Table 3.

Summary of Health Technology Assessments (HTAs) of radium-223 (Xofigo®) used in castration-resistant prostate cancer. (ICER = incremental cost-effectiveness ratio, QALY = quality adjusted life years, ALSYMPCA = pivotal phase III trial of radium-223)

Reference	Institution	Conclusions
NCPE, 2014.	National Centre for Pharmaco-economics (NCPE), Ireland.	Following the assessment of the company submission, the NCPE considers that the cost-effectiveness of radium-223 has not been demonstrated. Reimbursement is not recommended. ICER €79,948.
Ludwig Boltzmann Institute for Health Technology Assessment, 2014.	Ludwig Boltzmann Institute for Health Technology Assessment.	No ultimate statement can be made because radium-223 was not examined in combination with a valid comparator. Furthermore, the risk of secondary malignancies, contamination from body fluids for medical staff and family members as well as the optimal dose of radium-223 need to be examined. Cost for radium-223 was $69,000-$82,800 (€52,600-67,900) in a six-month course of treatment.
NICE, 2014.	National Institute for Health and Care Excellence	Base case ICER for radium-223 compared with best supportive care (BSC) was £55,500 (€70,800) per QALY. Concerns around the time horizon, utilities and costs would be likely to increase the ICER further. It was not possible to determine whether radium-223 could be considered a cost-effective use of NHS resources, because the appropriate comparison with docetaxel and abiraterone acetate had not been presented. Based on the comparison with BSC, radium-223 could not be considered a cost-effective use of NHS resources.
IQWIG, 2013.	German Institute for Quality and Efficiency in Health Care (IQWiG).	Radium-223 in prostate cancer: Major added benefit for certain patients. In comparison with best supportive care (BSC): Patients survive longer and get bone symptoms later/no evaluable data in comparison with docetaxel. Depending on the patients’ age (</> 65 yrs) and the concomitant treatment (with/without bisphosphonates), there is an indication of major and an indication of minor added benefit of radium-223 compared with BSC.
Aberdeen HTA-group, 2013.	Aberdeen HTA group. National Institute of Health Research (NIHR)	The evidence is weaker to support the use of radium-223 for first line use as the 1st line patient population in ALSYMPCA is highly selective and radium-223 has not been compared against all valid comparators. Abiraterone acetate should be evaluated as a comparator. It is difficult to conclude whether the submission contains an unbiased estimate of the cost effectiveness of radium-223 dichloride. The exclusion of patients with visceral metastatic disease could be problematic for generalizing results to the wider treatment population. Results are particularly sensitive to the time horizon. The analysis of the EQ-5D quality of life data is limited.
Swedish National Board for Health and Welfare, 2014.	Swedish National Board for Health and Welfare.	They conclude radium-223 offers a gain of 0.20 QALY compared to BSC. The cost/QALY was indicated SEK 905,000,- (€94,000). A sensitivity analysis indicated a range between SEK 492,000–2,203,000 (€51,000-229,000).