The Health Inequality Impact of Darolutamide for Nonmetastatic Castration-Resistant Prostate Cancer in the United States: A Distributional Cost-Effectiveness Analysis

Objectives Non-Hispanic (NH) Black patients are disproportionally affected by nonmetastatic castration-resistant prostate cancer (nmCRPC). The objective was to quantify the health inequality impact of darolutamide + androgen deprivation therapy (ADT) relative to ADT for nmCRPC in the United States using a distributional cost-effectiveness analysis. Methods With a health economic model, quality-adjusted life years (QALYs) and costs were estimated for NH-White, NH-Black, NH-Asian, and Hispanic patients. Given the lifetime risk of nmCRPC and assuming equally distributed opportunity costs, the incremental net health benefits of darolutamide were calculated, which were used to estimate general population quality-adjusted life expectancy at birth (QALE) by race and ethnicity with and without darolutamide. The extent of QALYs and QALE differences between race and ethnicity subgroups with each strategy was quantified with an inequality index, and their difference defined as the inequality impact of darolutamide. Results Darolutamide + ADT resulted in an additional 1.04 (95% uncertainty interval 0.56-1.51) QALYs per treated patient relative to ADT, with the greatest gain observed among NH-Black patients (1.48 [0.48-2.71]). The relative inequality in QALYs among patients reduced by 66%, from an inequality score of 0.033 (0.004-0.082) with ADT to 0.011 (0.000-0.051) with darolutamide + ADT. Factoring in disease risk and health opportunity costs, nmCRPC treatment with darolutamide resulted in the largest net gain in QALYs among the NH-Black population, thereby having a favorable impact on inequalities in QALE. Conclusions Darolutamide + ADT results in greater and a more even distribution of QALYs than ADT for nmCRPC. The greatest gains among NH-Black individuals implies a favorable health inequality impact with darolutamide.