Cost-effectiveness analysis of 7 treatments in metastatic hormone-sensitive prostate cancer: a public-payer perspective

Abstract

Background Recently several new treatment regimens have been approved for treating metastatic hormone-sensitive prostate cancer (mHSPC), building on androgen deprivation therapy (ADT) alone. These include docetaxel-ADT (DA), Abiraterone Acetate-Prednisone-ADT (AAP), Apalutamide-ADT (AAT), Enzalutamide-ADT (ET), Darolutamide-Docetaxel-ADT (DAD) and Abiraterone- Prednisone-ADT-Docetaxel (AAD). There are no validated predictive biomarkers for choosing a specific regimen. The goal of this study was to conduct a health economic outcome evaluation to determine the optimal treatment from the US public sector (VA). Methods We developed a partitioned survival model in which mHSPC patients transitioned between three health states (progression free, progressive disease to castrate resistance state, and death) at monthly intervals based on Weibull survival model estimated from published Kaplan-Meier curves using a Bayesian network meta-analysis of seven clinical trials (7,208 patients). The effectiveness outcome in our model was quality-adjusted life-years (QALYs). Cost input parameters included initial and subsequent treatment costs and costs for terminal care and for managing grade 3+ drug related adverse events, and were obtained from the Federal Supply Schedule and published literature. Results Average 10-year costs ranged from $34,349 (ADT) to $658,928 (DAD) and mean QALYs ranged from 3.25 (ADT) to 4.57 (ET). Treatment strategies DA, EAD, AAT, and DAD were eliminated due to dominance (ie, they were more costly and less effective than other strategies). Of the remaining strategies, AAP was the most cost-effective strategy at a willingness-to-pay threshold of $100,000/QALY (ICER = $21,247/QALY). Conclusions Our simulation model found AAP to be an optimal first-line treatment for mHSPC from a public (VA) payer perspective.