Perioperative Pembrolizumab May Not Be Cost-Effective in Advanced Head and Neck Cancer

Clinical Summary:

• Design/Population: This cost-effectiveness analysis used a Markov model to evaluate perioperative pembrolizumab for patients with locally advanced head and neck cancer from a public-payer perspective, incorporating clinical outcomes from KEYNOTE-689. 
• Key Outcomes: At current list pricing, perioperative pembrolizumab was not cost-effective across conventional willingness-to-pay thresholds. Modeling suggested that substantial reductions in drug price or treatment duration would be required to achieve commonly accepted cost-effectiveness thresholds.
• Clinical Relevance: These findings highlight the need to consider treatment value, affordability, and resource allocation as perioperative immunotherapy is incorporated into the management of locally advanced head and neck cancer.

Christopher Noel, MD, PhD, Princess Margaret Cancer Centre, Toronto, Canada, discusses a cost-effectiveness analysis evaluating perioperative pembrolizumab for patients with locally advanced head and neck cancer following the survival benefits demonstrated in KEYNOTE-689. 

Dr Noel reviews findings showing that perioperative pembrolizumab was unlikely to be cost-effective at current list pricing across commonly used willingness-to-pay thresholds and discusses how reductions in drug cost or treatment duration could improve value. He also explores the broader challenge of balancing clinical innovation with affordability, equitable access, and sustainable implementation of new cancer therapies.

Transcript:

My name is Chris Noel, I'm a head and neck surgeon at the Princess Margaret Cancer Center and assistant professor at the University of Toronto. 

In terms of this study, this is a paper we put out in JAMA Otolaryngology looking at the cost-effectiveness of perioperative pembrolizumab in locally advanced head and neck cancer. We are in a new era of immuno-oncology, and I think there's all these exciting drugs and promise and new modalities that we're seeing across disease sites. But like anything, there is a cost to these, and perioperative pembrolizumab has been shown to have survival benefits in a very prominent paper in the New England Journal of Medicine, KEYNOTE-689. We wanted to look at this from a public-payer perspective to see if it was something that's high value and cost-effective.

We did a Markov model and worked with some health economists affiliated with Ontario Health, and we determined that really at list prices it isn't cost-effective, but we defined the parameters when it would meet our typical ICER thresholds and outlined that. I think it's an important conversation, and a larger one of we're being confronted with all these new and exciting drugs and technologies, but how do we prioritize them and how do we scale them across health systems in an equitable and kind of cost-conscious way?

At the typical willingness to pay thresholds for this of anywhere from 50 to 150,000 dollars per quality, like the ICERs, the probability of cost-effectiveness in our simulations was zero. For it to be cost-effective, you'd need an 80% reduction in the price of pembrolizumab or you would need to dramatically reduce the number of doses administered. 

Source:

Noel CW, Guo J, Forner D, et al. Cost-effectiveness of perioperative pembrolizumab in locally advanced head and neck cancer. JAMA Otolaryngol Head Neck Surg. Published online: July 2, 2026. doi: 10.1001/jamaoto.2026.1659