Modeling study of cost-effectiveness of perioperative enfortumab vedotin and pembrolizumab for cisplatin-ineligible bladder cancer

Although cisplatin-based neoadjuvant chemotherapy for patients with localized muscle-invasive bladder cancer (MIBC) is associated with improved survival, nearly half of these patients are ineligible for cisplatin-based chemotherapy and historically proceed to radical cystectomy (RC) without neoadjuvant chemotherapy. Perioperative enfortumab vedotin (EV) plus pembrolizumab with RC is an alternative option, but little is known about its cost-effectiveness compared with RC alone. An economic evaluation developed a decision-analytic Markov model that compared neoadjuvant EV plus pembrolizumab followed by RC and adjuvant EV plus pembrolizumab (intervention arm) versus RC alone (control arm) in 10 000 simulated US patients with cisplatin-ineligible MIBC, over a 10-year time horizon. The model was informed by efficacy and safety data from KEYNOTE-905/EV-303, which had a median follow-up of 25.6 months (range 11.8-53.7). Over 10 years, adding perioperative EV plus pembrolizumab to treatment was associated with increased projected overall survival from 4.12 to 5.63 life-years per patient, quality-adjusted survival from 3.20 to 4.51 QALYs per patient, and total costs from $317 513 to $ 412 160. Perioperative EV plus pembrolizumab with RC achieved an ICER of $ 72 460 per QALY versus RC alone and therefore represented a cost-effective treatment approach. The authors conclude that the findings of this study support the intervention as a clinically valuable and economically reasonable standard treatment for cisplatin-ineligible MIBC.