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Purpose: Our previous study showed that the preventive effects of fosnetupitant (F-NTP) against chemotherapy-induced nausea and vomiting (CINV) were superior to those of fosaprepitant (F-APR) or aprepitant (APR). To evaluate the cost-effectiveness of F-NTP compared with F-APR or APR in Japan, a cost-utility analysis was performed., Methods: A decision tree model was developed based on real-world data to compare the CINV prevention ability of each neurokinin-1 receptor antagonist (NK 1 RA) in Japanese patients receiving cisplatin-based regimens. We evaluated the patients 7 days after the first course of treatment. Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were calculated to examine the cost-effectiveness of the antiemetic therapy. The probabilities of health states and medical costs were derived from the results of our previous study. These cost-utility analyses were performed from the perspective of the payers., Results: The incremental QALYs of F-NTP relative to F-APR and APR were 0.00180 and 0.00153, respectively. The ICER of F-NTP relative to F-APR was 22,802.21 US dollars (USD) per QALY gained, which was lower than the willingness-to-pay (WTP) threshold (38,043.06 USD: 5 million Japanese Yen/QALY). Contrastingly, the ICER of F-NTP relative to APR was 40,119.64 USD/QALY, which was slightly above the WTP threshold, indicating that F-NTP may be slightly less cost-effective., Conclusion: F-NTP is more cost-effective than F-APR, but slightly less cost-effective than APR., Competing Interests: Declarations. Ethics approval: This study was approved by the Ethics Committee of Kitasato University Hospital (Approval No. B22-231) and was conducted in accordance with the principles of the Declaration of Helsinki. Consent to participate and publish: Given that this was a retrospective study, and all data were collected retrospectively from electronic medical records, the requirement for informed consent was waived. However, we also offered participants the opportunity to opt out of the use of their data. Competing interests: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)