Cost-Effectiveness of Circulating Tumor DNA-Guided Adjuvant Atezolizumab in Muscle-Invasive Bladder Cancer Based on IMvigor011 Trial.

Abstract

The optimal adjuvant treatment approach for muscle-invasive bladder cancer (MIBC) remains unsettled. The IMvigor011 trial demonstrated that circulating tumor DNA (ctDNA)-guided adjuvant atezolizumab improves outcomes and advances precision oncology in this setting. However, the socioeconomic value of this biomarker-driven strategy is unclear. We therefore assessed the economic value of ctDNA-guided therapy in this postoperative setting. We constructed a three-state Markov model to estimate costs, quality-adjusted life-years (QALYs), incremental net monetary benefit (INMB), and incremental cost-effectiveness ratios (ICERs) in patients with MIBC. The model compared a ctDNA-guided adjuvant atezolizumab strategy with the standard of care (SOC) from a US health care payer perspective. Cost-effectiveness was assessed across willingness-to-pay (WTP) thresholds of $50,000-$150,000 in US dollars (USD) per QALY, and model robustness was examined through comprehensive sensitivity analyses. Over a 5-year horizon, the ctDNA-guided strategy yielded 3.05 QALYs at a cost of $78,796 USD, compared with 2.92 QALYs and $131,601 USD for SOC. This corresponded to an ICER of -$397,163 USD per QALY gained, demonstrating dominance through greater benefit at lower cost. Sensitivity analyses confirmed that the ctDNA-guided approach was consistently cost-effective across all WTP thresholds. ctDNA-guided atezolizumab adjuvant therapy proves to be a cost-effective strategy for MIBC, optimizing health care resource allocation and reducing overtreatment while improving patient outcomes. More standardized ctDNA testing protocols and transparent reporting of ctDNA status distributions are essential.