Clinical Trial

Breast Cancer Research and Treatment

, Volume 117, Issue 2, pp 305-317

First online:

Cost-utility analysis for advanced breast cancer therapy in Germany: results of the fulvestrant sequencing model

  • Michael Patrick LuxAffiliated withUniversitäts-Brustzentrum Franken (UBF), Frauenklinik, Universitätsklinikum Erlangen Email author 
  • , M. HartmannAffiliated withApotheke, Universitätsklinikum Jena
  • , C. JackischAffiliated withKlinik für Gynäkologie und Geburtshilfe, Klinikum Offenbach GmbH
  • , G. RaabAffiliated withFrauenarztpaxis mit Schwerpunkt Gynäkologische Operationen und Brustkrebschirurgie
  • , A. SchneeweißAffiliated withKlinik für Allgemeine Frauenheilkunde und Geburtshilfe mit Poliklinik, Universitätsklinikum Heidelberg
  • , K. PossingerAffiliated withMedizinische Klinik mit Schwerpunkt Hämatologie und Onkologie (CCM), Freie Universität Berlin
  • , J. OyeeAffiliated withMapi Values
  • , N. HarbeckAffiliated withFrauenklinik und Poliklinik, Technische Universität München

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Therapy decisions in advanced breast cancer (ABC) increasingly require assessment not only of treatment efficacy but also of cost-effectiveness. To this end, we performed a cost-utility analysis by comparing treatment sequences including/omitting fulvestrant in a hypothetical population of hormone receptor-positive (HR+) postmenopausal women with ABC. The analysis was performed from the German health care perspective. Using a first-order sequential Markov model, expected costs and utilities were calculated over a time horizon of 10 years for cohorts of patients with HR+ ABC, previously treated for at least 5 years using adjuvant endocrine therapies. Utilities were primarily quantified in terms of quality adjusted life years (QALY). “Base-case” estimates of state transition rates, resource utilization, and other model parameters were derived from published evidence and expert assessment. The impacts of uncertainties in all key model parameters were evaluated by sensitivity analysis. Costs and benefits were discounted at 3% annually. Including second-line fulvestrant in the treatment sequence led to greater estimated health gains (0.021 QALY) and cost savings of €564 ($745, £380) per patient, i.e. the fulvestrant-containing sequence was “dominant”. The prediction of a cost savings was robust with respect to variations in all key parameters. The probability of acceptable cost-effectiveness for the fulvestrant sequence was 72% at a willingness to pay (WTP) of €30,000/QALY ($39,621/QALY, £20,198/QALY); the probability was even higher at lower WTP and substantially exceeded 50% for any realistic WTP. In a representative population of women with HR+ advanced breast cancer, inclusion of fulvestrant in the treatment sequence provides a cost-effective alternative from the German health care perspective. A high probability of cost-effectiveness is maintained under variations in all key parameters. The results reflect a tendency for patients receiving fulvestrant at an early stage to maintain high quality of life for a longer interval.


Breast cancer Cost-effectiveness Fulvestrant