Treatments for endocrine-refractory or triple-negative metastatic breast cancer (mBC) are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative mBC.

Using three dynamic microsimulation models of 10,000 patients each, three cohorts were simulated, based upon prior chemotherapy exposure: (1) unexposed to either taxane or anthracycline, (2) taxane- and anthracycline-exposed, and (3) taxane-exposed/anthracycline-naive. We focused on the following single-agent chemotherapy regimens as reasonable and commonly used options in the first three lines of therapy for each cohort, based upon feedback from oncologists treating endocrine-refractory or triple-negative mBC: (1) for taxane- and anthracycline-unexposed patients, paclitaxel, capecitabine (CAPE), or pegylated liposomal doxorubicin; (2) for taxane- and anthracycline-exposed patients, Eribulin, CAPE, or carboplatin; and (3) for taxane-exposed/anthracycline-naive patients, pegylated liposomal doxorubicin, CAPE, or Eribulin.

In each cohort, accumulated quality-adjusted life-years were similar between regimens, but total societal costs varied considerably. Sequences beginning first-line treatment with paclitaxel, carboplatin, and CAPE, respectively, for cohorts 1, 2, and 3, had lower costs and similar or slightly better outcomes compared with alternative options.

In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.

CONTEXT

Key Objective

To estimate cost-effectiveness of therapeutic alternatives in first- to third-line systemic treatment sequences among three cohorts of patients with endocrine-refractory or triple-negative metastatic breast cancer (mBC), based upon prior chemotherapy exposure: (1) those unexposed to either taxane or anthracycline, (2) those taxane- and anthracycline-exposed, and (3) those taxane-exposed/anthracycline-naive.

Knowledge Generated

In the mBC setting—where multiple therapeutic options are recommended by guidelines and share similar survival and adverse event trajectories—large incremental differences in costs are not associated with better outcomes at the population level.

Relevance

Given the substantial cost burden associated with mBC, treatment sequencing approaches that minimize costs early may lead to higher-value care.

Supported by the Centers for Disease Control and Prevention through the Prevention Research Centers Program (5-U48-DP005017-04-01, PIs: J.G.T. and S.B.W.).

Conception and design: Stephanie B. Wheeler, Jason Rotter, Anagha Gogate, Katherine E. Reeder-Hayes, Temeika Fairley, Justin G. Trogdon

Financial support: Sarah Drier

Administrative support: Sarah Drier

Collection and assembly of data: Stephanie B. Wheeler, Anagha Gogate, Katherine E. Reeder-Hayes, Sarah Drier

Data analysis and interpretation: Stephanie B. Wheeler, Jason Rotter, Anagha Gogate, Katherine E. Reeder-Hayes, Donatus U. Ekwueme, Gabrielle Rocque

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Cost-Effectiveness of Pharmacologic Treatment Options for Women With Endocrine-Refractory or Triple-Negative Metastatic Breast Cancer

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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Stephanie B. Wheeler

This author is an Associate Editor for Journal of Clinical Oncology. Journal policy recused the author from having any role in the peer review of this manuscript.

Research Funding: Pfizer (Inst)

Travel, Accommodations, Expenses: Pfizer

Anagha Gogate

Employment: Bristol Myers Squibb/Celgene

Stock and Other Ownership Interests: Bristol Myers Squibb/Celgene

Katherine E. Reeder-Hayes

Research Funding: Pfizer (Inst)

Gabrielle Rocque

Consulting or Advisory Role: Pfizer, Flatiron Health, Gilead Sciences

Research Funding: Carevive Systems, Genentech, Pfizer

No other potential conflicts of interest were reported.