Cost-Effectiveness Analysis of ¹⁷⁷ Lu-PSMA-617 Versus Cabazitaxel in Metastatic Castration-Resistant Prostate Cancer from a U.S. Health Care Perspective

The TheraP trial demonstrated that ¹⁷⁷Lu-PSMA-617 improved progression-free survival (PFS) compared with cabazitaxel, with no significant difference in overall survival (OS). However, ¹⁷⁷Lu-PSMA-617 was associated with fewer severe adverse events, better patient-reported outcomes, and lower health care utilization rates. In this study, we evaluated the impact of these benefits on the cost-effectiveness of ¹⁷⁷Lu-PSMA-617 versus cabazitaxel from a U.S. health care perspective. Methods: A partitioned survival model was developed to estimate lifetime costs and health outcomes associated with ¹⁷⁷Lu-PSMA-617 versus cabazitaxel over a 60-mo horizon. OS and PFS associated with¹⁷⁷Lu-PSMA-617 were derived from a retrospective cohort, and relative treatment effects (hazard ratios [HRs]) from the TheraP trial were applied to generate outcomes for patients treated with cabazitaxel. Health state utilities, adverse-event disutilities, and costs were obtained from published sources. Outcomes included total costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio, and net monetary benefit at willingness-to-pay (WTP) thresholds up to $200,000/QALY. Results: In the base case analysis, ¹⁷⁷Lu-PSMA-617 was not cost-effective compared with cabazitaxel (incremental cost-effectiveness ratio, $358,990/QALY). Cost-effectiveness results were most sensitive to the OS HR, the per-cycle cost of ¹⁷⁷Lu-PSMA-617, and the per-cycle cost of cabazitaxel. ¹⁷⁷Lu-PSMA-617 would become cost-effective if the per-cycle treatment cost was $27,656 or if the OS HR improved to 0.76 at a WTP threshold of $200,000/QALY. Probabilistic analyses found that ¹⁷⁷Lu-PSMA-617 was cost-effective in 19.7% of iterations at a WTP threshold of $200,000/QALY, 4.7% at $100,000/QALY, and 2.2% at $50,000/QALY. Conclusion: Although ¹⁷⁷Lu-PSMA-617 was not cost-effective compared with cabazitaxel in the base case analysis, it may achieve cost-effectiveness under more favorable assumptions of survival benefit or reduced cost per cycle. Probabilistic analyses further highlighted substantial uncertainty, with a low likelihood of cost-effectiveness.