Docetaxel Plus ADT Most Cost-Effective Treatment in Some Prostate Cancers

Docetaxel added to androgen deprivation therapy (ADT) was the most cost-effective first-line regimen for patients with homologous recombination repair–altered metastatic hormone-sensitive prostate cancer, according to findings from a cost-effectiveness analysis presented at the ASCO Genitourinary Cancers Symposium.

Although Akeega (niraparib plus abiraterone acetate)/prednisone plus abiraterone acetate and prednisone combined with ADT demonstrated increased radiographic progression-free survival in this population, its current pricing limited cost-effectiveness relative to established treatment intensification strategies.

Across 8 evaluated strategies, lifetime costs ranged from $41,287 with ADT alone to $729,270 with Nubeqa (darolutamide) plus docetaxel and ADT. Quality-adjusted life-years ranged from 3.25 to 4.29. Among non-dominated strategies, docetaxel plus ADT produced an incremental cost-effectiveness ratio of $35,505 per quality-adjusted life-year gained versus ADT alone.

Abiraterone acetate and prednisone plus ADT yielded an incremental cost-effectiveness ratio of $189,589 per quality-adjusted life-year, approaching the upper bound of commonly cited United States willingness-to-pay thresholds of $150,000 to $200,000 per quality-adjusted life-year.

In contrast, Akeega plus abiraterone acetate and prednisone plus ADT was associated with higher costs and lower effectiveness than alternative regimens, meeting criteria for dominance. Similarly, Xtandi (enzalutamide) plus ADT, Xtandi plus docetaxel and ADT, Erleada (apalutamide) plus ADT and Nubeqa plus docetaxel and ADT were either absolutely or extendedly dominated in the base-case analysis.

“From a United States public-payer perspective, docetaxel plus ADT was consistently cost-effective across conventional willingness-to-pay thresholds,” investigators reported in a poster presentation at the conference.

Cost-effectiveness outcomes across 8 regimens

Using a partitioned-survival model with monthly cycles over a lifetime horizon, investigators evaluated ADT alone and 7 treatment intensification strategies in homologous recombination repair–altered metastatic hormone-sensitive prostate cancer. Health states included progression-free survival, post-progression and death. Clinical inputs for overall survival and progression-free survival were derived from published survival curves and costs were estimated in 2025 United States dollars.

Among all strategies, ADT alone had the lowest lifetime cost at $41,287 and generated 3.25 quality-adjusted life-years. The addition of docetaxel increased lifetime cost to $60,334 and improved effectiveness to 3.79 quality-adjusted life-years, producing an incremental cost-effectiveness ratio of $35,505 per quality-adjusted life-year versus ADT alone.

Abiraterone acetate and prednisone plus ADT increased effectiveness to 3.83 quality-adjusted life-years at a lifetime cost of $67,585, resulting in an incremental cost-effectiveness ratio of $189,589 per quality-adjusted life-year compared with the next least costly non-dominated strategy.

Although Nubeqa plus docetaxel and ADT achieved the highest projected lifetime quality-adjusted life-years at 4.29, its incremental cost was substantial, resulting in an incremental cost-effectiveness ratio of $1,432,592 per quality-adjusted life-year, exceeding accepted willingness-to-pay thresholds.

Akeega plus abiraterone acetate and prednisone plus ADT resulted in 3.45 quality-adjusted life-years at a cost of $116,712 and was more costly and less effective than alternative regimens, qualifying as absolutely dominated. Xtandi plus ADT, Xtandi plus docetaxel and ADT and Erleada plus ADT were also more costly and less effective than competing strategies or were subject to extended dominance.

Background on the AMPLITUDE trial

The analysis was motivated by efficacy findings from the phase 3 AMPLITUDE trial, which demonstrated improved radiographic progression-free survival with the addition of niraparib to abiraterone acetate and prednisone and ADT in patients with homologous recombination repair–deficient metastatic hormone-sensitive prostate cancer.

Investigative design and assumptions

The cost-effectiveness model adopted a United States public-payer perspective. Outcomes included total costs and quality-adjusted life-years over a lifetime horizon. Drug acquisition costs were derived from 2025 Federal Supply Schedule pricing. Administration, subsequent therapy, side effect management costs and health state utilities were obtained from published literature.

Incremental cost-effectiveness ratios were estimated at willingness-to-pay thresholds of $150,000 to $200,000 per quality-adjusted life-year. Deterministic and probabilistic sensitivity analyses were conducted to evaluate parameter uncertainty.

For comparators lacking homologous recombination repair–stratified progression-free survival data, investigators assumed that 25% of the metastatic hormone-sensitive prostate cancer population harbored a homologous recombination repair alteration.

Homologous recombination repair–specific progression-free survival estimates were generated using time-varying hazard multipliers calibrated to match intention-to-treat survival curves. Overall survival inputs were based on intention-to-treat populations.

Across approximately 9,027 modeled patients, lifetime quality-adjusted life-years ranged from 3.25 to 4.29, reflecting incremental gains with more intensive regimens at the expense of substantial cost increases.

Sensitivity analyses and economic drivers

One-way sensitivity analyses identified drug acquisition costs and overall survival parameters as the primary drivers of incremental net monetary benefit. Probabilistic sensitivity analyses confirmed robustness of the base-case findings, with no change in the preferred strategy across plausible parameter ranges at conventional willingness-to-pay thresholds.

At lower willingness-to-pay thresholds, ADT alone was favored due to minimal cost. As thresholds increased, docetaxel plus ADT consistently emerged as the preferred cost-effective strategy. Abiraterone acetate and prednisone plus ADT became more favorable only at higher willingness-to-pay thresholds approaching $200,000 per quality-adjusted life-year.

Akeega plus abiraterone acetate and prednisone did not achieve cost-effectiveness under current pricing assumptions. Investigators noted that niraparib pricing was derived from its metastatic castration-resistant prostate cancer indication, which may not reflect potential adjustments in earlier disease settings.

Importantly, investigators emphasized that the analysis describes relative economic profiles rather than direct head-to-head clinical comparisons. Treatment decisions should continue to integrate efficacy, toxicity, patient comorbidities, biomarker status and patient preference.

References

1. “Cost-Effectiveness of Eight First-line Regimens for Metastatic Hormone-Sensitive Prostate Cancer (mHSPC) in HRR-Altered Patients, Including Niraparib + Abiraterone Acetate/Prednisone,” by Dr. Manish Kohli, et al. The Journal of Clinical Oncology.