Breast Cancer Research and Treatment

, Volume 160, Issue 1, pp 187–196 | Cite as

Cost-effectiveness analysis of 1st through 3rd line sequential targeted therapy in HER2-positive metastatic breast cancer in the United States

  • Vakaramoko Diaby
  • Georges Adunlin
  • Askal A. Ali
  • Simon B. Zeichner
  • Gilberto de Lima Lopes
  • Christine G. Kohn
  • Alberto J. Montero
Brief Report



Based on available phase III trial data, we performed a cost-effectiveness analysis of different treatment strategies that can be used in patients with newly diagnosed HER2-positive metastatic breast cancer (mBC).

Patients and methods

We constructed a Markov model to assess the cost-effectiveness of four different HER2 targeted treatment sequences in patients with HER2-positive mBC treated in the U.S. The model followed patients weekly over their remaining life expectancies. Health states considered were progression-free survival (PFS) 1st to 3rd lines, and death. Transitional probabilities were based on published phase III trials. Cost data (2015 US dollars) were captured from the U.S. Centers for Medicare and Medicaid Services (CMS) drug payment table and physician fee schedule. Health utility data were extracted from published studies. The outcomes considered were PFS, OS, costs, QALYs, the incremental cost per QALY gained ratio, and the net monetary benefit. Deterministic and probabilistic sensitivity analyses assessed the uncertainty around key model parameters and their joint impact on the base-case results.


The combination of trastuzumab, pertuzumab, and docetaxel (THP) as first-line therapy, trastuzumab emtansine (T-DM1) as second-line therapy, and lapatinib/capecitabine third-line resulted in 1.81 QALYs, at a cost of $335,231.35. The combination of trastuzumab/docetaxel as first line without subsequent T-DM1 or pertuzumab yielded 1.41 QALYs, at a cost of $175,240.69. The least clinically effective sequence (1.27 QALYs), but most cost-effective at a total cost of $149,250.19, was trastuzumab/docetaxel as first-line therapy, T-DM1 as second-line therapy, and trastuzumab/lapatinib as third-line therapy.


Our results suggest that THP as first-line therapy, followed by T-DM1 as second-line therapy, would require at least a 50 % reduction in the total drug acquisition cost for it to be considered a cost-effective strategy.


cost-effectiveness analysis breast cancer Markov HER2-positive metastatic breast cancer Trastuzumab sequential therapy pertuzumab lapatinib T-DM1 



The authors would like to thank Andrew Munzer (Director of Training & Support, TreeAge) and Dr. Vassiki Sanogo (Senior researcher, Center for Economic Forecasting and Analysis at Florida State University) for their technical assistance.

Compliance with Ethical Standards


This study was funded in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award No. G12MD007582 (to V.D.), and by National Cancer Institute Grant No. 5R25CA093423-10 Virginia Commonwealth University/Massey Cancer Center (to G.A.).

Conflict of Interest

Vakaramoko Diaby declares that he has no conflict of interest. Georges Adunlin declares that he has no conflict of interest. Askal Ayalew Ali declares that she has no conflict of interest. Simon B. Zeichner declares that he has no conflict of interest. Gilberto de Lima Lopes declares that he has no conflict of interest. Christine G. Kohn declares that she has no conflict of interest. Alberto J. Montero declares that he has no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

10549_2016_3978_MOESM1_ESM.docx (97 kb)
Supplementary material 1 (DOCX 97 kb)


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Vakaramoko Diaby
    • 1
  • Georges Adunlin
    • 2
  • Askal A. Ali
    • 1
  • Simon B. Zeichner
    • 3
  • Gilberto de Lima Lopes
    • 4
  • Christine G. Kohn
    • 5
  • Alberto J. Montero
    • 6
  1. 1.Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical SciencesFlorida A&M UniversityTallahasseeUSA
  2. 2.Department of Health Behavior and PolicyVirginia Commonwealth University School of MedicineRichmondUSA
  3. 3.Winship Cancer Institute at Emory UniversityAtlantaUSA
  4. 4.Oncoclinicas GroupSão PauloBrazil
  5. 5.Health Economics and Outcomes ResearchUniversity of Saint Joseph School of Pharmacy, UConn/Hartford Hospital Evidence-based Practice CenterHartfordUSA
  6. 6.Department of Solid Tumor Oncology, Cleveland ClinicTaussig Cancer InstituteClevelandUSA

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