Observation Versus Initial Treatment for Men With Localized, Low-Risk Prostate Cancer

Abstract

Background Observation is underused among men with localized, low-risk prostate cancer. Objective To assess the costs and benefits of observation versus initial treatment. Design Decision analysis simulating treatment or observation. Data Sources Medicare schedules, published literature. Target Population Men ages 65 and 75 years with newly diagnosed low-risk prostate cancer (prostate-specific antigen level <10 μg/L, stage ≤T2a, Gleason score ≤3+3). Time Horizon Lifetime. Perspective Societal. Intervention Treatment (brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy) or observation (active surveillance [AS] or watchful waiting [WW]). Outcome Measures Quality-adjusted life expectancy, costs. Results of Base-Case Analysis Observation was more effective and less costly than initial treatment. Compared with AS, WW provided 2 additional months of quality-adjusted life expectancy (9.02 vs. 8.85 years) at a savings of $15 374 ($24 520 vs. $39 894) in men aged 65 years and 2 additional months (6.14 vs. 5.98 years) at a savings of $11 746 ($18 302 vs. $30 048) in men aged 75 years. Brachytherapy was the most effective and least expensive initial treatment. Results of Sensitivity Analysis Treatment became more effective than observation when it led to more dramatic reductions in prostate cancer death (hazard ratio, 0.47 vs. WW and 0.64 vs. AS). Active surveillance became as effective as WW in men aged 65 years when the probability of progressing to treatment on AS decreased below 63% or when the quality of life with AS versus WW was 4% higher in men aged 65 years or 1% higher in men aged 75 years. Watchful waiting remained least expensive in all analyses. Limitation Results depend on outcomes reported in the published literature, which is limited. Conclusion Among these men, observation is more effective and costs less than initial treatment, and WW is most effective and least expensive under a wide range of clinical scenarios. Primary Funding Source National Cancer Institute, U.S. Department of Defense, Prostate Cancer Foundation, and Blue Shield of California Foundation.

Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer

“…Other studies have focused on comparisons among surgical techniques (28)(29)(30). Perhaps the most pertinent studies have looked at the costs among various treatment modalities, including radiotherapy, surgery, or active surveillance (31)(32)(33)(34)(35)(36). Consistent with the body of literature, in vivo 32: 113-120 (2018) 118 our findings suggest that the cost of EBRT significantly outpaces the costs of surgery or brachytherapy.…”

Radiation Costing Methods: A Systematic Review

“…As shown in Figure 2, twenty-two studies provided costs for imrt 7,[9][10][11]14,[16][17][18][19][20][21][22][23][24]27,28,29,[31][32][33][34][35] ; sixteen, for 3D-c rt 11,14,15,17,19,20,22,23,28,[31][32][33][34][35]37,39 ; six, for bt 9,13,22,24,31,32 ; and six, for sbrt 7,10,20,23,27,37 . A number of studies also costed other modalities of rt (rt in general, whole-breast radiation, external-beam partial-breast irradiation, etc.…”

“…The disease site most often evaluated in rt costing studies was prostate cancer (39%) 7,9,10,[15][16][17][18]24,27,29,31,32,34 , followed by breast cancer (18%) 8,19,22,25,26,28 , non-smallcell lung cancer (12%) 20,23,37,39 , head-and-neck cancer (9%) 14,33,38 , cervical cancer (6%) 13,21 , and other sites [bone metastases (6%) 12,30 , metastatic epidural spinal cord (3%) 36 , oropharyngeal cancer (3%) 35 , and squamous cell cancer of the anus (3%) 11 ]. Thirteen studies used original costing data to conduct the costing analysis 8,19,20,[24][25][26]28,[29][30][31][32][33]37 ; the remaining twenty studies modelled outcomes using hypothetical patient cohorts 7,…”

Cost-Effectiveness of a Biopsy-Based 8-Protein Prostate Cancer Prognostic Assay to Optimize Treatment Decision Making in Gleason 3 + 3 and 3 + 4 Early Stage Prostate Cancer

“…We used treatment and procedure costs derived from recent studies of prostate cancer expenditure, and adjusted all costs to 2014 U.S. dollars using the medical component of the consumer price index (Table 1) [5,17]. The cost of the Roth, Ramsey, Carlson 8-protein prostate cancer prognostic assay was provided by Metamark Genetics ($3,800).…”

“…This transition probability was derived from a prior prostate cancer decision modeling study conducted by Hayes et al and applied an assumption that 75% of men with PSA progression would receive prostatectomy [17].…”