Brief Report

Breast Cancer Research and Treatment

, Volume 147, Issue 2, pp 433-441

First online:

Cost-effectiveness analysis of everolimus plus exemestane versus exemestane alone for treatment of hormone receptor positive metastatic breast cancer

  • Vakaramoko DiabyAffiliated withDivision of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University (FAMU) Email author 
  • , Georges AdunlinAffiliated withDivision of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University (FAMU)
  • , Simon B. ZeichnerAffiliated withDepartment of Internal Medicine, Mount Sinai Medical Center
  • , Kiran AvanchaAffiliated withHartford Healthcare Cancer Institute
  • , Gilberto LopesAffiliated withHCor OncoCentro Paulista de OncologiaJohns Hopkins University
  • , Stefan GluckAffiliated withDivision of Hematology/Oncology, Department of Medicine, Sylvester Comprehensive Cancer Center, Leonard M. Miller School of Medicine, University of Miami
  • , Alberto J. MonteroAffiliated withDepartment of Solid Tumor Oncology, Taussig Cancer Center

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Everolimus in combination with exemestane significantly improved progression-free survival compared to exemestane alone in patients previously treated with non-steroidal aromatase inhibitors in the BOLERO-2 trial. As a result, this combination has been approved by the food and drug administration to treat postmenopausal women with hormone receptor positive and HER2 negative metastatic breast cancer. A cost-effectiveness analysis was conducted to determine whether everolimus represents good value for money, utilizing data from BOLERO-2. A decision-analytic model was used to estimate the incremental cost-effectiveness ratio between treatment arms of the BOLERO-2 trial. Costs were obtained from the Center for Medicare Services drug payment table and physician fee schedule. Benefits were expressed as quality-adjusted progression-free survival weeks (QAPFW) and quality-adjusted progression-free years (QAPFY), with utilities/disutilities derived from the literature. Deterministic and probabilistic sensitivity analyses were performed. A willingness to pay threshold of 1–3 times the per capita gross domestic product was adopted, as per the definition of the World Health Organization. The U.S. per capita gross domestic product in 2013 was $49,965; thus, a threshold varying between $49,965 and $149,895 was considered. Everolimus/exemestane had an incremental benefit of 11.88 QAPFW (0.22 QAPFY) compared to exemestane and an incremental cost of $60,574. This translated into an ICER of $265,498.5/QAPFY. Univariate sensitivity analyses showed important variations of the ICER, ranging between $189,836.4 and $530,947/QAPFY. A tornado analysis suggested that the key drivers of our model, by order of importance, included health utility value for stable disease, everolimus acquisition costs, and transition probabilities from the stable to the progression states. The Monte-Carlo simulation showed results that were similar to the base-case analysis. This cost-effectiveness analysis showed that everolimus plus exemestane is not cost-effective compared to exemestane alone. Further research is needed to investigate the cost-effectiveness of the drug combination within sub-groups of the population studied in BOLERO-2.


Metastatic breast cancer Aromatase inhibitor therapy Everolimus Exemestane Health-related quality of life Progression-free survival BOLERO-2 Cost-effectiveness Analysis