Background: For advanced pancreatic cancer, there are new treatment options that are more effective than gemcitabine alone (G). In this analysis we utilized data from a recently published Bayesian network meta-analysis (NMA) to assess the cost effectiveness of G, G+5-fluorouracil (GF), G+capecitabine (GCap), G+cisplatin (GCisp), G+oxaliplatin, G+erlotinib, G+nab-paclitaxel (GnP) and FOLFIRINOX from a Canadian health care perspective. Methods: Analysis was conducted through a three-state Markov model which follows a cohort of patients with advanced pancreatic cancer until death. Analysis used data on the progression of disease with treatment from the G arms of RCTs combined with estimates from the NMA of the effect of the newer regimens on disease progression and adverse events. Estimates of heath care costs were obtained from local providers and utilities were derived from the literature. The Markov model estimated the effect of treatment regimens on costs and quality adjusted life years (QALYs) discounted at 5% per annum. Detailed sensitivity analyses were conducted. Results: If a decision maker was willing to pay between $15,259 and $182,723 for a QALY, GF would be the optimal treatment regimen. For a willingness to pay of greater than $182,723, FOLFIRINOX would be optimal. Based on a willingness to pay for a QALY of $50,000, the price of oxaliplatin would need to be reduced by 83.4% for FOLFIRINOX to be optimal, whilst the price of nab-paclitaxel would need to be reduced by 93.1% for GnP to be optimal. At this threshold, the probability that GF is optimal is 52.7%, compared to 26.8% for GCisp, 19.0% for GCap and 1.6% for G and 0% for all other treatment regimens. Conclusions: At the current time with current drug prices and from the Canadian health care perspective, GF is the optimal treatment regimen based on the criteria of cost effectiveness. The acquisition costs of oxaliplatin is expected to decrease significantly once generic, and may make FOLFIRINOX more cost effective in advanced pancreatic cancer. GnP does not appear to be cost-effective regardless of willingness to pay threshold with its current pricing.