The treatment paradigm of metastatic hormone-sensitive prostate cancer (mHSPC) has significantly changed over the past decade. Currently, approved first-line treatment options 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. The objective of this study was to compare the cost-effectiveness of these treatment options in mHSPC from the US payer perspective to guide treatment sequence.
A Markov model was developed to compare the lifetime cost and effectiveness of ADT alone, docetaxel plus ADT, abiraterone plus ADT, enzalutamide plus ADT, and apalutamide plus ADT in the first-line treatment of 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 in 2020 US dollars. We extrapolated survival beyond closure of the trials. Model robustness was addressed in univariable and probabilistic analyses. A willingness-to-pay (WTP) threshold of US$100,000 per QALY was used.
Compared to ADT alone, docetaxel plus ADT provided a 0.31 QALY gain at an ICER of US$1,542 per QALY. Abiraterone plus ADT provided an additional 1.29 QALYs against docetaxel plus ADT, with an ICER of US$26,416 per QALY. Compared to abiraterone plus ADT, enzalutamide plus ADT provided an additional 0.06 QALYs at an ICER of US$3,826,216 per QALY. Given the WTP threshold of US$100,000 per QALY, abiraterone plus ADT represented high-value health care Base case results QALY=quality-adjusted life-year; ICER=incremental cost-effectiveness ratio; DCX=docetaxel; ADT=androgen deprivation therapy; AA=abiraterone; APA=apalutamide; ENZ=enzalutamide.
Strategy Total Incremental ICER (US$/QALY) Cost (US$) QALYs Life-years Cost (US$) QALYs ADT only 97,767 3.56 4.70 --- --- Baseline DCX + ADT 98,237 3.87 5.08 470 0.31 1,542 AA + ADT 132,403 5.16 6.45 34,165 1.29 26,416 APA + ADT 300,891 4.14 5.30 --- --- Dominated ENZ + ADT 366,476 5.22 6.51 234,073 0.06 3,826,216
Abiraterone plus ADT is the preferred treatment option for men with mHSPC at a WTP threshold of US$100,000 per QALY.
The authors.
Has not received any funding.
All authors have declared no conflicts of interest.