OBJECTIVES: The treatment of advanced renal cell carcinoma (aRCC) has transformed with the authorization of combination therapies. The CheckMate9ER study demonstrated significantly prolonged progression-free (PFS) and overall survival (OS) for cabozantinib+nivolumab (CaboNivo) compared with sunitinib in first-line therapy. The objective of this analysis was to assess the lifetime efficacy and lifetime costs of CaboNivo compared to other therapies (i.e., sunitinib, lenvatinib+pembrolizumab (LenPem), axitinib+pembrolizumab (AxiPem), and axitinib+avelumab (AxiAve)) in Germany, taking the public payer perspective.

METHODS: A partitioned survival model with three health states was developed to predict life years (LY) and total treatment costs from the beginning of treatment until death. The health states included in the model were: pre-progression, post-progression, and death. A network meta-analyses based on CheckMate9ER and published phase-III studies with fractional polynomial was estimated to compare the efficacy outcomes of CaboNivo vs. other first-line therapies with comparable label. A 3% discount rate was applied for costs and effects. The model encompasses costs for drug acquisition, adverse events (AE), health states and terminal care. The sensitivity analyses tested the robustness regarding variation in key-variables.

RESULTS: Model predictions demonstrated the following total expected lifetime costs: Lowest costs for sunitinib: 41,139€, followed by CaboNivo: 186,409€, LenPem: 213,555€, AxiPem: 217,216€, AxiAve: 237,721€. For combination therapies 80% of lifetime costs were caused by primary intervention. At a lifetime horizon, expected overall LYs and LYs in the pre-progression state were the following: sunitinib: overall LYs 4.0 (pre-progression: 1.3); CaboNivo: 4.9 (2.2), LenPem: 4.8 (2.0), AxiPem: 4.6 (1.9), AxiAve: 4.9 (1.8). Joint discount rates, baseline age and AE costs for CaboNivo were main drivers on the estimation.

CONCLUSIONS: Overall, the costs over a lifetime horizon for first-line aRCC combinations differ. Monotherapy sunitinib was associated with the lowest costs followed by combination therapy CaboNivo, which had the longest time in the pre-progression state and (matching AxiAve) overall LY.