Objective: Erythropoiesis-stimulating agents (ESAs) are an option for the treatment of chemotherapy-induced anemia (CIA). The primary objective was to assess published cost-effectiveness analyses using ESAs as standard care (SC) for the treatment of CIA in non-myeloid cancer.

Method: A targeted literature review for studies reporting economic evaluations was conducted (July 2020, updated in 2021) using bibliographic databases, health technology assessment reports/regulatory agency websites, and systematic review reference checking. Two reviewers independently assessed studies for inclusion; data from eligible studies were extracted and reviewed. Risk of bias was evaluated using the 36-point Drummond and Jefferson criteria.

Results: Data from nine cost-utility studies were included (three from the UK, one each from the USA, Canada, Thailand, France, Sweden, and one unconfirmed location) comparing ESAs (epoetin-alfa, -beta, -zeta or darbepoetin alfa, supplemented with blood transfusions as necessary) with blood transfusions with no ESAs/placebo, as SC for CIA. Considerable study heterogeneity existed: model structures included decision tree (n=2), Markov (n=3), or cost integration with trial data/medical records (n=5); time horizons ranged from 15 weeks to lifetime; seven studies included a heterogenous cancer population, while two studies included breast cancer only; and various methods were used to assess health-related quality of life (HRQoL). All studies included scenario analyses, seven including univariate or probabilistic sensitivity analyses. Against blood transfusions alone as SC, three studies estimated incremental cost-effectiveness ratios around or below the country’s accepted cost-effectiveness threshold, one study estimated ESAs to be 23% more cost-effective, and five studies concluded that ESAs were not cost-effective. Limitations included assumptions around hemoglobin normalization and a lack of robust evidence for estimating survival benefit and HRQoL.

Conclusion: Evidence for the cost-effectiveness of ESAs as SC for the treatment of CIA is mixed and therefore inconclusive. Future research should focus on the survival benefits associated with anemia treatments in cancer patients.