Assessing the cost-effectiveness of adding aprepitant to the ASCO standard for prophylaxis of chemotherapy induced nausea and vomiting

Abstract

6009 Background: Chemotherapy-induced nausea and vomiting (CINV) is cited as a great concern for cancer patients. ASCO guidelines for prophylaxis of CINV in patients receiving highly-emetogenic chemotherapy (HEC) recommend use of a 5HT3 antagonist with a corticosteroid (SOC). Aprepitant, a novel NK1 antiemetic, is approved for use with a 5HT3 antagonist and a corticosteroid to manage CINV. Although clinical studies of aprepitant have demonstrated its efficacy, the settings in which it will be cost-effective remain unclear. Methods: We developed a Markov model to compare managing CINV for a hypothetical patient cohort receiving 4 cycles of HEC with: SOC, SOC + aprepitant (A1), or SOC therapy adding aprepitant only after CINV occurs (A2). Data from published clinical trials provided probabilities and utilities for the model. Costs from a payer perspective were based on resource use for CINV management, Medicare reimbursement rates for hospital and physician services, and the average wholesale price for medications. Clinical outcomes were valued in healthy-day equivalents (HDEs) and converted to quality-adjusted life years (QALYs) for cost-effectiveness (CE) comparisons. Univariate and probabilistic sensitivity analyses addressed uncertainty in parameters. Results: The SOC strategy, provided 11.9 HDEs at a cost of $455. The A1 regimen provided 14.4 HDEs at $1,619. A2 provided 13.2 HDEs at $996. The CE ratios for the three regimens were $13,907, $41,060 and $27,619, per QALY respectively. The incremental CE ratios (compared to SOC) were $172,789/QALY for strategy A1 and $160,236/QALY for A2. In univariate analysis, A1 became CE at a cost of aprepitant of $94. In 10,000 probablistic Monte Carlo trials, A1 was not CE in 98.7% of trials using a $50,000/QALY threshold. Conclusions: Managing CINV with aprepitant is not CE when compared with the current ASCO standard of care. Probabilistic sensitivity analyses suggest that this finding holds despite wide variations in model assumptions. Adding aprepitant after CINV occurs or targeting particular high-risk populations will likely be necessary to identify a cost-effective use for this drug. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Solvay