Several randomized control trials (RCTs) have showed that adding either abiraterone acetate (AA) or docetaxel (D) to androgen-deprivation therapy (ADT) improves survival of metastatic castration-sensitive prostate cancer patients (mCSPC). Yet, the cost-effectiveness of these treatment options has not been fully compared under Hong Kong’s setting. This cost-effectiveness analysis (CEA) serves as the first study in Hong Kong to compare the economic value of these two combinations ADT + AA vs. ADT + D.
A deterministic Markov model is used to project cost-effectiveness of each treatment until death. Survival curves for progression/death were extracted and digitized from the five RCTs (CHAARTED, LATITUDE, two STAMPEDE (2016/2017), and GETUG-AFU15). Clinically significant adverse events (AEs) were modeled; utility values were obtained from the literature. Primary outcomes were the quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). We used the societal perspective from Hong Kong and considered three times of local gross domestic product per capita (GDPpc) as the willingness-to-pay (WTP) threshold (i.e., US$138,649). We estimated the break-even cost of AA in case ADT + AA is not a cost-effective strategy under this WTP threshold. While considering the standard AA dosage (1000 mg) as the main analysis, we also examined the potential impact of the low-dose AA (250 mg) strategy.
Integrating simulations with probabilistic sensitivity analysis, ADT + D returns 0.79 (median; 95% credible interval 0.56–0.97) QALY with an ICER of US$14,397/QALY ($7824–22,632) compared to ADT-alone. A head-to-head comparison indicates that ADT + AA further gains 0.79 (0.45–1.17) QALY but with an ICER of $361,439/QALY ($260,615–599,683) when compared to ADT + D. Considering three times of GDPpc as WTP threshold, ADT + D is more cost-effective in all simulations; while ADT + AA is more cost-effective than ADT + D only if the cost of AA is reduced by at least 63%. The low-dose AA (250 mg) strategy is potentially cost-effective when it generates equivalent efficacy as the standard dosage (1000 mg).
ADT + D is therefore shown to be a more cost-effective strategy than ADT + AA in metastatic castration-sensitive prostate cancer patients in developed economies. Addition of AA substantially improved QALY compared to D but at a significant cost.
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Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394–424.
Kyriakopoulos CE, Chen Y-H, Carducci MA, Liu G, Jarrard DF, Hahn NM, et al. Chemohormonal therapy in metastatic hormone-sensitive prostate cancer: Long-term survival analysis of the randomized phase III E3805 CHAARTED trial. J Clin Oncol. 2018;36:1080–7.
James ND, Sydes MR, Clarke NW, Mason MD, Dearnaley DP, Spears MR, et al. Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet. 2016;387:1163–77.
Gravis G, Boher J-M, Joly F, Soulie M, Albiges L, Priou F, et al. Androgen deprivation therapy (ADT) plus docetaxel versus ADT alone in metastatic non castrate prostate cancer: Impact of metastatic burden and long-term survival analysis of the randomized phase 3 GETUG-AFU15 trial. Eur Urol. 2016;70:256–62.
Fizazi K, Tran N, Fein L, Matsubara N, Rodriguez-Antolin A, Alekseev BY, et al. Abiraterone plus Prednisone in metastatic, castration-sensitive prostate cancer. N Engl J Med. 2017;377:352–60.
James ND, de Bono JS, Spears MR, Clarke NW, Mason MD, Dearnaley DP, et al. Abiraterone for prostate cancer not previously treated with hormone therapy. N Engl J Med. 2017;377:338–51.
Sydes MR, Spears MR, Mason MD, Clarke NW, Dearnaley DP, de Bono JS, et al. Adding abiraterone or docetaxel to long-term hormone therapy for prostate cancer: directly randomised data from the STAMPEDE multi-arm, multi-stage platform protocol. Ann Oncol. 2018;29:1235–48.
Wallis CJD, Klaassen Z, Bhindi B, Goldberg H, Chandrasekar T, Farrell AM, et al. Comparison of abiraterone acetate and docetaxel with androgen deprivation therapy in high-risk and metastatic hormone-naive prostate cancer: a systematic review and network meta-analysis. Eur Urol. 2018;73:834–44.
Feyerabend S, Saad F, Li T, Ito T, Diels J, Van Sanden S, et al. Survival benefit, disease progression and quality-of-life outcomes of abiraterone acetate plus prednisone versus docetaxel in metastatic hormone-sensitive prostate cancer: A network meta-analysis. Eur J Cancer. 2018;103:78–87.
Tan PS, Aguiar P Jr, Haaland B, Lopes G. Addition of abiraterone, docetaxel, bisphosphonate, celecoxib or combinations to androgen-deprivation therapy (ADT) for metastatic hormone-sensitive prostate cancer (mHSPC): a network meta-analysis. Prostate Cancer Prostatic Dis. 2018;21:516–23.
Morris MJ, Rumble RB, Basch E, Hotte SJ, Loblaw A, Rathkopf D, et al. Optimizing anticancer therapy in metastatic non-castrate prostate cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2018;36:1521–39.
Guyot P, Ades AE, Ouwens MJNM, Welton NJ. Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves. BMC Med Res Method. 2012;12:9.
Morgans AK, Chen Y-H, Sweeney CJ, Jarrard DF, Plimack ER, Gartrell BA, et al. Quality of life during treatment with chemohormonal therapy: Analysis of E3805 chemohormonal androgen ablation randomized trial in prostate cancer. J Clin Oncol. 2018;36:1088–95.
Woo PPS, Kim JJ, Leung GM. What is the most cost-effective population-based cancer screening program for Chinese woman? J Clin Oncol. 2007;25:617–24.
Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Mak. 1993;13:322–38.
Hospital Authority. List of private charges: Hong Kong Special Administrative Region. 2019. https://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=10045&Lang=ENG. Accessed on 12 Mar. 2019.
World Health Organization. Making Choices in Health: WHO Guide to Cost-effectiveness Analysis. In: Tan-Torres ET, Baltussen RMPM, Adam T, Hutubessy R, Acharya A, Evans DB et al, editors. Geneva, Switzerland: World Health Organization; 2003.
Census and Statistics Department. Table 30: gross domestic product (GDP), implict price deflator of GDP and per capita GDP. 2019. http://www.censtatd.gov.hk/hkstat/sub/sp250.jsp?subjectID=250&tableID=030&ID=0&productType=8. Accessed on 12 Mar. 2019.
McKay MD, Beckman RJ, Conover WJ. A comparison of three methods for selecting values of input variables in the analysis of output from a computer code. Technometrics. 1979;21:239–45.
Szmulewitz RZ, Peer CJ, Ibraheem A, Martinez E, Kozloff MF, Carthon B, et al. Prospective international randomized phase II study of low-dose abiraterone with food versus standard dose abiraterone in castration-resistant prostate cancer. J Clin Oncol. 2018;36:1389–95.
Kassem L, Shohdy KS, Abdel-Rahman O. Abiraterone acetate/androgen deprivation therapy combination versus docetaxel/androgen deprivation therapy combination in advanced hormone-sensitive prostate cancer: a network meta-analysis on safety and efficacy. Curr Med Res Opin. 2018;34:903–10.
Aguiar PN Jr, Tan PS, Simko S, Barreto CMN, Gutierres BS, del Giglio A, et al. Cost-effectiveness analysis of abiraterone, docetaxel or placebo plus androgen deprivation therapy for hormone-sensitive advanced prostate cancer. Einst (Sao Paulo). 2019;17:eGS4414.
Ramamurthy C, Correa AF, Handorf EA, Beck R, Geynisman DM. Cost-effectiveness analysis of abiraterone versus docetaxel in the treatment of metastatic hormonenaive prostate cancer. American Society of Clinical Oncology (ASCO), Annual Meeting. Chicago, IL.
Sathianathen NJ, Alarid-Escudero F, Kuntz KM, Lawrentschuk N, Bolton DM, Murphy DG, et al. A cost-effectiveness analysis of systemic therapy for metastatic hormone-sensitive prostate cancer. Eur Urol Oncol. 2019. https://doi.org/10.1016/j.euo.2019.01.004.
Klaassen Z, Wallis CJD, Fleshner NE. Abiraterone acetate for nonmetastatic castration-resistant prostate cancer—the forgotten dance partner? JAMA Oncol. 2019;5:144–5.
Conti RM, Berndt ER. Specialty drug prices and utilization after loss of U.S. patent exclusivity. Cambridge: National Bureau of Economic Research; 2014.
Vogler S, Vitry A, Babar Z-U-D. Cancer drugs in 16 European countries, Australia, and New Zealand: a cross-country price comparison study. Lancet Oncol. 2016;17:39–47.
Zhong L, Pon V, Srinivas S, Nguyen N, Frear M, Kwon S, et al. Therapeutic options in docetaxel-refractory metastatic castration-resistant prostate cancer: a cost-effectiveness analysis. PLoS ONE. 2013;8:e64275.
Zheng HR, Wen F, Wu YF, Wheeler JRC, Li Q. Cost-effectiveness analysis of additional docetaxel for metastatic hormone-sensitive prostate cancer treated with androgen-deprivation therapy from a Chinese perspective. Eur J Cancer Care. 2017;26:e12505.
Sweeney CJ, Chen Y-H, Carducci M, Liu G, Jarrard DF, Eisenberger M, et al. Chemohormonal therapy in metastatic hormone-sensitive prostate cancer. N Engl J Med. 2015;373:737–46.
Francini E, Gray KP, Xie W, Shaw GK, Valenca L, Bernard B, et al. Time of metastatic disease presentation and volume of disease are prognostic for metastatic hormone sensitive prostate cancer (mHSPC). Prostate. 2018;78:889–95.
Armstrong AJ, Szmulewitz RZ, Petrylak DP, Villers A, Azad A, Alcaraz A, et al. Phase 3 study of androgen deprivation therapy (ADT) with enzalutamide (ENZA) or placebo (PBO) in metastatic hormone-sensitive prostate cancer (mHSPC): The ARCHES trial. J Clin Oncol. 2019;37(7 Suppl):687.
National Institute for Health and Clinical Excellence. Guide to the methods of technology appraisal. London: National Institute for Clinical Excellence; 2004.
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness: The curious resilience of the $50,000-per-QALY threshold. N Engl J Med. 2014;371:796–7.
Gravis G, Fizazi K, Joly F, Oudard S, Priou F, Esterni B, et al. Androgen-deprivation therapy alone or with docetaxel in non-castrate metastatic prostate cancer (GETUG-AFU 15): a randomised, open-label, phase 3 trial. Lancet Oncol. 2013;14:149–58.
Tse DMW, Chan KS, Lam WM, Leu KS, Lam PT. The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths. Palliat Med. 2007;21:425–33.
Census and Statistics Department. Women and men in Hong Kong key statistics (2017 edition); 2017. https://www.censtatd.gov.hk/hkstat/sub/sp180.jsp?productCode=B1130303.
Korfage IJ, de Koning HJ, Roobol M, Schroder FH, Essink-Bot M-L. Prostate cancer diagnosis: the impact on patients’ mental health. Eur J Cancer. 2006;42:165–70.
Heijnsdijk EAM, Wever E, Auvinen A, Hugosson J, Ciatto S, Nelen V, et al. Quality-of-life effects of prostate-specific antigen screening. N Engl J Med. 2012;367:85–95.
We thank John Fong, Jennifer Ha and Steven Tsang for technical support.
Conflict of interest
The authors declare that they have no conflict of interest.
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