Breast Cancer Research and Treatment

, Volume 147, Issue 2, pp 433–441 | Cite as

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

  • Vakaramoko Diaby
  • Georges Adunlin
  • Simon B. Zeichner
  • Kiran Avancha
  • Gilberto Lopes
  • Stefan Gluck
  • Alberto J. Montero
Brief Report


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 



The authors would like to thank Gordon Blackhouse (Programs for Assessment of Technology in Health (PATH) Research Institute, Hamilton, Ontario, Canada), Askal Ali, Dr. Janet Barber, and Dr. Ellen Campbell (Division of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University (FAMU), Tallahassee, FL, United States) for their insightful comments on earlier versions of the paper.

Conflict of interest

The authors certify that they have no conflict of interest with any financial organization regarding the material discussed in the manuscript.


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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Vakaramoko Diaby
    • 1
  • Georges Adunlin
    • 1
  • Simon B. Zeichner
    • 2
  • Kiran Avancha
    • 3
  • Gilberto Lopes
    • 4
    • 5
    • 6
  • Stefan Gluck
    • 7
  • Alberto J. Montero
    • 8
  1. 1.Division of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical SciencesFlorida A&M University (FAMU)TallahasseeUSA
  2. 2.Department of Internal MedicineMount Sinai Medical CenterMiami BeachUSA
  3. 3.Hartford Healthcare Cancer InstituteHartfordUSA
  4. 4.HCor OncoSão PauloBrazil
  5. 5.Centro Paulista de OncologiaSão PauloBrazil
  6. 6.Johns Hopkins UniversityBaltimoreUSA
  7. 7.Division of Hematology/Oncology, Department of Medicine, Sylvester Comprehensive Cancer Center, Leonard M. Miller School of MedicineUniversity of MiamiCoral GablesUSA
  8. 8.Department of Solid Tumor OncologyTaussig Cancer CenterClevelandUSA

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