Cost Effectiveness of Treatment Sequences in Advanced Renal Cell Carcinoma

This is the first comprehensive cost-effectiveness analysis of the five current National Comprehensive Cancer Network (NCCN)-recommended first-line therapies with appropriate second-line therapy for metastatic renal cell cancer (mRCC) in patient cohorts with International mRCC Database Consortium favorable and intermediate/poor risk. This detailed Markov model with one-way and probabilistic sensitivity analyses highlights the most cost-effective options across the different first- and second-line therapy sequences for mRCC endorsed by the European Association of Urology, European Society for Medical Oncology, and NCCN guidelines. The treatment landscape for metastatic renal cell carcinoma (mRCC) has significantly evolved in recent years. Without direct comparator trials, factors such as cost effectiveness (CE) are important to guide decision-making. To assess the CE of guideline-recommended approved first- and second-line treatment regimens. A comprehensive Markov model was developed to analyze the CE of the five current National Comprehensive Cancer Network–recommended first-line therapies with appropriate second-line therapy for patient cohorts with International Metastatic RCC Database Consortium favorable and intermediate/poor risk. Life years, quality-adjusted life years (QALYs), and total accumulated costs were estimated using a willingness-to-pay threshold of $150 000 per QALY. One-way and probabilistic sensitivity analyses were performed. In patients with favorable risk, pembrolizumab + lenvatinib followed by cabozantinib added $32 935 in costs and yielded 0.28 QALYs, resulting in an incremental CE ratio (ICER) of $117 625 per QALY in comparison to pembrolizumab + axitinib followed by cabozantinib. In patients with intermediate/poor risk, nivolumab + ipilimumab followed by cabozantinib added $2252 in costs and yielded 0.60 QALYs compared to cabozantinib followed by nivolumab, yielding an ICER of $4184. Limitations include differences in median follow-up duration between treatments. Pembrolizumab + lenvatinib followed by cabozantinib, and pembrolizumab + axitinib followed by cabozantinib were cost-effective treatment sequences for patients with favorable-risk mRCC. Nivolumab +ipilimumab followed by cabozantinib was the most cost-effective treatment sequence for patients with intermediate-/poor-risk mRCC, dominating all preferred treatments. Because new treatments for kidney cancer have not been compared head to head, comparison of their cost and eff