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. 2022 May;25(5):796-802.
doi: 10.1016/j.jval.2021.10.016. Epub 2021 Dec 1.

Cost-Effectiveness of Systemic Treatments for Metastatic Castration-Sensitive Prostate Cancer: An Economic Evaluation Based on Network Meta-Analysis

Lin Wang  1 , Hwanhee Hong  2 , G Caleb Alexander  1 , Otis W Brawley  3 , Channing J Paller  4 , Jeromie Ballreich  5
Affiliations

Cost-Effectiveness of Systemic Treatments for Metastatic Castration-Sensitive Prostate Cancer: An Economic Evaluation Based on Network Meta-Analysis

Lin Wang et al. Value Health. 2022 May.

Abstract

Objectives: To assess the cost-effectiveness of systemic treatments for metastatic castration-sensitive prostate cancer from the US healthcare sector perspective with a lifetime horizon.

Methods: We built a partitioned survival model based on a network meta-analysis of 7 clinical trials with 7287 patients aged 36 to 94 years between 2004 and 2018 to predict patient health trajectories by treatment. We tested parameter uncertainties with probabilistic sensitivity analyses. We estimated drug acquisition costs using the Federal Supply Schedule and adopted generic drug prices when available. We measured cost-effectiveness by an incremental cost-effectiveness ratio (ICER).

Results: The mean costs were approximately $392 000 with androgen deprivation therapy (ADT) alone and approximately $415 000, $464 000, $597 000, and $959 000 with docetaxel, abiraterone acetate, enzalutamide, and apalutamide, added to ADT, respectively. The mean quality-adjusted life-years (QALYs) were 3.38 with ADT alone and 3.92, 4.76, 3.92, and 5.01 with docetaxel, abiraterone acetate, enzalutamide, and apalutamide, added to ADT, respectively. As add-on therapy to ADT, docetaxel had an ICER of $42 069 per QALY over ADT alone; abiraterone acetate had an ICER of $58 814 per QALY over docetaxel; apalutamide had an ICER of $1 979 676 per QALY over abiraterone acetate; enzalutamide was dominated. At a willingness to pay below $50 000 per QALY, docetaxel plus ADT is likely the most cost-effective treatment; at any willingness to pay between $50 000 and $200 000 per QALY, abiraterone acetate plus ADT is likely the most cost-effective treatment.

Conclusions: These findings underscore the value of abiraterone acetate plus ADT given its relative cost-effectiveness to other systemic treatments for metastatic castration-sensitive prostate cancer.

Keywords: chemotherapy; clinical trial; cost-effectiveness; drug therapy; economic evaluation; hormonal therapy; network meta-analysis; partitioned survival model; prostate cancer.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Wang reported receiving the Ellen B. Gold Scholarship from the Ellen B. Gold Fund, reported receiving the Pharmaceutical Research and Manufacturers of America Foundation 2020 Predoctoral Fellowship in Health Outcomes Research from the Pharmaceutical Research and Manufacturers of America Foundation, and reported recently joining Merck as an Associate Principal Scientist after she completed this research and submitted this manuscript as a part of her PhD dissertation with Johns Hopkins University Bloomberg School of Public Health. Dr Alexander reported serving as a member and past Chair of the US Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee, is a cofounding Principal and equity holder in Monument Analytics, a healthcare consultancy whose clients include the life sciences industry and plaintiffs in opioid litigation, and is a past member of OptumRx’s National Pharmacy and Therapeutics Committee. These arrangements have been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. Dr Brawley reported receiving a consulting fee for consultation for Grail on cancer screening and reported serving on the board of Lyell Immunopharma and PDS Biotech, neither of which makes a prostate cancer product. No other disclosures were reported.

Figures

Figure 1.
Figure 1.
Partitioned survival model. The area under the rPFS curve indicates the proportion of patients remaining in mCSPC state over time; the area above OS curve indicates the proportion of patients deceased over time; the area between the rPFS and OS curve indicates the proportion of patients in mCRPC state over time. mCRPC indicates metastatic castration-resistant prostate cancer; mCSPC, metastatic castration-sensitive prostate cancer; OS, overall survival; rPFS, radiographic progression-free survival.
Figure 2.
Figure 2.
Cost-effectiveness plane and efficiency frontier. The cost-effectiveness plane plots the costs against the QALYs for each treatment. The scattered points represent 7500 model iterations in the probabilistic sensitivity analysis, where values of parameter inputs (including treatment effect, cost, and utility) were drawn from their respective distributions. The circles represent the mean costs and QALYs of individual treatments. The line connecting successive circles is called the “cost-effectiveness frontier.” The gradient of a line segment represents the ICER comparing 2 treatment alternatives. The steeper the gradient, the higher the ICER. Treatments on the right end of a line segment are cost-effective at a willingness-to-pay threshold lower than the ICER represented by that line segment. Treatments not on the frontier are not cost-effective at any willingness-to-pay thresholds. Because for the same QALYs, they resulted in higher costs than other treatments. ADT indicates androgen deprivation therapy; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year.
Figure 3.
Figure 3.
Cost-effectiveness acceptability curve. The cost-effectiveness acceptability curve plots the probability of a treatment being the most cost-effective across all treatments against a range of willingness-to-pay thresholds. The probabilities were derived from 7500 model iterations in the probabilistic sensitivity analysis where values of parameter inputs (including treatment effect, cost, and utility) were drawn from their respective distributions. ADT indicates androgen deprivation therapy; QALY, quality-adjusted life-year.
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