Cost-Utility Analysis of Palbociclib, Ribociclib and Letrozole in the First Line Treatment of Metastatic Breast Cancer in Iran Using Partitioned Survival Model
Abstract Background and ObjectivesPalbociclib and Ribociclib are a cyclin-dependent kinase (CDK 4/6) oral molecular inhibitors may improve overall survival (OS), progression free survival (PFS) and quality of life (QoL) in metastatic breast cancer (MBC) patients. We aimed to cost utility analysis (CUA) of Palbociclib in comparison with other alternative regimens in the first line treatment of patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2–) MBC in Iran.MethodsCUA was performed using partitioned survival model (PSM) from Iranian healthcare system perspective. Comparative strategies were Palbociclib+letrozole, Ribociclib+letrozole and Letrozole mono-therapy. Model structured with 1-month cycle length and 15 years as time horizon. Clinical safety and efficacy of interventions and survival functions in terms of PFS and OS for Palbociclib+letrozole, and Ribociclib+Letrozole was obtained from the latest update of PALOMA-1, 2 and MONALEESA-2 study, respectively. Direct medical costs include the cost of drugs, visits, hospitalization, CT scan, bone x-rays, monitoring and testing, and the medications side effects were considered. In order to uncertainty evaluations, deterministic sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were performed. Excel 2016 and TreeAge 2020 were used in all stages of evaluation.ResultsBase case results showed that despite the lower effectiveness, Letrozole mono-therapy was the most cost-effective strategy and Palbociclib+letrozole and Ribociclib+letrozole were not cost effective. The incremental cost effectiveness ratio (ICER) of the Palbociclib+Letrozole and Ribociclib+Letrozole compared to Letrozole mono-therapy was estimated at $137,302 and $120,478 per quality adjusted life year (QALY), respectively, indicating a large interval from the target threshold ($4956). DSA showed that the results of the CUA were not significantly sensitive to changes in the values of uncertain variables. PSA also showed Palbociclib+letrozole and Ribociclib+letrozole did not have a chance to be cost effective based on changes in various parameters and simulations.Conclusionsalbociclib and Ribociclib showed significant efficacy in the addition to Letrozole based on the PFS but were not cost effective strategies in the first line treatment of MBC.
