomarker-driven treatment algorithms — if implemented with affordable immunohistochemistry testing — could optimise resource allocation in constrained settings.

The Swiss analysis also highlights methodological lessons for LMIC health technology assessment. The use of a 4-state Markov structure with multi-state parametric modelling, extensive sensitivity analyses, and explicit treatment-waning scenarios provides a template that could be adapted to LMIC data sources. However, the study’s reliance on expert opinion for cost inputs underscores the even greater data gaps in most LMICs, where routine cost collection, national tariff schedules, and health utility value sets are frequently unavailable. Closing these evidence gaps will be essential for LMICs to conduct contextually relevant cost-effectiveness analyses and make informed reimbursement decisions as immunotherapy indications expand.