All of the current treatment strategies for castration-resistant prostate cancer (CRPC) exceed the generally accepted criteria for cost-effectiveness, according to an analysis reported here.

The least costly of the regimens exceeded the $100,000 threshold by about $60,000, and the most costly approached three times the threshold for willingness to pay per life-year saved.

The analysis did not incorporate the costs related to adverse events, palliative care, quality of life, or a number of other factors that could influence cost, Matthew Pollard, MD, of Mount Sinai Medical Center in New York City, said at the American Urological Association meeting.

"All current treatment options exceeded the societal threshold for willingness to pay of $100,000," said Pollard. "However, the effectiveness of the current paradigm is likely to improve and costs are likely to reduce due to learning and competition that would potentially decrease the incremental cost-effectiveness ratio (ICER)."

After decades with few treatment options for men with metastatic CRPC, multiple agents have become available in the past few years. The emergence of new options and strategies gave rise to questions about the cost-effectiveness of different therapeutic approaches, said Pollard.

To estimate cost-effectiveness, investigators used data from randomized phase III clinical trials to establish a decision tree for use of available therapies in metastatic CRPC. Survival data and costs of interventions were incorporated into cost-effectiveness calculations.

On the basis of survival benefits associated with each therapy, Pollard and colleagues developed a model that incorporated a hierarchical therapeutic paradigm of sipuleucel-T (Provenge), followed by abiraterone (Zytiga), docetaxel, enzalutamide (Xtandi), and cabazitaxel (Jevtana). The analysis included a recently reported 78% response rate with sipuleucel-T, said Pollard.

Each treatment strategy evaluated included concurrent administration of leuprolide and denosumab (Xgeva). Cost-effectiveness was compared with the societal willingness-to-pay threshold of $100,000 per life-year saved.

The survival benefit associated with the therapies ranged from 2.4 months with cabazitaxel to 11 months with sipuleucel-T, resulting in a cumulative survival benefit of 23.4 months. Total cost of the individual therapies (including leuprolide and denosumab) was $361,954.

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