Cost-saving analysis of neoadjuvant versus adjuvant immunotherapy in clinical stage III melanoma: A real-world Brazilian perspective.

Abstract

e21544 Background: Neoadjuvant immunotherapy has become a new standard for resectable clinical stage III melanoma, driven by improved event-free survival and high pathological response rates in randomized trials. In addition to clinical benefit, this strategy may reduce cumulative treatment exposure compared with conventional adjuvant anti–PD-1 therapy. However, real-world economic evaluations comparing neoadjuvant and adjuvant approaches remain limited, particularly in middle-income countries. We estimated and compared direct medical costs of a neoadjuvant strategy based on the NADINA protocol versus standard adjuvant anti–PD-1 therapy in clinical stage III melanoma. Methods: This cost-saving estimate analysis evaluated direct medical costs related to medications and exams using the care pathway of A.C.Camargo Cancer Center, a Brazilian private cancer center. Neoadjuvant and adjuvant treatment protocols, including dosages and frequencies, were defined according to expert opinion and contemporary clinical literature. Drug costs were based on the hospital’s 2025 mean acquisition prices, and exam costs reflected institutional delivery costs without profit margin. Cost differences were calculated per complete treatment cycle. All costs were collected in Brazilian reais (R$) and converted to US dollars (US$). Results: In the neoadjuvant scenario, patients received 2 cycles of nivolumab (240 mg) plus ipilimumab (80 mg), with 40% requiring additional adjuvant therapy consisting of 10 cycles of nivolumab (480 mg). In the adjuvant scenario, all patients received 12 cycles of nivolumab (480 mg). Exam frequency was identical between scenarios, except for one additional PET/CT in the neoadjuvant strategy. Total estimated cost per treatment cycle was R$ 365,949 (US$ 69,177) for the neoadjuvant approach and R$ 581,595 (US$ 109,942) for the adjuvant approach, yielding an estimated cost saving of R$ 215,645 (US$ 40,764) per cycle. Conclusions: A neoadjuvant immunotherapy strategy based on the NADINA protocol was associated with meaningful direct cost savings compared with standard adjuvant anti–PD-1 therapy in clinical stage III melanoma. Reduced exposure to prolonged adjuvant treatment offset the higher upfront costs of combination immunotherapy. These findings suggest that neoadjuvant immunotherapy may offer not only clinical advantages but also improved economic efficiency in real-world practice. Prospective health economic analyses incorporating long-term outcomes are warranted to further inform policy and reimbursement decisions.