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Cost-Effectiveness Analysis of Systemic Therapy for Intensification of Treatment in Metastatic Hormone-Sensitive Prostate Cancer in India

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Abstract

Background and Objective

Androgen-deprivation therapy is the mainstay of treatment for patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC). However, the intensification of treatment with either docetaxel or novel anti-androgens (abiraterone-acetate plus prednisone [AAP], enzalutamide, and apalutamide) is being recommended based on the improved clinical outcomes and quality of life among patients. This study aimed to determine the most cost-effective drug for treatment intensification for patients with mHSPC in India.

Methods

A Markov model was developed with four health states: progression-free survival, progressive disease, best supportive care, and death. Lifetime costs and consequences were estimated for four treatment sequences: AAP-first, enzalutamide-first, apalutamide-first, and docetaxel-first. Incremental cost per quality-adjusted life-year (QALY) gained with a given treatment option was compared against the next best alternative and assessed for cost effectiveness using a willingness to pay threshold of 1 × per capita gross domestic product in India.

Results

We estimated that the total lifetime cost per patient was ₹1,367,454 (US$17,487), ₹2,168,885 (US$27,735), ₹7,678,501 (US$98,190), and ₹1,358,746 (US$17,375) in the AAP-first, enzalutamide-first, apalutamide-first, and docetaxel-first treatment sequence, respectively. The mean quality-adjusted life-years lived per patient were 4.78, 5.03, 3.22, and 2.61, respectively. The AAP-first sequence incurs an incremental cost of ₹4014 (US$51) per quality-adjusted life-year gained as compared with the docetaxel-first sequence, with a 87% probability of being cost effective at the willingness-to-pay threshold of 1 × per-capita gross domestic product of India. The use of AAP-first also incurs an incremental net monetary benefit of ₹396,491 (US$5070) as compared with the docetaxel-first treatment sequence. Nearly a 48% reduction in the price of enzalutamide is required to make it a cost-effective treatment sequence as compared with AAP-first in India.

Conclusions

We concur with the inclusion of standard-dose AAP in India’s publicly financed health insurance scheme for the intensification of treatment in mHSPC as it is the only cost-effective sequence among the various novel anti-androgens when compared with the docetaxel-first treatment sequence. Furthermore, a systematic reduction in the price of enzalutamide would further help to improve clinical outcomes among patients with mHSPC.

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Author notes

  1. Nidhi Gupta and Dharna Gupta are joint lead authors and contributed equally to the article.

Authors and Affiliations

  1. Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India

    Nidhi Gupta

  2. Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Madhya Marg, Near Gol Market, Sector 14, Chandigarh, 160014, India

    Dharna Gupta & Shankar Prinja

  3. National Health Authority, Ayushman Bharat PM-JAY, Government of India, New Delhi, India

    Kiran Gopal Vaska

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  1. Nidhi Gupta
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  4. Shankar Prinja
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Corresponding author

Correspondence to Shankar Prinja.

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Funding

This work was supported by the Department of Health Research, Ministry of Health and Family Welfare, Government of India vide grant number F.No.T.11011/02/2017-HR/3100291.

Conflict of Interest

Nidhi Gupta, Dharna Gupta, Kiran Gopal Vaska, and Shankar Prinja have no conflicts of interest that are directly relevant to the content of this article.

Ethics Approval

The study protocol was approved by the Institute Ethics Committee of the Post Graduate Institute of Medical Education and Research, Chandigarh, India (IEC-03/2020-1565).

Consent to Participate

Written informed consent was obtained from all the study participants for QoL and OOP expenditures.

Consent for Publication

The study participants consented to their data being used for publication.

Availability of Data and Material

The datasets generated and/or analyzed during the current study are available from the corresponding author on request.

Code Availability

The code that supports the findings of this study is available from the corresponding author on request.

Author Contributions

Study conception: DG, NG, and SP. Study design: NG and DG. Analysis: DG, NG, and SP. Writing (first draft): DG, NG, and SP. Writing (review and editing): DG, NG, SP and KGV.

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Gupta, N., Gupta, D., Vaska, K.G. et al. Cost-Effectiveness Analysis of Systemic Therapy for Intensification of Treatment in Metastatic Hormone-Sensitive Prostate Cancer in India. Appl Health Econ Health Policy 22, 415–426 (2024). https://doi.org/10.1007/s40258-023-00866-w

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