The cost-utility of open prostatectomy compared with active surveillance in early localised prostate cancer

Abstract

BackgroundThere is an on-going debate about whether to perform surgery on early stage localised prostate cancer and risk the common long term side effects such as urinary incontinence and erectile dysfunction. Alternatively these patients could be closely monitored and treated only in case of disease progression (active surveillance). The aim of this paper is to develop a decision-analytic model comparing the cost-utility of active surveillance (AS) and radical prostatectomy (PE) for a cohort of 65 year old men with newly diagnosed low risk prostate cancer.MethodsA Markov model comparing PE and AS over a lifetime horizon was programmed in TreeAge from a German societal perspective. Comparative disease specific mortality was obtained from the Scandinavian Prostate Cancer Group trial. Direct costs were identified via national treatment guidelines and expert interviews covering in-patient, out-patient, medication, aids and remedies as well as out of pocket payments. Utility values were used as factor weights for age specific quality of life values of the German population. Uncertainty was assessed deterministically and probabilistically.ResultsWith quality adjustment, AS was the dominant strategy compared with initial treatment. In the base case, it was associated with an additional 0.04 quality adjusted life years (7.60 QALYs vs. 7.56 QALYs) and a cost reduction of €6,883 per patient (2011 prices). Considering only life-years gained, PE was more effective with an incremental cost-effectiveness ratio of €96,420/life year gained. Sensitivity analysis showed that the probability of developing metastases under AS and utility weights under AS are a major sources of uncertainty. A Monte Carlo simulation revealed that AS was more likely to be cost-effective even under very high willingness to pay thresholds.ConclusionAS is likely to be a cost-saving treatment strategy for some patients with early stage localised prostate cancer. However, cost-effectiveness is dependent on patients’ valuation of health states. Better predictability of tumour progression and modified reimbursement practice would support widespread use of AS in the context of the German health care system. More research is necessary in order to reliably quantify the health benefits compared with initial treatment and account for patient preferences.

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.…”

Costs of conservative management of early-stage prostate cancer compared to radical prostatectomy–a claims data analysis

“…Andersson et al [23] report €6123 lower costs of WW compared to RP over a follow-up of 12 years based on data from the SPCG-4 clinical trial [23]. In a lifetime modeling study, Koerber et al [7] estimate that under AS compared to RP costs are reduced by about €6900 [7]. Both in the published studies and in our study, the cost difference between CM and RP is almost exclusively due to the costs of the initial RP-surgery.…”

Concepts of ‘Personalization’ in Personalized Medicine: Implications for Economic Evaluation

“…If PM is interpreted as better accounting for patient preferences (at a population level), this has a fundamental impact on the role and methods of economic evaluation as preferences can also be used to define what constitutes expected ‘benefits’ or ‘harms’ and thus determine the quantified expected effect from a treatment [see e.g. 34]. …”

“…For example, patients with low-risk prostate cancer can either undergo active surveillance or prophylactic surgery. It has been shown that the health state valuations of certain adverse effects, such as sexual dysfunction, can affect the decision about which is the optimal intervention in terms of relative cost-effectiveness [34]. A related issue might emerge if genetic screening extends to several diseases.…”