OBJECTIVES: Metastatic renal cell carcinoma (mRCC) is one of the most common adult malignancies. Overall survival (OS) without treatment ranges from 6 to 12 months and in Ecuador, 269 patients were estimated in 2008 with mRCC. The aim of this study was to assess the cost-effectiveness of first-line therapies for patients with mRCC from the payer’s perspective over five years. METHODS: Cost–effectiveness and cost-utility analyses were developed using a Markov model to compare within a six-week cycle: sunitinib (50mg/day, four weeks treatment and two week off) vs. sorafenib (800mg/day) and bevacizumab (10mg/kg bi-weekly) + IFN (9MU every 3 weeks). Model contains 5 health states (first-line treatment-no progression-, second-line treatment, palliative care, death due to mRCC and death due to other causes). It simulates overall costs, progression free-years (PFY), life years gained (LYG) and Quality Adjusted Life Years (QALYs) gained. Transition probabilities/utilities were obtained from previous published trials. Resource use and costs data was obtained from National Ecuadorian Health Formulary (Minister of Health 2012) which includes costs data from MoH Centers, IESS, Military Hospital and Police Hospital). Official Epi data from the Ecuadorian Institute of Social Security (IESS), Globocan, SOLCA, and other local institutions were considered. Both costs and effectiveness were discounted using a 5% annual rate. RESULTS: First-line treatment with sunitinib showed the highest PFY, LYG and QALYs (1.27; 2.35; 1.56 years, respectively) followed by bevacizumab+IFN- (1.11; 2.22; 1.45 years) and sorafenib (0.81; 2.26; 1.43 years). Expected healthcare costs related to sunitinib resulted lower: US$72,599 vs. US$111,286 for sorafenib and US$ 192,208 for bevacizumab+IFN. Other costs related with therapy administration, caregivers and adverse events were also lower with sunitinib. Probabilistic sensitivity analyses showed robustness of these results CONCLUSIONS: Sunitinib is cost–saving among the new agents for patients with mRCC, achieving higher clinical outcomes and lower costs in Ecuador.