Department of Clinical Oncology, University of Hong Kong, Hong Kong, China.
Department of Clinical Oncology, University of Hong Kong - Shenzhen Hospital, Hong Kong, China.
Prostate Cancer Prostatic Dis. 2020 Mar;23(1):108-115. doi: 10.1038/s41391-019-0161-2. Epub 2019 Jul 4.
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.
几项随机对照试验（RCTs）表明，在雄激素剥夺治疗（ADT）的基础上添加醋酸阿比特龙（AA）或多西他赛（D）可改善转移性去势敏感前列腺癌患者（mCSPC）的生存。然而，这些治疗方案的成本效益尚未在香港的环境下进行充分比较。这项成本效益分析（CEA）是香港首次比较这两种 ADT+AA 与 ADT+D 联合治疗方案的经济价值的研究。
使用确定性马尔可夫模型预测每种治疗方法直至死亡的成本效益。从五个 RCTs（CHAARTED、LATITUDE、两个 STAMPEDE（2016/2017 年）和 GETUG-AFU15）中提取和数字化进展/死亡的生存曲线。对临床显著的不良事件（AE）进行建模；效用值从文献中获得。主要结局是质量调整生命年（QALYs）和增量成本效益比（ICER）。我们使用了香港的社会视角，并考虑了当地人均国内生产总值（GDPpc）的三倍作为支付意愿（WTP）阈值（即 138649 美元）。我们估计了 AA 的盈亏平衡成本，以确定在该 WTP 阈值下，ADT+AA 不是一种具有成本效益的策略。在考虑标准 AA 剂量（1000mg）作为主要分析的同时，我们还研究了低剂量 AA（250mg）策略的潜在影响。
通过模拟和概率敏感性分析，与 ADT 单药治疗相比，ADT+D 可获得 0.79（中位数；95%置信区间为 0.56-0.97）个 QALY，ICER 为 14397 美元/QALY（7824-22632 美元）。头对头比较表明，与 ADT+D 相比，ADT+AA 进一步获得 0.79（0.45-1.17）个 QALY，但 ICER 为 361439 美元/QALY（260615-599683 美元）。如果将 GDPpc 的三倍作为支付意愿阈值，在所有模拟中，ADT+D 都是更具成本效益的方案；而只有当 AA 的成本降低至少 63%时，ADT+AA 才比 ADT+D 更具成本效益。当低剂量 AA（250mg）策略与标准剂量（1000mg）产生等效疗效时，其具有潜在的成本效益。
因此，在发达经济体的转移性去势敏感前列腺癌患者中，与 ADT+AA 相比，ADT+D 是一种更具成本效益的治疗策略。与 D 相比，AA 的添加显著提高了 QALY，但成本也显著增加。
