1015 - A Cost-Effectiveness and Health Equity Analysis of Radioligand Therapy for Metastatic Castration-Resistant Prostate Cancer

Purpose/Objective(s):

Radioligand therapy (RLT) with 177Lu-PSMA-617 significantly improves survival in metastatic castration-resistant prostate cancer (mCRPC) but carries a high acquisition cost (>$42,000/dose). Concurrently, African American men with mCRPC face disproportionate mortality rates driven by systemic barriers to care, including logistical complexity (transportation burdens) and adherence gaps associated with daily oral standard of care (SOC). This study aims to evaluate the cost-effectiveness of RLT versus SOC and, uniquely, to quantify its impact on health equity by modeling value in underserved populations.

Materials/Methods:

A probabilistic continuous-time state-transition microsimulation model was developed using R (v4.5.2) to simulate the clinical trajectory of 100,000 hypothetical patients with mCRPC progressing after taxane/ARPI therapy. Transition rates and health state utilities were derived from the Phase III VISION trial and NICE technology appraisals. Costs were assessed from a US health sector perspective using Wholesale Acquisition Costs (WAC) and CMS Physician Fee Schedules. To model health equity, a dedicated "Underserved Cohort" analysis was performed. This scenario adjusted model parameters to reflect real-world barriers reported in literature: (1) a 17% adherence penalty applied to the SOC arm (simulating lower adherence to daily oral oncolytic/frequent infusions in vulnerable populations) and (2) increased indirect costs ($165/visit)¹¹ representing transportation and lost wages. The primary outcome was the Incremental Cost-Effectiveness Ratio (ICER) with a willingness-to-pay (WTP) threshold of $150,000 per QALY.

Results: In the base-case analysis of the general population, RLT provided a mean survival gain of 0.337 QALYs compared to SOC, with an incremental cost of $147,593. This resulted in an ICER of $437,838/QALY, significantly exceeding standard WTP thresholds. In the Underserved Cohort analysis, the value proposition of RLT improved. Due to the "rescue effect" of RLT—where the provider-administered, 6-week dosing schedule bypasses the adherence barriers inherent to daily oral/infusion SOC—the incremental survival benefit widened. Consequently, the ICER for the underserved cohort decreased to $381,225/QALY. A threshold analysis indicated that a price reduction of 48.4% would be required for RLT to achieve cost-effectiveness at the $150,000/QALY benchmark in the general population.

Conclusion: At current list prices, 177Lu-PSMA-617 is not cost-effective by our designated metrics. However, this analysis identifies RLT as an equity-enhancing intervention: it delivers higher relative economic and clinical value to underserved populations by mitigating the logistical toxicities and adherence gaps associated with standard therapies. Alternative payment models are needed to ensure safety-net hospitals can sustain access to this life-prolonging therapy.