(UroToday.com) The 2022 Advanced Prostate Cancer Consensus Conference (APCCC) Hybrid Meeting included a session on the management of metastatic hormone sensitive prostate cancer (mHSPC) and a presentation by Dr. Caroline S. Clarke discussing the optimal treatment for mHSPC from a health economics standpoint. Dr. Clarke started by providing information with regard to the purpose and context of health economics. These types of analyses provide evidence for decision makers, helping decide how to best use limited resources (ie. time and money), given that health care resources are always finite. Importantly, new treatment may get approved if extra benefit balances the extra cost of therapy, which then allows a particular treatment to be offered to all eligible patients.
Dr. Clarke notes that in a perfectly competitive market, the allocation of goods and services is left to market forces, leading to fair prices. However, the issue in medicine is that market allocation of health care fails. As such, the provision of health care is not left entirely to the market (ie. orphan drug status), whereby the information on ‘value for money’ is missing and must be generated. Economic evaluation is the technique used to generate this specific information, which is defined as the comparative analysis of alternative courses of action in terms of both their costs and their consequences. A schematic of this assessment is as follows:
An important metric of interest in any economic analysis is the incremental cost-effectiveness ratio (ICER) defined as follows:
Quality-Adjusted Life-Years (QALYs) is another important metric and is equal to the area under the curve and is definite as 1 year lived in perfect health. However, 1 QALY may also be 2 years lived in half perfect health, or 0.5 years lived in perfect health by 2 people. Dr. Clarke emphasized that quality of life is easiest measured using the EQ-5D-5L questionnaire, given that it is short, easy to complete, is already included in some trials, and can be included in routine follow-up appointments. An example of the EQ-5D-5L questionnaire is as follows:
Dr. Clarke notes that evidence for decision-makers is provided by the cost-effectiveness plane (new versus old), as highlighted in the following figure demonstrating the intersection between differences in costs and differences in QALYs:
Dr. Clarke then discussed a case study regarding an abiraterone price scenario analysis based on STAMPEDE cost-utility analysis, as well as based on costs in England. Overall, abiraterone + ADT was not cost effective compared to ADT alone (ICERs were too high), however the actual price paid for abiraterone by the NHS was not known and was assumed to be £98/day. In a scenario analysis, abiraterone + prednisolone could be cost effective if (i) in M0 abiraterone was priced below £28/day and (ii) in M1 abiraterone was priced below £62/day. Furthermore, abiraterone + prednisolone could dominate ADT in the M0 subgroup (ie. be cheaper and better) with the price below £11/day. A summary of this scenario analysis is as follows:
The goal of health economics is to improve patient care. Aspects of dose-response/pharmacokinetics may lead to over/under-treatment; specific to abiraterone, lower doses with food provides similar outcomes in advanced prostate cancer. Another example in advanced kidney cancer is the use of reduced frequency of nivolumab therapy providing similar outcomes of efficacy. Importantly, trials investigating reduced dose could be funded by future drug cost savings.
Dr. Clarke concluded her presentation of health economics for the optimal treatment of mHSPC with the following summary points:
- Health care resources are always limited and an economic evaluation helps to use them wisely, using transparent analyses
- Routine collection of EQ-5D-5L data is helpful, particularly among patients that progress during a clinical trial
- Over-treatment can be a problem, and more studies are required to identify where this occurs. Health economics can help drive funding for these studies to improve patient care
Presented By: Caroline S. Clarke, PhD, MSci, BA (Hons), Senior Research Associate in Health Economics, University College London, London, UK
Written By: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2022 Advanced Prostate Cancer Consensus Conference (APCCC) Annual Hybrid Meeting, Lugano, Switzerland, Thurs, Apr 28 – Sat, Apr 30, 2022.