Cost-effectiveness comparison between neoadjuvant chemohormonal therapy and extended pelvic lymph node dissection in high-risk prostate cancer patients treated with radical prostatectomy: a multi-institutional analysis

Abstract

The aim of the present study was to assess the cost-effectiveness of extended pelvic lymph node dissection (ePLND) compared to neoadjuvant chemohormonal therapy using gonadotropin-releasing hormone agonist/antagonist and estramustine. We retrospectively analyzed data within Michinoku Urological Cancer Study Group database containing 2971 PC patients treated with radical prostatectomy (RP) at four institutes between July 1996 and July 2017. We identified 237 and 403 high-risk patients who underwent RP and ePLND (ePLND group), and neoadjuvant chemohormonal therapy followed by RP and limited PLND (neoadjuvant group), respectively. The oncological outcomes and cost-effectiveness were compared between groups. Medical cost calculation focused on PC-related medication and adjuvant radiotherapy. Biochemical recurrence-free and overall survival rates in the neoadjuvant group were significantly higher than those in the ePLND group. Significantly higher number of patients progressed to castration-resistant PC in the ePLND group than in the neoadjuvant group. Background-adjusted multivariate Cox regression analysis using inverse probability of treatment weighting (IPTW) revealed that neoadjuvant chemohormonal therapy independently reduced the risk of biochemical recurrence after RP. The 5-year cost per person was significantly higher in the ePLND group than in the neoadjuvant group. Although the present study was retrospective, neoadjuvant chemohormonal therapy followed by RP as a concurrent strategy has potential to improve oncological outcome and cost-effectiveness.

Economic Evaluation of Neoadjuvant Versus Adjuvant Chemotherapy in Cancer Treatment: A Systematic Review and Meta-Analysis

“…For high-risk patients (IV, age ≥ 75 years, comorbidity) with ovarian cancer, NAC was cost-effective with higher QALY and similar cost, with the opposite result for patients who are not high risk. 28 In prostate cancer, 34 NAC was the dominant strategy in high-risk patients (clinical stage T2c or T3, initial prostatespeci c antigen levels ≥ 20 ng/mL, biopsy Gleason score (GS) ≥ 8 according to the D'Amico risk strati cation system). 40 Patient numbers at various stages (Table S 4 in the Supplement), revealed NAC as dominant among majority of patients at stage IV.…”

“…study retrospectively analyzed the cost-effectiveness of NAC and AC in high-risk patients with prostate cancer. 34 The cost of AC was $4,174 higher than that of NAC. The 5-year biochemical recurrence-free rates of AC and NAC were 59% and 86%, respectively.…”

Neoadjuvant Chemohormonal Therapy before Radical Prostatectomy for Japanese Patients with High-Risk Localized Prostate Cancer

“…In our study, the median number of resected lymph nodes was 10 (range: 2–28; Table 1 ). A previous study showed that the number of resected lymph nodes by ePLND was significantly higher than that of limited PLND (median: 6 (range: 2–9), 16 (range: 13–21), respectively) [ 23 ]. By ePLND, resection of a greater number of metastatic lymph nodes might lead to improved oncological outcomes.…”

Frailty is a predictor of moderate to severe pain after robot‐assisted laparoscopic prostatectomy: A case‐control study (FRAP study)

“…Procedures of RARP and standard pelvic lymph node dissection were performed using the basic technique described previously. 21 , 22 Extended pelvic lymph node dissection was not performed in this study. The exclusion criteria were as follows: (1) patients who could not be evaluated for frailty and postoperative pain and (2) those treated with open radical prostatectomy.…”