OBJECTIVES: Cabozantinib has been approved in the EU as first-line treatment for patients with advanced renal cell carcinoma (aRCC) of intermediate or poor risk, based on demonstrating superior progression-free survival (PFS) over sunitinib in the CABOSUN trial. We evaluated the cost-effectiveness of cabozantinib compared with that of sunitinib and pazopanib, the current standard of care first-line treatments for aRCC for the English National Health Service (NHS).

METHODS: A partitioned, three-state (progression-free, post-progression, death) survival model with a 20-year time horizon was used to estimate the proportion of patients in each state and the total costs associated with each treatment. Model inputs included overall survival (OS), PFS, time to treatment discontinuation (TTD) and treatment-emergent adverse events (AEs). For cabozantinib and sunitinib, OS, PFS, TTD and AEs were derived from CABOSUN; for pazopanib, OS, PFS and TTD were assumed to be equal as with sunitinib (based on clinical experience), and AEs were derived from the COMPARZ trial (pazopanib versus sunitinib in aRCC). Efficacy outcomes were estimated by fitting Gompertz (OS) and log-normal (PFS, TTD) distributions. Utility values were based on the sunitinib NICE single technology appraisal. Prices were based on the British National Formulary (including agreed confidential discounts for all treatments) and NHS Reference Costs 2016/2017.

RESULTS: Compared with sunitinib, cabozantinib was associated with an incremental gain of 0.54 QALYs at an incremental cost of £14,735 per patient, corresponding to an incremental cost-effectiveness ratio (ICER) of £27,372/QALY gained. Compared with pazopanib, cabozantinib was associated with an incremental gain of 0.54 QALYs at an incremental cost of £14,012 per patient, corresponding to an ICER of £26,139/QALY gained. ICERs were sensitive to OS distribution and scenario choice.

CONCLUSIONS: According to this model, cabozantinib is a cost-effective (ICER <£30,000/QALY) alternative to sunitinib or pazopanib for the first-line treatment of aRCC of intermediate or poor risk.