Presentation (CTI)

OBJECTIVES: Immune checkpoint inhibitors (ICIs) have transformed the treatment landscape for metastatic urothelial carcinoma (mUC), but high acquisition costs raise affordability concerns. Existing economic evaluations report heterogeneous findings due to differences in modeling approaches and regional willingness-to-pay (WTP) thresholds. This study applied the Comparative Efficiency Research (COMER) framework to synthesize the total incremental net benefit (TINB) of ICI-based therapies across treatment settings and healthcare perspectives.
METHODS: A systematic search of electronic databases was conducted from inception to March 12, 2026, to identify full economic evaluations of ICIs in mUC. Cost-effectiveness outcomes were standardized into INBs using the COMER methodology. Study-specific INBs and variances were pooled using inverse-variance weighting to estimate total incremental net benefit (TINB). Random-effects meta-analyses with Hartung-Knapp adjustments were performed for overall and subgroup analyses by treatment strategy and clinical setting.
RESULTS: Forty-three studies were included across first-line (1L), second-line (2L), maintenance, and adjuvant settings. For ICI monotherapy versus control, the TINB was 105,250 (95% CI: 29,100-181,400), indicating overall cost-effectiveness. Adjuvant nivolumab demonstrated favourable economic value with a TINB of 407,000 (95% CI: 28,060-785,950), whereas 1L, 2L, and maintenance monotherapies showed uncertain cost-effectiveness. In contrast, ICI plus platinum-based chemotherapy versus control produced a negative TINB of −58,780 (95% CI: −95,650 to −21,910). Pembrolizumab plus enfortumab vedotin versus control also showed unfavourable economic value with a TINB of −372,270 (95% CI: −558,480 to −186,050).
CONCLUSIONS: ICI monotherapy, particularly in the adjuvant setting, appears cost-effective in mUC, whereas first-line combination regimens remain economically unfavourable at standard WTP thresholds. Strategic pricing and value-based reimbursement strategies are needed to improve the affordability of advanced combination therapies.