Cost Effectiveness of Abiraterone vs Docetaxel in the Treatment of Hormone-Naïve Prostate Cancer

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•In combination with androgen-deprivation therapy (ADT), both abiraterone and docetaxel have been associated with improved survival in select men with metastatic hormone-naïve prostate cancer. Whereas clinical factors and patient preferences may dictate which therapy is chosen, the authors sought to determine the cost-effectiveness of each approach over a 3-year window. Cost estimates were derived from direct costs associated with drug acquisition, administration, and monitoring. In 2018 US dollars, as compared with ADT alone, docetaxel added 0.32 progression-free quality-adjusted life years (PF-QALYs) at a cost of $16,100 and abiraterone 0.52 PF-QALYs at a cost of $215,800. The incremental cost-effectiveness ratio for abiraterone versus docetaxel was $1,010,000 per PF-QALY. Sensitivity analysis suggested that abiraterone was very unlikely to achieve cost-effectiveness at a willingness-to-pay threshold of $150,000/QALY.

•These results suggest that docetaxel is more cost-effective than abiraterone in the initial treatment window in the setting of hormone-naïve prostate cancer.

– Joshua Cohn, MD

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Urology 

Written by Mario Eisenberger MD

In six of seven prospectively randomized studies of patients with newly diagnosed, hormone-naïve metastatic prostate cancer, comparing various combinations of standard gonadal androgen-deprivation treatment (ADT) with either docetaxel or one of the novel androgen receptor (AR)–targeting drugs (abiraterone, enzalutamide, or apalutamide) with ADT alone, the primary study endpoint (overall survival; OS) was met. The evidence is substantial, consistent, clinically meaningful, and, in my opinion, practice-changing.

The benefits with AR-targeted drugs, including abiraterone acetate, are very similar to those reported with docetaxel + ADT regimens. The proponents argue that AR-targeted treatments have a more favorable therapeutic index and easier mode of administration than chemotherapy; however, this argument needs to be carefully balanced against the cost and potential long-term toxicities with AR-targeted treatments.

In the NCI-sponsored docetaxel study (CHAARTED), 86% of patients were able to receive six cycles of docetaxel, and toxicity was low and reversible. The incidence of severe adverse events with chemotherapy was low and usually reversible, including neutropenic fever (<5%), 1/390 sudden death, and grade 3 motor/sensory neuropathy (1%). Long-term administration of abiraterone and other AR-targeting drugs is associated with risks of infection, diabetes, myocardial infarction, liver disease, seizure disorders, and drug–drug interactions (anticoagulants, antiretrovirals, antidepressants, etc).

This article illustrates that docetaxel treatment (which is covered by most insurance plans in the United States) is substantially more cost-effective than abiraterone (not entirely covered by most insurance plans). The difference is staggering and compelling. It is hoped that, with longer follow-up, the results of all studies will provide additional clarity to facilitate patient and treatment selection and to further assess cost-effectiveness in this relatively heterogeneous group of patients.

PURPOSE

Prostate cancer is the second leading cause of cancer death in men in the US. Since 2015, landmark studies have demonstrated improved survival outcomes with the use of docetaxel (DCT) or abiraterone (AA) in addition to androgen deprivation therapy (ADT) in the metastatic hormone-naïve setting. These treatment strategies have not been prospectively compared but have similar overall survival benefits despite differing mechanisms of action, toxicity, and cost. We performed a cost-effectiveness analysis to provide insight into the value of AA vs. DCT in the first-line treatment of metastatic prostate cancer.

MATERIALS AND METHODS

We developed Markov models by using a US-payer perspective and a 3-year time horizon to estimate costs (2018 US$) and progression-free quality-adjusted life years (PF-QALYs) for ADT alone, DCT, and AA. Health states were defined as initial state, treatment states according to experience of an adverse event, and progressed disease/death. State transition probabilities were derived from rates for drug discontinuation, frequency of adverse events, disease progression, and death from the randomized phase III trials ChemoHormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) and LATITUDE. Univariate and probabilistic sensitivity analyses were conducted to evaluate model uncertainty.

RESULTS

DCT resulted in an increase of 0.32 PF-QALYs and $16,100 in cost and AA resulted in an increase of 0.52 PF-QALYs and $215,800 in cost compared to ADT alone. The incremental cost-effectiveness ratio for DCT vs. ADT was $50,500/PF-QALY and for AA vs. DCT was $1,010,000/PF-QALY. Probabilistic sensitivity analysis demonstrated that at a willingness-to-pay threshold of $150,000/PF-QALY AA was highly unlikely to be cost-effective.

CONCLUSION

DCT is substantially more cost-effective than AA in the treatment of metastatic hormone naïve prostate cancer.

Urologic Oncology: Seminars & Original Investigations

Cost Effectiveness of Abiraterone Versus Docetaxel in the Treatment of Metastatic Hormone-Naïve Prostate Cancer

Urol. Oncol 2019 Aug 06;[EPub Ahead of Print], C Ramamurthy, EA Handorf, AF Correa, JR Beck, DM Geynisman

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

[Hidden]

I heard in some government-run healthcare systems, if you can get Abiraterone at all, you have to have had Docetaxel first. They look at the cost vs. benefit and determine whether it's worth it. In terms of "early use" benefit, Abiraterone and Docetaxel have similar results, but drastically different prices. Healthcare money is limited so providers want to make sure they spend it in the most cost-efficient manner.

In the US, drugs only need to show benefit to get approved. My doctor was saying if there is a benefit for 30% of patients, that's a big deal in the cancer world. In the US, once drugs are approved, you can generally get them. The patient is usually paying for at least part of the cost though.

[LearnAll in reply to Hidden]

Please do not forget that the price of Abiraterone is falling now. In 2017, Abiraterone was being sold at $9500 per month and in 2019, the price has come down to $2200 per month in USA.

Overseas, prices of Abiraterone is very very low...In India..it is about $110 per month and many other countries ,prices are on decline as the J&J could not get patent renewed.

A new jersy court did not allowed continued patent. So, the cost effectiveness has to be re calculated based on new prices of Abiraterone.

Also, the dose required of Abiraterone is only 250 mg if it is taken with a moderately fatty meal. That is 1/4th of the old recommended dose.

[Brbnbrn in reply to LearnAll]

I'd like to hear Dr. Cohn's reply to your post. My husband's Oncologist refuses to let him lower his dosage of Abiraterone with food and insists he take Zytiga. He just went on Medicare D and they refuse to approve generic due to Dr. so the reduced dose would help a lot financially with no impact on effectiveness. I'd LOVE to know where we could get a $2,200 price! We paid $2,800 in copay!

Is there a study or anything to support the reduced dosage of Abiraterone WITH food? The study I gave them only had 76 participants and they said it wasn't large enough.

[LearnAll in reply to Brbnbrn]

yes. there is a study which concluded that Abiraterone absorption is 4 times higher if taken with a moderately fatty meal.

Someone posted that study right on this forum only 2 months ago...you will have to search this forum for that post.