Abstract
Objectives: Metastatic renal cell cancer (mRCC) is becoming an important part of Dutch health care expenditure due to expensive pharmaceutical options for disease control and lack of adequate prevention methods. New targeted therapeutics, such as sunitinib, sorafenib and everolimus, have recently emerged with relevant benefits on progression-free survival (PFS) for mRCC patients. This study aims to assess the cost-effectiveness of the most recent of these introductions, i.e. everolimus, in comparison to best supportive care in second line treatment of mRCC patients in The Netherlands. Methods: A Markov model was designed in line with Dutch treatment protocols. Transitions between health states were modeled by timedependent probabilities extracted from published Kaplan-Meier curves for PFS and overall survival (OS). The cohorts were followed over 18 cycles, each cycle lasting 8 weeks. Annual discount rates of 1.5% for health and 4% for costs were applied and a health-care perspective was taken. One-way and probabilistic sensitivity analyses (PSA) were performed to test the robustness and uncertainty around the base-case estimate. Results: The incremental cost-effectiveness ratio (ICER) for everolimus was esimated at € 92,258/QALY. Sensitivity analysis identified the hazard multiplier, an estimate of OS gain, as the main driver of everolimus' cost-effectiveness. Through PSA a wide 95% confidence interval around the base-case ICER estimate was revealed (€ 49,677 - € 453,941/QALY). Additionally, at the threshold of three times GDP per capita (€ 95,700 in The Netherlands) everolimus had a 54% probability of being cost-effective. Conclusions: The base-case ICER was just below the upper cost-effectiveness limit recommended by WHO, indicating that everolimus might be a cost-effective option in the Dutch setting. However, reasonable uncertainty of the main finding resulted from everolimus' unpredictable gain in OS. Efforts should be undertaken to perform an integral assessment of the economic attractiveness of all current and new therapeutics in mRCC.
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