Health Services Research
PV QA 3 - Poster Viewing Q&A 3
Purpose/Objective(s): The recent SARAH and SIRveNIB trials showed no statistically significant difference in overall survival (OS) for randomization to selective internal radiotherapy (SIRT) with yttrium-90 resin microspheres versus sorafenib. However, SIRT was better tolerated and associated with significantly higher quality of life than sorafenib. Given the high cost associated with both treatments, we sought to investigate the cost-effectiveness of these two modalities of treatment for locally advanced, inoperable hepatocellular carcinoma (HCC).
Materials/Methods: A multi-state Markov model was constructed to simulate patients allocated to sorafenib versus SIRT for advanced HCC using an intention-to-treat principle. Hazard rates of disease progression and death were based on a pooled analysis of individual patient data generated using extracted Kaplan-Meier coordinates from the SARAH and SIRveNIB trials. Model input parameters for adverse events, treatment adherence, and quality of life utility weights were derived from the trial data. Costs were based on Medicare reimbursement rates. We performed probabilistic sensitivity analysis using bootstrap hazard rates and estimated incremental costs and quality-adjusted life years (QALYs) over a 5-year time horizon. We evaluated sensitivity of results to parameter uncertainty of key model inputs.
Results: Costs were $135,256 vs $90,911 (difference $44,345; 95% CI $29,927 to 60,643) and QALYs were 0.63 vs 0.60 (difference 0.03; 95% CI -0.04 to 0.10) for sorafenib vs SIRT, respectively. The resulting incremental cost-effectiveness ratio (ICER) of sorafenib was $1,479,020 per QALY gained. The likelihood that sorafenib would be cost-effective did not exceed 1%, assuming cost-effectiveness thresholds up to $200k/QALY. If the monthly price of sorafenib decreased from $16,390 to $7,250, the ICER of sorafenib fell below $200k /QALY, and an ICER < $100k/QALY was reached if the monthly price fell below $6,500. Results were robust against modeling the SARAH and SIRveNIB trials separately (Table).
Conclusion: Our analysis suggests that sorafenib is unlikely to provide a gain in quality-adjusted survival compared to SIRT at a cost considered to be cost-effective according to current US societal cost-effectiveness thresholds. Only if the current price decreased by more than 50%, would sorafenib be considered economically attractive.
|Scenario||Cost Sorafenib||Cost SIRT||Δ Cost (95% CI)||QALY Sorafenib||QALY SIRT||Δ QALY (95% CI)||ICER ($/QALY)|
|Base Case (pooled trials)||$135,256||$90,911||$44,345 ($29,927-60,643)||0.63||0.60||0.03 (-0.04-0.10)||1,479,020|
|SARAH trial||$131,603||$90,998||$40,606 ($23,612-58,655)||0.61||0.58||0.04 (-0.06-0.14)||1,097,855|
|SIRveNIB trial||$138,953||$89,401||$49,552 ($30,659-70,836)||0.64||0.61||0.03 (-0.07-0.14)||1,653,381|
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