Abstract
BackgroundCurrently, approved first-line treatment options of metastatic hormone-sensitive prostate cancer (mHSPC) include (1) androgen deprivation therapy (ADT) alone, ADT plus one of the following: (2) docetaxel, (3) abiraterone, (4) enzalutamide, and (5) apalutamide. The high cost of novel androgen receptor pathway inhibitors warrants an understanding of the combinations’ value by considering both efficacy and cost.ObjectiveThis study aimed to compare the cost-effectiveness of these five treatment options in mHSPC from the US payer perspective to guide treatment sequence.MethodsA Markov model was developed to compare the lifetime cost and effectiveness of these five first-line treatment options for mHSPC using outcomes data from published literature. Health outcomes were measured in life-years and quality-adjusted life-years (QALYs). Drug costs were obtained from the Veterans Affairs Pharmaceutical Catalog. We extrapolated survival beyond closure of the trials.Outcome Measurements and Statistical AnalysisLife-years, QALYs, lifetime costs, and incremental cost-effectiveness ratios (ICERs) were estimated. Univariable, 2-way, and probabilistic sensitivity analyses were performed to evaluate parameter uncertainty. A willingness-to-pay (WTP) threshold of US$100,000 per QALY was used.ResultsCompared to ADT alone, docetaxel plus ADT provided a 0.28 QALY gain at an ICER of US$12,870 per QALY. Abiraterone plus ADT provided an additional 1.70 QALYs against docetaxel plus ADT, with an ICER of US$38,897 per QALY. Compared to abiraterone plus ADT, enzalutamide plus ADT provided an additional 0.87 QALYs at an ICER of US$509,813 per QALY. Apalutamide plus ADT was strongly dominated by enzalutamide plus ADT. Given the WTP threshold of US$100,000 per QALY, abiraterone plus ADT represented high-value health care.ConclusionsAbiraterone plus ADT is the preferred treatment option for men with mHSPC at a WTP threshold of US$100,000 per QALY.
Highlights
In the US, prostate cancer accounts for one in five new cancers, making it the most diagnosed cancer in men; it is the second most common cancer-related death in men [1]
Apalutamide plus androgen deprivation therapy (ADT) was strongly dominated by enzalutamide plus ADT
Even at its best estimated efficacy, the monthly cost of enzalutamide has to drop by 58% to US$3,104 in order for enzalutamide to be recommended over abiraterone
Summary
In the US, prostate cancer accounts for one in five new cancers, making it the most diagnosed cancer in men; it is the second most common cancer-related death in men [1]. The treatment landscape for metastatic hormone-sensitive prostate cancer (mHSPC) has significantly changed over the past decade, with emerging evidence supporting the addition of novel agents including chemotherapy or androgen receptor pathway inhibitors to the backbone treatment of androgen deprivation therapy (ADT). In 2015, STAMPEDE [4] and CHAARTED [5] were the two pivotal clinical trials that demonstrated an overall survival (OS) benefit of upfront docetaxel in addition to ADT in patients with mHSPC. Approved first-line treatment options of metastatic hormonesensitive prostate cancer (mHSPC) include [1] androgen deprivation therapy (ADT) alone, ADT plus one of the following: [2] docetaxel, [3] abiraterone, [4] enzalutamide, and [5] apalutamide. The high cost of novel androgen receptor pathway inhibitors warrants an understanding of the combinations’ value by considering both efficacy and cost
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