Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost‐utility analysis

Abstract

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.

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.…”

Re: Quality-of-life Effects of Prostate-specific Antigen Screening

“…The clinical model-the possible treatments and health states-is substantially oversimplified [1], and the authors acknowledge some of the limitations associated with their selection of utility values in the model. The broad message of the paper-that harms should be considered in evaluating the impact of screening-is clearly true, but the model is nowhere close to robust enough for the specific quantitative findings reported to be considered reliable or clinically useful.…”

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).…”

“…(Table 2). The proportion of patients experiencing these events and the costs of treatment were derived from a prior decisionmodeling study comparing treatment strategies in localized prostate cancer [5].We assumed that all complications lasted 1 year in the base case analysis.…”

“…Invasive treatment options (e.g., prostatectomy, IMRT, and brachytherapy) are often accompanied by adverse events and complications with serious potential impact on health-related quality of life [1,4,5].These include short-and long-term urinary and erectile difficulties and incontinence [1]. In this context, active surveillance is an increasingly attractive treatment option for patients who are unlikely to have aggressive disease (i.e., rapidly progressing tumors); however, use of active surveillance remains low.…”