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Page 743 Giuliani et al. Cancer Drug Resist 2021;4:740-4 https://dx.doi.org/10.20517/cdr.2021.14

In addition, the annual cost of drugs treatment (€116,880 for osimertinib, €118,840 for gefitinib and €
165,528 for erlotinib) are not in line with those reported in the literature, which indicate implementing
[18]
intervention for thresholds of less than $61,500 (€57,138) per life-year gained .

We also compared the pharmacy costs of TKIs (osimertinib, erlotinib, gefitinib and afatinib) with the
pharmacy costs of other immune check-point inhibitors (ICIs), such as nivolumab, pembrolizumab and
atezolizumab, registered in other tumors (e.g., NSCLC, head and neck carcinoma and urological
malignancies) and known as the most expensive new drugs in medical oncology [19-24] , as well as the costs of
the reference elements in international markets, 18 karat (K) gold and platinum. All TKIs have the highest
cost per gram, with €305.33 for erlotinib, €288.24 for gefitinib, €3292.50 for afatinib and €1816.00 for
osimertinib, with a Δ toward 18 K gold and platinum per gram of €258.43 and €283.88 for erlotinib,
respectively; €241.34 and €266.79 for gefitinib, respectively; €3245.60 and €3271.05 for afatinib, respectively;
and €1769.10 and €1794.55 for osimertinib, respectively. This leads us to think that ICIs are not the most
expensive targeted agents, but there are other more expensive ones. Thus, there is no doubt that data on
osimertinib are good in daily clinical practice [11,13] , but a reduction in pharmacological costs is mandatory if
we want to consider TKIs (in particular, osimertinib) more advantageous in terms of cost-effectiveness.

In conclusion, based on ICER, osimertinib is more cost-effective than the other TKIs (erlotinib, gefitinib
and afatinib) in patients with activating EGFR mutations in first-line treatment for advanced NSCLC. The
data on osimertinib are good in daily clinical practice (also confirmed by the high grade of clinical benefit
[3]
on ESMO scale ), but a reduction in pharmacological costs is mandatory if we want to consider osimertinib
more cost-effective in first-line treatment for EGFR-mutated advanced NSCLC.

DECLARATIONS
Authors’ contributions
Conception and design, acquisition of data, or analysis and interpretation of data: Giuliani J, Bonetti A
Drafting the article and revising it critically for important intellectual content: Giuliani J, Bonetti A
Final approval of the version to be published: Giuliani J, Bonetti A
Each author contributed equally.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a
financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.
This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants
or patents received or pending, or royalties.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.