Cost-effectiveness analysis of everolimus plus exemestane versus exemestane alone for treatment of hormone receptor positive metastatic breast cancer
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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.
KeywordsMetastatic 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.
- 1.American Cancer Society (2013) Cancer Facts & Figures 2013. American Cancer Society, AtlantaGoogle Scholar
- 2.Finn R, Crown J, Boer K et al (2012) Results of a randomized phase 2 study of PD 0332991, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with letrozole vs letrozole alone for first-line treatment of ER/HER2-advanced breast cancer (BC). Cancer Res 72(24 Suppl):S1–S6Google Scholar
- 8.Piccart M, Baselga J, Noguchi S et al (2012) Final progression-free survival analysis of BOLERO-2: a phase III trial of everolimus for postmenopausal women with advanced breast cancer. Chemotherapy 42:59Google Scholar
- 12.Gold MR (1996) Cost-effectiveness in health and medicine. Oxford University Press, New YorkGoogle Scholar
- 13.The National Institute for Health and Care Excellence (NICE) (2013) Everolimus in combination with exemestane for treating advanced HER2-negative hormone-receptor-positive breast cancer after endocrine therapyGoogle Scholar
- 15.Piccart M, Hortobagyi GN, Campone M et al (2014) Everolimus plus exemestane for hormone receptor-positive (HR+), human epidermal growth factor receptor-2-negative (HER2–) advanced breast cancer (BC): overall survival results from BOLERO-2. Oral Presentation Abstract #LBA1. European Breast Cancer Conference (EBCC-9), 2014, Glasgow, ScotlandGoogle Scholar
- 18.Centers for Medicare and Medicaid Services (2014) Medicare physician fee schedule (MPFS)Google Scholar
- 19.Centers for Medicare and Medicaid Services (2013) Payment allowance limits for medicare, Part B. DrugsGoogle Scholar
- 21.Pfuntner A, Wier LM, Steiner C (2013) Costs for hospital stays in the United States, 2011. Agency for Health Care Policy and Research (US)Google Scholar