AUA 2023: Cost-Effectiveness of Systemic Treatment Intensification in Men With Metastatic Hormone-Sensitive Prostate Cancer

(UroToday.com) The 2023 American Urological Association (AUA) annual meeting held in Chicago, IL between April 28 and May 1st, 2023, was host to an advanced prostate cancer podium session. Dr. Niranjan Sathianathen presented the results of a cost-effectiveness analysis of systemic treatment intensification in men with metastatic hormone-sensitive prostate cancer (mHSPC).

Novel trials have suggested that treatment intensification with triplet therapy (i.e., androgen deprivation therapy (ADT), docetaxel, and androgen receptor antagonists) results in improved survival outcomes.^1,2 However, these novel systemic agents are costly, and, as such, are associated with an underappreciated financial toxicity burden. Therefore, it is important to assess whether the increased cost is justified within the context of a resource-constrained health system. The objective of this study was to perform a cost-effectiveness analysis of systemic treatment options for men with mHSPC utilizing cost estimates from the United States healthcare system.

A state-transition Markov model was built to simulate the natural progression of metastatic prostate cancer. Model parameters were derived from the published literature and through calibration to observed epidemiological data. The hypothetical cohort of men with metastatic hormone-sensitive prostate cancer could receive treatment with any of the current FDA-approved agents:

Triplet therapy with abiraterone or darolutamide in addition to docetaxel/ADT
Doublet therapy: abiraterone, apalutamide, enzalutamide or docetaxel combination with ADT)
ADT alone

Once the disease progresses to the castration-resistant state in the simulated model, treatment with one of the approved therapies in the mCRPC setting was permitted. Quality adjusted life years (QALYs) and costs were estimated from a United States health sector perspective. Cost-effectiveness was estimated using the incremental cost effectiveness ratio (ICER).

Compared to ADT alone, doublet therapy with abiraterone, apalutamide, enzalutamide, or docetaxel improved quality-adjusted survival by 9.4, 29.6, 17.2, and 1.2 months, respectively. Triplet therapy with abiraterone or darolutamide resulted in an improved quality-adjusted survival of 21.2 and 22.8 months, respectively.

The ICER for each of the therapies was as follows:

Docetaxel: $75,546 per QALY
Apalutamide: $245,145 per QALY

While Dr. Sathianathen’s team argued that docetaxel is cost-effective at an ICER of approximately 75,000 USD, it is important to note that ICER thresholds/cut-offs vary by each country’s healthcare system policy, with an ICER of CAD 50,000 commonly accepted in the publicly funded Canadian health care system as a reasonable cut-off to deem an intervention cost-effective.

Triplet therapy with any strategy was not cost-effective (no exact figures provided). The cost of darolutamide had to be less than $4,230 (63% discount on listed price) for triplet therapy to be potentially cost-effective. Similarly, the cost of abiraterone acetate had to be below $4,051 for doublet therapy for it to be potentially cost-effective.

The authors concluded that based on the price of systemic agents in the United States, systemic treatment intensification with doublet therapy only using docetaxel may be cost-effective. Doublet therapy with androgen-receptor agents or triplet therapy is not cost-effective based on standard thresholds. A significant reduction in the price of these agents is required for them to be potentially considered cost-effective.

Presented by: Niranjan Sathianathen, PhD, Urology Registrar, University of Melbourne, Melbourne, Australia

Written by: Rashid K. Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2023 American Urological Association (AUA) Annual Meeting, Chicago, IL, April 27 – May 1, 2023

References:

Login