Objectives To characterize the costs and outcomes associated with radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (dose-escalated 3-dimensional conformal radiation, intensity-modulated radiation, brachytherapy, or combination), using a comprehensive, lifetime decision analytic model. Patients and Methods A Markov model was constructed to follow hypothetical men with low-, intermediate-, and high-risk prostate cancer over their lifetimes following primary treatment; probabilities of outcomes were based on an exhaustive literature search yielding 232 unique publications. Patients could experience remission, recurrence, salvage treatment, metastasis, death from prostate cancer, and death from other causes. Utilities for each health state were determined, and disutilities were applied for complications and toxicities of treatment. Costs were determined from the U.S. payer perspective, with incorporation of patient costs in a sensitivity analysis. Results Differences in quality-adjusted life years across modalities were modest, ranging from 10.3 to 11.3 for low-risk patients, 9.6 to 10.5 for intermediate-risk patients, and 7.8 to 9.3 for high-risk patients. There were no statistically significant differences among surgical modalities, which tended to be more effective than radiation modalities, with the exception of combination external beam + brachytherapy for high-risk disease. Radiation modalities were consistently more expensive than surgical modalities; costs ranged from $19,901 (robot-assisted prostatectomy for low-risk disease) to $50,276 (combination radiation for high-risk disease). These findings were robust to an extensive set of sensitivity analyses. Conclusions Our analysis found small differences in outcomes and substantial differences in payer and patient costs across treatment alternatives. These findings may inform future policy discussions regarding strategies to improve efficiency of treatment selection for localized prostate cancer.

Background Most HIV-infected persons in the US present to care with advanced disease and many discontinue therapy prematurely. We sought to evaluate gender and racial/ethnic disparities in life-years lost due to risk behavior, late presentation and early discontinuation of HIV care, and to compare these survival losses in HIV-infected persons with losses from high-risk behavior and HIV disease itself. Methods Using a state-transition model of HIV disease, we simulated cohorts of HIV-infected persons and compared them to non-infected individuals with similar demographic characteristics. We estimated non-HIV-related mortality using risk-adjusted standardized mortality ratios as well as years of life lost due to late presentation and early discontinuation of antiretroviral therapy (ART) for HIV infection. Data from the national HIV Research Network, stratified by gender and race/ethnicity, were used for estimating CD4 counts at ART initiation. Results In HIV-uninfected persons in the US with risk profiles similar to those with HIV, the projected life expectancy starting at age 33 was 34.58 years, compared to 42.91 years for the general US population. Those with HIV lost an additional 11.92 years if they received HIV care concordant with guidelines; late treatment initiation resulted in 2.60 additional years of life lost, while premature ART discontinuation led to 0.70 more years of life lost. Losses from late initiation and early discontinuation were greatest for Hispanics (3.90 years). Conclusions The high-risk profile of HIV-infected persons, HIV infection itself, as well as late initiation and early discontinuation of care, all lead to substantial decreases in life expectancy. Survival disparities from late initiation and early discontinuation are most pronounced for Hispanic HIV-infected men and women. Interventions focused on risk behaviors as well as earlier linkage and better retention in care will lead to improved survival of HIV-infected persons in the US.

Genotype-resistance testing of chronically HIV-infected, antiretroviral-naive patients is likely to improve clinical outcomes and is cost-effective, compared with other HIV care in the United States. Resistance testing at the time of diagnosis should be the standard of care.

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