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Keywords:

  • prostate neoplasms;
  • decision analysis;
  • comparative effectiveness;
  • surgery;
  • radiation

What's known on the subject? and What does the study add?

  • Multiple treatment alternatives exist for localised prostate cancer, with few high-quality studies directly comparing their comparative effectiveness and costs.
  • The present study is the most comprehensive cost-effectiveness analysis to date for localised prostate cancer, conducted with a lifetime horizon and accounting for survival, health-related quality-of-life, and cost impact of secondary treatments and other downstream events, as well as primary treatment choices. The analysis found minor differences, generally slightly favouring surgical methods, in quality-adjusted life years across treatment options. However, radiation therapy (RT) was consistently more expensive than surgery, and some alternatives, e.g. intensity-modulated RT for low-risk disease, were dominated – that is, both more expensive and less effective than competing alternatives.

Objective

  • To characterise the costs and outcomes associated with radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (RT: dose-escalated three-dimensional conformal RT, intensity-modulated RT, brachytherapy, or combination), using a comprehensive, lifetime decision analytical model.

Patients and Methods

  • A Markov model was constructed to follow hypothetical men with low-, intermediate-, and high-risk prostate cancer over their lifetimes after primary treatment; probabilities of outcomes were based on an exhaustive literature search yielding 232 unique publications.
  • In each Markov cycle, patients could have 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 USA payer perspective, with incorporation of patient costs in a sensitivity analysis.

Results

  • Differences across treatments in quality-adjusted life years across methods were modest, ranging from 10.3 to 11.3 for low-risk patients, 9.6–10.5 for intermediate-risk patients and 7.8–9.3 for high-risk patients.
  • There were no statistically significant differences among surgical methods, which tended to be more effective than RT methods, with the exception of combined external beam + brachytherapy for high-risk disease.
  • RT methods were consistently more expensive than surgical methods; costs ranged from $19 901 (robot-assisted prostatectomy for low-risk disease) to $50 276 (combined RT 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 about strategies to improve efficiency of treatment selection for localised prostate cancer.