•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
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.
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.
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.
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.