Cost‐effectiveness of neoadjuvant FOLFIRINOX versus gemcitabine plus nab‐paclitaxel in borderline resectable/locally advanced pancreatic cancer patients

BACKGROUND: The 2020 National Comprehensive Cancer Network guidelines recommend neoadjuvant FOLFIRINOX or neoadjuvant gemcitabine plus nab‐paclitaxel (G‐nP) for borderline resectable/locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC). AIM: The purpose of our study was to compare treatment outcomes, toxicity profiles, costs, and quality‐of‐life measures between these two treatments to further inform clinical decision‐making. METHODS AND RESULTS: We developed a decision‐analytic mathematical model to compare the total cost and health outcomes of neoadjuvant FOLFIRINOX against G‐nP over 12 years. The model inputs were estimated using clinical trial data and published literature. The primary endpoint was incremental cost‐effectiveness ratios (ICERs) with a willingness‐to‐pay threshold of $100 000 per quality‐adjusted‐life‐year (QALY). Secondary endpoints included overall (OS) and progression‐free survival (PFS), total cost of care, QALYs, PDAC resection rate, and monthly treatment‐related adverse events (TRAE) costs (USD). FOLFIRINOX was the cost‐effective strategy, with an ICER of $60856.47 per QALY when compared to G‐nP. G‐nP had an ICER of $44639.71 per QALY when compared to natural history. For clinical outcomes, more patients underwent an “R0” resection with FOLFIRINOX compared to G‐nP (84.9 vs. 81.0%), but FOLFIRINOX had higher TRAE costs than G‐nP ($10905.19 vs. $4894.11). A one‐way sensitivity analysis found that the ICER of FOLFIRINOX exceeded the threshold when TRAE costs were higher or PDAC recurrence rates were lower. CONCLUSION: Our modeling analysis suggests that FOLFIRNOX is the cost‐effective treatment compared to G‐nP for BR/LA PDAC despite having a higher cost of total care due to TRAE costs. Trial data with sufficient follow‐up are needed to confirm our findings.