A Cost–Utility Analysis of Atezolizumab in the Second-Line Treatment of Patients with Metastatic Bladder Cancer

Background: Despite initial promising results, the IMvigor211 clinical trial failed to demonstrate an overall survival (OS) benefit for atezolizumab compared with chemotherapy as second-line treatment for metastatic bladder cancer (mBC). However, given lessened adverse events (AES) and preserved quality of life (QOL) with atezolizumab, there might still be investment value. To evaluate that potential value, we conducted a cost–utility analysis (CUA) of atezolizumab compared with chemotherapy from the perspective of the Canadian health care payer. Methods: A partitioned survival model was used to evaluate atezolizumab compared with chemotherapy over a lifetime horizon (5 years). The base-case analysis was conducted for the intention-to-treat (ITT) population, with additional scenario analyses for subgroups by IMvigor-defined PD-L1 status. Health outcomes were evaluated through life–year gains and quality-adjusted life–years (QALYS). Cost estimates in 2018 Canadian dollars for systemic treatment, AES, and end-of-life care were incorporated. The incremental cost-effectiveness ratio (ICER) was used to compare treatment strategies. Parameter and model uncertainty were assessed through sensitivity and scenario analyses. Per Canadian guidelines, cost and effectiveness were discounted at 1.5%. Results: For the ITT population, the expected qalys for atezolizumab and chemotherapy were 0.75 and 0.56, with expected costs of $90,290 and $8,466 respectively. The resultant ICER for atezolizumab compared with chemotherapy was $430,652 per QALY. Scenario analysis of patients with PD-L1 expression levels of 5% or greater led to a lower ICER ($334,387 per QALY). Scenario analysis of observed compared with expected benefits demonstrated a higher icer, with a shorter time horizon ($928,950 per QALY). Conclusions: Despite lessened aes and preserved QOL, atezolizumab is not considered cost-effective for the second-line treatment of mbc.