Cost-Effectiveness in England of Cabozantinib for Patients with Advanced Renal Cell Carcinoma (ARCC) After Failure of Prior Therapy

OBJECTIVES: The aim of this study was to compare the cost-effectiveness of cabo-zantinib with an appropriate comparator in adult patients with aRCC following prior vascular endothelial growth factor receptor (VEGFR) targeted therapy from an English National Health Service (NHS) perspective. METHODS: A 3-stage, partitioned-survival model was developed to assess the cost-effectiveness of cabozantinib and its comparators. Efficacy (time to discontinuation, progression free survival [PFS], overall survival [OS]) and tolerability (grade 3 and 4 adverse events) data came from the METEOR (NCT01865747, cabozantinib vs everolimus), CheckMate025 (NCT01668784, nivolumab vs everolimus) and AXIS (NCT00678392, axitinib vs sorafenib) trials. An indirect treatment comparison was used to compare cabozantinib and nivolumab. Based on previous analyses, equal efficacy for axitinib and everolimus was assumed. Treatment durations for cabozantinib, everolimus, and nivolumab were modelled through estimating time to treatment discontinuation (TTD), while treatment duration for axitinib was assumed to be equal to PFS. For all efficacy endpoints, fractional polynomial curves were used to estimate outcomes during and beyond the trial period. Utilities were taken from METEOR. Drug prices from British National Formulary were used. RESULTS: In the base case, treatment with cabozantinib was estimated to cost an average of 84,136 GBP per patient while providing them with 2.26 life-years (LY) and 1.78 quality-adjusted life-years (QALY). It resulted in an ICER of 98,967 and 137,450 GBP/QALY compared to axitinib and everolimus, respectively. Cabozantinib was less costly and more effective than nivolumab, with incremental cost -6,742 and QALY gain of 0.18 over 30 years. CONCLUSIONS: The use of cabozantinib represents an efficient option in England versus nivolumab with numerically better efficacy and lower cost. Treatment with cabozantinib was more costly but also more effective than treatment with axitinib or everolimus. These conclusions held true across a range of scenarios and sensitivity analyses, including one-way and probabilistic analyses.