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Cost and Cost-Effectiveness of Treating Human Epidermal Growth Factor Receptor 2-Low Metastatic Breast Cancer
James C Dickerson1,2, Marcus T Moen3, Perry Nielsen2
1Department of Medicine (Hematology and Oncology), Stanford University, Stanford, CA.
Purpose:
Creating value-aligned treatment pathways in breast cancer requires understanding the cost and cost-effectiveness of new therapies. To address uncertainty in the optimal treatment sequence, we developed a decision model to assess the cost-effectiveness of various treatment sequences for patients with human epidermal growth factor receptor 2 (HER2)-low metastatic breast cancer who are eligible for trastuzumab deruxtecan (T-DXd) and sacituzumab govitecan (SG) under current US Food and Drug Administration labeling.
Methods:
We derived disease progression and therapy data from the Destiny-Breast04 trial and sourced cost and quality-of-life data from the published literature. Our simulation modeled 57-year-old women with HER2-low, endocrine refractory, and triple-negative metastatic breast cancer eligible for third-line treatment. We evaluated four sequences: chemotherapy (chemo) → chemo, T-DXd → chemo, chemo → T-DXd, and T-DXd → SG. Outcomes included quality-adjusted life years (QALYs), total lifetime costs (2020 US dollars [USD], 3% annual discount), and incremental cost-effectiveness ratios. Sequences that cost <$150,000 USD to gain an additional QALY were considered cost effective.
Results:
Chemo → chemo has the lowest cost at $176,000 (USD) per patient and yields 0.82 QALYs. T-DXd → chemo costs $282,000 (USD) and yields 1.08 QALYs, with an incremental cost-effectiveness ratio of $408,000 (USD) per QALY gained. T-DXd → SG costs $304,000 (USD) and yields 1.09 QALYs, with an incremental cost-effectiveness ratio of $2,200,000 (USD) per QALY gained. Drug cost drives the cost differences between each strategy. For T-DXd → chemo to be cost effective at the $150,000 (USD) per QALY threshold, we estimate that a 41% price reduction for T-DXd is needed.
Conclusion:
At its current price, T-DXd is not cost effective for HER2-low metastatic breast cancer. Price reductions can make this drug cost effective. Optimal value-based sequencing in this patient population uses a single antibody-drug conjugate rather than back-to-back conjugates.
Insights
Trastuzumab deruxtecan (T-DXd) is not cost-effective for HER2-low metastatic breast cancer at its current price. A 41% price reduction for T-DXd could make it cost-effective, favoring single antibody-drug conjugate use.
Area of Science:
- Oncology
- Health Economics
- Pharmacoeconomics
Background:
- Value-based care in oncology requires understanding treatment costs and effectiveness.
- Human epidermal growth factor receptor 2 (HER2)-low metastatic breast cancer presents complex treatment sequencing challenges.
- New therapies like trastuzumab deruxtecan (T-DXd) and sacituzumab govitecan (SG) require cost-effectiveness analysis.
Purpose of the Study:
- To assess the cost-effectiveness of various treatment sequences for HER2-low metastatic breast cancer.
- To model treatment sequences involving T-DXd and SG for eligible patients.
- To inform value-based treatment pathway creation in this patient population.
Main Methods:
- A decision model simulated treatment sequences for a 57-year-old woman with HER2-low, endocrine refractory, triple-negative metastatic breast cancer.
- Data on disease progression, therapy, costs, and quality-of-life were derived from the Destiny-Breast04 trial and literature.
- Four sequences were evaluated: chemotherapy (chemo) → chemo, T-DXd → chemo, chemo → T-DXd, and T-DXd → SG.
Main Results:
- The chemo → chemo sequence was the least expensive ($176,000 USD) with 0.82 quality-adjusted life years (QALYs).
- T-DXd → chemo yielded 1.08 QALYs at $282,000 USD, with an incremental cost-effectiveness ratio (ICER) of $408,000 USD/QALY.
- T-DXd → SG yielded 1.09 QALYs at $304,000 USD, with an ICER of $2,200,000 USD/QALY.
- Drug costs significantly influenced strategy costs; a 41% T-DXd price reduction is needed for cost-effectiveness at $150,000 USD/QALY.
Conclusions:
- Trastuzumab deruxtecan (T-DXd) is not currently cost-effective for HER2-low metastatic breast cancer at its existing price point.
- Price reductions for T-DXd are necessary to achieve cost-effectiveness.
- Optimal value-based sequencing involves using a single antibody-drug conjugate, not sequential administration.
