Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis
Correspondence: Matthew R. Cooperberg, University of California, San Francisco, Box 1695, 1600 Divisadero St, A-624, San Francisco, CA 94143-1695, USA.
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.
- 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.
- 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.
- 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.