Economic evaluation of treatments for patients with localized prostate cancer in Europe: a systematic review

Abstract

BackgroundOur objective was to assess the efficiency of treatments in patients with localized prostate cancer, by synthesizing available evidence from European economic evaluations through systematic review.MethodsArticles published 2000–2015 were searched in MEDLINE, EMBASE and NHS EED (Prospero protocol CRD42015022063). Two authors independently selected studies for inclusion and extracted the data. A third reviewer resolved discrepancies. We included European economic evaluations or cost comparison studies, of any modality of surgery or radiotherapy treatments, regardless the comparator/s. Drummond’s Checklist was used for quality assessment.ResultsAfter reviewing 8,789 titles, 13 European eligible studies were included: eight cost-utility, two cost-effectiveness, one cost-minimization, and two cost-comparison analyses. Of them, five compared interventions with expectant management, four contrasted robotic with non robotic-assisted surgery, three assessed new modalities of radiotherapy, and three compared radical prostatectomy with brachytherapy. All but two studies scored ≥8 in the quality checklist. Considering scenario and comparator, three interventions were qualified as dominant strategies (active surveillance, robotic-assisted surgery and IMRT), and six were cost-effective (radical prostatectomy, robotic-assisted surgery, IMRT, proton therapy, brachytherapy, and 3DCRT). However, QALY gains in most of them were small. For interventions considered as dominant strategies, QALY gain was 0.013 for active surveillance over radical prostatectomy; and 0.007 for robotic-assisted over non-robotic techniques. The highest QALY gains were 0.57–0.86 for radical prostatectomy vs watchful waiting, and 0.72 for brachytherapy vs conventional radiotherapy.ConclusionsCurrently, relevant treatment alternatives for localized prostate cancer are scarcely evaluated in Europe. Very limited available evidence supports the cost-effectiveness of radical prostatectomy over watchful waiting, brachytherapy over radical prostatectomy, and new treatment modalities over traditional procedures. Relevant disparities were detected among studies, mainly based on effectiveness. These apparently contradictory results may be reflecting the difficulty of interpreting small differences between treatments regarding QALY gains.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1781-z) contains supplementary material, which is available to authorized users.

When the Evidence Basis Breeds Controversies: Exploring the Value Profile of Robotic Surgery Beyond the Early Introduction Phase

“…Likewise, two CERs with cost analysis conclude respectively: “significant clinical benefits may justify higher total costs” (Turchetti et al, 2017); and “higher costs do not seem to support the decision to introduce a robotic system” (Tedesco, Faggiano, Leo, Derrico, & Ritrovato, 2016). Economic analyses conclude “no” or “extremely small” added value (QALY gains) of RARP, while also reporting uncertainty in cost-effectiveness “mainly due to contradictory results on effectiveness” (Becerra et al, 2016). An Austrian HTA report concludes “whether the benefits legitimises the high costs is highly questionable’ and recommends ‘hold off on the purchase of a surgical robot until other manufacturers will enter the playing field and the price will decrease” (Fischer & Kisser, 2015).…”

Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial

“…This is the first study to compare the lifetime cost-effectiveness of managing clinically localised prostate cancer by risk group with active monitoring, external beam radiotherapy with neoadjuvant androgen deprivation, and radical prostatectomy by extrapolating from prospectively collected trial data. In continental Europe other model-based cost-utility analyses have used cohort studies and extrapolation from an earlier trial (SPCG-4 which compared watchful waiting to prostatectomy for clinically detected prostate cancer [ 14 ]) to assess the cost-effectiveness of active surveillance or watchful waiting compared with prostatectomy, radiotherapy versus prostatectomy, different modalities of radiotherapy against one another, or different surgical techniques against one another [ 15 ]. A review of these studies concluded that across all of these studies only small differences in QALY gains were detected between strategies and limited evidence supported cost-effectiveness recommendations of prostatectomy instead of watchful waiting, brachytherapy over prostatectomy, and newer treatment approaches above traditional methods [ 15 ].…”

“…In continental Europe other model-based cost-utility analyses have used cohort studies and extrapolation from an earlier trial (SPCG-4 which compared watchful waiting to prostatectomy for clinically detected prostate cancer [ 14 ]) to assess the cost-effectiveness of active surveillance or watchful waiting compared with prostatectomy, radiotherapy versus prostatectomy, different modalities of radiotherapy against one another, or different surgical techniques against one another [ 15 ]. A review of these studies concluded that across all of these studies only small differences in QALY gains were detected between strategies and limited evidence supported cost-effectiveness recommendations of prostatectomy instead of watchful waiting, brachytherapy over prostatectomy, and newer treatment approaches above traditional methods [ 15 ]. The within trial analysis for the ProtecT trial over a 10-year time period showed that radiotherapy was the most cost-effective strategy for all men and the subgroup analysis at 10 years showed that active monitoring was most cost-effective for low risk men (D’Amico and Grade group) and men younger than 65 years old.…”

Treatment patterns of high-dose-rate and low-dose-rate brachytherapy as monotherapy for prostate cancer

“…Management options include radical prostatectomy (RP), external beam radiotherapy (EBRT), brachytherapy (BT), or active surveillance (AS). Despite an overall decline in the use of BT alone or as a boost in combination with EBRT since the early 2000s, monotherapy using either high-dose-rate (HDR) or low-dose-rate (LDR) brachytherapy remains one of the most cost-effective options for patients with localized prostate cancer compared to other modalities [4,5,6,7].…”