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Subiela JD, Gomis Sellés E, Maldonado A, Lopez Campos F, Aumatell Ovide J, Ajuria Illarramendi O, González-Padilla DA, Gajate P, Ortega Polledo LE, Alonso Y Gregorio S, Guerrero-Ramos F, Gómez Dos Santos V, Rodríguez-Patrón R, Calais J, Kishan AU, Burgos Revilla FJ, Couñago F. Clinical Usefulness of Prostate-specific Membrane Antigen-ligand Positron Emission Tomography/Computed Tomography for the Detection of Prostate Cancer Biochemical Recurrence after Primary Radiation Therapy in Patients with Prostate-specific Antigen Below the Phoenix Threshold: Systematic Review and Meta-analysis. Clin Oncol (R Coll Radiol) 2023; 35:e676-e688. [PMID: 37802722 DOI: 10.1016/j.clon.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/01/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023]
Abstract
AIMS After primary radiotherapy, biochemical recurrence is defined according to the Phoenix criteria as a prostate-specific antigen (PSA) value >2 ng/ml relative to the nadir. Several studies have shown that prostate-specific membrane antigen (PSMA)-ligand positron emission tomography/computed tomography (PET/CT) can help in detecting recurrence in patients with low PSA values. This study aimed to assess the detection rate and patterns of PSMA-ligand PET/CT uptake in patients with suspected biochemical recurrence after primary radiotherapy and with PSA levels below the Phoenix threshold. MATERIALS AND METHODS The meta-analysis was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Articles providing data on patients with suspected prostate cancer recurrence after primary radiotherapy with a PSA value below the Phoenix threshold and who underwent PSMA-ligand PET/CT were included. Quality assessment was carried out using the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2). RESULTS In total, five studies were included, recruiting 909 patients (202 with PSA ≤2 ng/ml). The PSMA-ligand detection rate in the patients with ≤2 ng/ml ranged from 66 to 83%. The most frequent source of PSMA-ligand PET/CT uptake was local recurrence, followed by lymph node metastasis and bone metastasis. PSMA-ligand PET/CT uptake due to local-only recurrence was more likely in patients with PSA ≤2 ng/ml compared with PSA > 2 ng/ml: risk ratio 0.72 (95% confidence interval 0.58-0.89), P = 0.003. No significant differences were observed in the detection of PSMA-ligand uptake in other areas. Limitations include a lack of biopsy confirmation, cohort reports with small sample sizes and a potentially high risk of bias. CONCLUSION A significant detection of PSMA-ligand-avid disease was observed in patients with PSA levels below the Phoenix threshold. There was a higher likelihood of detecting local-only uptake when the PSA value was ≤2 ng/ml. The findings suggest that a critical review of the Phoenix criteria may be warranted in the era of PSMA-ligand PET/CT and highlight the need for further prospective trials.
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Affiliation(s)
- J D Subiela
- Department of Urology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain.
| | - E Gomis Sellés
- Radiation Oncology Department, University Hospital Virgen del Rocío, Biomedical Institute of Seville (IBIS)/CSIC/University of Seville, Seville, Spain
| | - A Maldonado
- Nuclear Medicine and Molecular Imaging Department, University Hospital Quiron-salud Madrid/La Luz Hospital, Madrid, Spain
| | - F Lopez Campos
- Radiation Oncology Department, University Hospital Ramon y Cajal, Madrid, Spain
| | - J Aumatell Ovide
- Department of Urology, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | | | | | - P Gajate
- Medical Oncology Department, Ramon y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - L E Ortega Polledo
- Department of Urology, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Spain
| | | | - F Guerrero-Ramos
- Department of Urology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - V Gómez Dos Santos
- Department of Urology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - R Rodríguez-Patrón
- Department of Urology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - J Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - A U Kishan
- Department of Radiation Oncology and Department of Urology, University of California, Los Angeles, CA, USA
| | - F J Burgos Revilla
- Department of Urology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - F Couñago
- Department of Radiation Oncology, San Francisco de Asís Hospital, Madrid, Spain; Department of Radiation Oncology, La Milagrosa Hospital, Madrid, Spain; National Chair of Research, GenesisCare, Madrid, Spain
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Moll M, Goldner G. Comparison of treatment costs for primary localized prostate cancer in Austria and Vienna: an economic analysis. Front Public Health 2023; 11:1016860. [PMID: 37325333 PMCID: PMC10267377 DOI: 10.3389/fpubh.2023.1016860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 05/11/2023] [Indexed: 06/17/2023] Open
Abstract
Background Prostate cancer is the most common cancer in men. Several efficient treatments are available for primary prostate cancer, but an economic comparison of these modalities has not been done in Austria. Objective and setting The current study provides an economic comparison of radiotherapy and surgery for prostate cancer in Vienna and Austria. Methods We analyzed the catalog of medical services of the Austrian Federal Ministry of Social Affairs, Health, Care and Consumer Protection and present the treatment costs for the public health sector with an LKF-point value and monetary value in 2022. Results External beam radiotherapy, especially ultrahypofractionated, is the least costly treatment modality for low-risk prostate cancer, with costs of 2,492 € per treatment. For intermediate-risk prostate cancer, differences between moderate hypofractionation and brachytherapy are small, with costs of 4,638-5,140 €. In a high-risk setting, differences between radical prostatectomy and radiotherapy with androgen deprivation therapy are small (7,087 € vs. 7474.06 €). Conclusion From a purely financial point of view, treatment of low- and intermediate-risk prostate cancer in Vienna and Austria should consist of radiotherapy as long as the current catalog of services is up to date. For high-risk prostate cancer, no major difference was found.
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Naser-Tavakolian A, Venkataramana A, Spiegel B, Almario C, Kokorowski P, Freedland SJ, Anger JT, Leppert JT, Daskivich TJ. The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer. Urol Oncol 2023; 41:205.e1-205.e10. [PMID: 36737259 DOI: 10.1016/j.urolonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/22/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease. METHODS We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments. RESULTS AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores. CONCLUSIONS LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.
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Affiliation(s)
| | - Abhishek Venkataramana
- The Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Christopher Almario
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paul Kokorowski
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Section of Urology, Durham VA Medical Center, Durham, NC
| | | | | | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA.
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4
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Reddy D, van Son M, Peters M, Bertoncelli Tanaka M, Dudderidge T, Cullen E, Ho CLT, Hindley RG, Emara A, McCracken S, Orczyk C, Shergill I, Mangar S, Nigam R, Virdi J, Moore CM, Arya M, Shah TT, Winkler M, Emberton M, Falconer A, Belsey J, Ahmed HU. Focal therapy versus radical prostatectomy and external beam radiotherapy as primary treatment options for non-metastatic prostate cancer: results of a cost-effectiveness analysis. J Med Econ 2023; 26:1099-1107. [PMID: 37656223 DOI: 10.1080/13696998.2023.2251849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023]
Abstract
AIMS Focal therapy treats individual areas of tumour in non-metastatic prostate cancer in patients unsuitable for active surveillance. The aim of this work was to evaluate the cost-effectiveness of focal therapy versus prostatectomy and external beam radiotherapy (EBRT). MATERIALS AND METHODS A Markov cohort health state transition model with four health states (stable disease, local recurrence, metastatic disease and death) was created, evaluating costs and utilities over a 10-year time horizon for patients diagnosed with non-metastatic prostate cancer. National Health Service (NHS) for England perspective was used, based on direct healthcare costs. Clinical transition probabilities were derived from prostate cancer registries in patients undergoing radical prostatectomy, EBRT and focal therapy using cryotherapy (Boston Scientific) or high-intensity focused ultrasound (HIFU) (Sonablate). Propensity score matching was used to ensure that at-risk populations were comparable. Variables included age, prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group, maximum cancer core length (mm), T-stage and year of treatment. RESULTS Focal therapy was associated with a lower overall cost and higher quality-adjusted life year (QALY) gains than either prostatectomy or EBRT, dominating both treatment strategies. Positive incremental net monetary benefit (NMB) values confirm focal therapy as cost-effective versus the alternatives at a willingness to pay (WTP) threshold of £30,000/QALY. One-way deterministic sensitivity analyses revealed consistent results. LIMITATIONS Data used to calculate the transition probabilities were derived from a limited number of hospitals meaning that other potential treatment options were excluded. Limited data were available on later outcomes and none on quality of life data, therefore, literature-based estimates were used. CONCLUSIONS Cost-effectiveness modelling demonstrates use of focal therapy (cryotherapy or HIFU) is associated with greater QALY gains at a lower overall cost than either radical prostatectomy or EBRT, representing good value for money in the NHS.
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Affiliation(s)
| | | | - Max Peters
- Amsterdam University Medical Centers, The Netherlands
| | | | - Tim Dudderidge
- University Hospital Southampton NHS Trust, Southampton, UK
| | | | | | - Richard G Hindley
- Hampshire Hospitals NHS Foundation Trust, UK
- BMI The Hampshire Clinic, Basingstoke, UK
| | - Amr Emara
- Hampshire Hospitals NHS Foundation Trust, UK
| | | | - Clement Orczyk
- University College London NHS Foundation Trust, London, UK
| | | | | | - Raj Nigam
- Royal Surrey NHS Foundation Trust, Guildford, UK
- BMI Mount Alvernia Hospital, Guildford, UK
| | - Jaspal Virdi
- Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Caroline M Moore
- University College London NHS Foundation Trust, London, UK
- Princess Grace Hospital, London, UK
- King Edward VII Hospital, London, UK
| | - Manit Arya
- Imperial College NHS Healthcare Trust, London, UK
- University College London NHS Foundation Trust, London, UK
| | - Taimur T Shah
- Imperial College, London, UK
- Imperial College NHS Healthcare Trust, London, UK
| | - Mathias Winkler
- Imperial College, London, UK
- Imperial College NHS Healthcare Trust, London, UK
| | - Mark Emberton
- University College London NHS Foundation Trust, London, UK
- Princess Grace Hospital, London, UK
- King Edward VII Hospital, London, UK
| | | | | | - Hashim U Ahmed
- Imperial College, London, UK
- Imperial College NHS Healthcare Trust, London, UK
- King Edward VII Hospital, London, UK
- Department of Urology, Cromwell Hospital, London, UK
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Radioresistance Mechanisms in Prostate Cancer Cell Lines Surviving Ultra-Hypo-Fractionated EBRT: Implications and Possible Clinical Applications. Cancers (Basel) 2022; 14:cancers14225504. [PMID: 36428597 PMCID: PMC9688510 DOI: 10.3390/cancers14225504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/12/2022] Open
Abstract
The use of a higher dose per fraction to overcome the high radioresistance of prostate cancer cells has been unsuccessfully proposed. Herein, we present PC3 and DU-145, castration-resistant prostate cancer cell lines that survived a clinically used ultra-higher dose per fraction, namely, radioresistant PC3 and DU-145 cells (PC3RR and DU-145RR). Compared to PC3, PC3RR showed a higher level of aggressive behaviour, with enhanced clonogenic potential, DNA damage repair, migration ability and cancer stem cell features. Furthermore, compared to PC3, PC3RR more efficiently survived further radiation by increasing proliferation and down-regulating pro-apoptotic proteins. No significant changes of the above parameters were described in DU-145RR, suggesting that different prostate cancer cell lines that survive ultra-higher dose per fraction do not display the same grade of aggressive phenotype. Furthermore, both PC3RR and DU-145RR increased antioxidant enzymes and mesenchymal markers. Our data suggest that different molecular mechanisms could be potential targets for future treatments plans based on sequential strategies and synergistic effects of different modalities, possibly in a patient-tailored fashion. Moreover, PC3RR cells displayed an increase in specific markers involved in bone remodeling, indicating that radiotherapy selects a PC3 population capable of migrating to secondary metastatic sites. Finally, PC3RR cells showed a better sensitivity to Docetaxel as compared to native PC3 cells. This suggests that a subset of patients with castration-resistant metastatic disease could benefit from upfront Docetaxel treatment after the failure of radiotherapy.
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6
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Kato T, Yokomizo A, Matsumoto R, Tohi Y, Miyakawa J, Mitsuzuka K, Sasaki H, Inokuchi J, Matsumura M, Sakamoto S, Kinoshita H, Fukuhara H, Kamiya N, Kimura R, Nitta M, Okuno H, Akakura K, Kakehi Y, Sugimoto M. Comparison of the medical costs between active surveillance and other treatments for early prostate cancer in Japan using data from the PRIAS-JAPAN study. Int J Urol 2022; 29:1271-1278. [PMID: 35855586 DOI: 10.1111/iju.14977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/19/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the medical costs of active surveillance with those of robot-assisted laparoscopic prostatectomy, brachytherapy, intensity-modulated radiation therapy, and hormone therapy for low-risk prostate cancer. METHODS The costs of protocol biopsies performed in the first year of surveillance (between January 2010 and June 2020) and those of brachytherapy and radiation therapy performed between May 2019 and June 2020 at the Kagawa University Hospital were analyzed. Hormone therapy costs were assumed to be the costs of luteinizing hormone-releasing hormone analogs for over 5 years. Active surveillance-eligible patients were defined based on the following: age <74 years, ≤T2, Gleason score ≤6, prostate-specific antigen level ≤10 ng/ml, and 1-2 positive cores. We estimated the total number of active surveillance-eligible patients in Japan based on the Japan Study Group of Prostate Cancer (J-CAP) study and the 2017 cancer statistical data. We then calculated the 5-year treatment costs of active surveillance-eligible patients using the J-CAP and PRIAS-JAPAN study data. RESULTS In 2017, number of active surveillance-eligible patients in Japan was estimated to be 2808. The 5-year total costs of surveillance, prostatectomy, brachytherapy, radiation therapy, and hormone therapy were 1.65, 14.0, 4.61, 4.04, and 5.87 million United States dollar (USD), respectively. If 50% and 100% of the patients in each treatment group had opted for active surveillance as the initial treatment, the total treatment cost would have been reduced by USD 6.89 million (JPY 889 million) and USD 13.8 million (JPY 1.78 billion), respectively. CONCLUSION Expanding active surveillance to eligible patients with prostate cancer helps save medical costs.
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Affiliation(s)
- Takuma Kato
- Department of Urology, Faculty of Medicine, Kagawa University, Kita-gun, Japan
| | - Akira Yokomizo
- Department of Urology, Harasanshin Hospital, Fukuoka, Japan
| | - Ryuji Matsumoto
- Department of Renal and Genito-Urinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoichiro Tohi
- Department of Urology, Faculty of Medicine, Kagawa University, Kita-gun, Japan
| | - Jimpei Miyakawa
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Mitsuzuka
- Department of Urology, Tohoku University School of Medicine, Sendai, Japan
| | - Hiroshi Sasaki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Junichi Inokuchi
- Department of Urology, Faculty of Medicine, Kyushu University, Fukuoka, Japan
| | - Masafumi Matsumura
- Department of Urology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Shinichi Sakamoto
- Department of Urology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hidefumi Kinoshita
- Department of Urology and Andrology, Graduate School of Medicine, Kansai Medical University, Hirakata, Japan
| | - Hiroshi Fukuhara
- Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Naoto Kamiya
- Department of Urology, Toho University Sakura Medical Center, Sakura, Japan
| | - Ryu Kimura
- Department of Urology, University of the Ryukyus, Graduate School of Medicine, Nishihara, Japan
| | - Masahiro Nitta
- Department of Urology, Tokai University School of Medicine, Hiratsuka, Japan
| | - Hiroshi Okuno
- Department of Urology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Koichiro Akakura
- Department of Urology, Japan Community Health Care Organization, Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Yoshiyuki Kakehi
- Department of Urology, Faculty of Medicine, Kagawa University, Kita-gun, Japan
| | - Mikio Sugimoto
- Department of Urology, Faculty of Medicine, Kagawa University, Kita-gun, Japan
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Weng X, Zhong L, Xiang P, Li Y, Paciorek A, Dong L, Broering J, Carroll PR, Sanda M, Wilson L. Cost-effectiveness analysis of primary treatments for localised prostate cancer: A population-based Markov analysis using real-world evidence. Eur J Cancer Care (Engl) 2022; 31:e13740. [PMID: 36239065 DOI: 10.1111/ecc.13740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We evaluate cost-effectiveness of primary treatments for localised prostate cancer by uniquely combining prospectively collected real-world outcomes and costs from UCSF Cancer of Prostate Strategic Urologic Research Endeavor (CaPSURE™). METHODS Markov models assessed cost-effectiveness of radical prostatectomy (RP), brachytherapy, electron beam radiation therapy (EBRT) and brachytherapy with EBRT by risk from US payers perspective over 8 years. Treatment costs included office visits, hospitalisation, procedures, medication and long-term care. Patients' surveyed HRQoL were mapped into utilities. Incremental cost-effectiveness ratios (ICERs) used cost per quality-adjusted life years (QALYs) and willingness-to-pay of $150,000/QALY. RESULTS Cost-effectiveness analysis (CEA) showed for low-risk prostate cancer, EBRT dominated the lowest cost brachytherapy, but RPns and brachytherapy plus EBRT were cost-effective compared to brachytherapy with ICERs of $18,926 and $41,662 per QALY. In medium-risk patients, RP, EBRT and brachytherapy plus EBRT all were cost-effective compared with brachytherapy, with ICERs of $30,604, $22,588 and $21,627/QALY. In high-risk, brachytherapy dominated all treatments. Procedure cost and utility are driving ICER, but probabilistic sensitivity analysis showed the model was robust across variables. CONCLUSION This first CEA combining prospective real-world evidence for HRQOL outcomes with costs shows cost-effectiveness of treatments vary by risk groups, providing new evidence for treatment decisions.
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Affiliation(s)
- Xiuhua Weng
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Lixian Zhong
- College of Pharmacy, Texas A&M University, College Station, Texas, USA
| | - Pin Xiang
- Department of Clinical Pharmacy, School of Pharmacy, The University of California, San Francisco, California, USA
| | - Yiyuan Li
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Alan Paciorek
- Helen Diller Family Comprehensive Cancer Center, The University of California, San Francisco, California, USA
| | - Liangliang Dong
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jeanette Broering
- Department of Urology, University of California, San Francisco, California, USA
| | - Peter R Carroll
- Department of Urology, University of California, San Francisco, California, USA
| | - Martin Sanda
- Department of Urology, Emory University, School of Medicine, Atlanta, Georgia, USA
| | - Leslie Wilson
- Department of Clinical Pharmacy, School of Pharmacy, The University of California, San Francisco, California, USA
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The Economic Burden of Localized Prostate Cancer and Insights Derived from Cost-Effectiveness Studies of the Different Treatments. Cancers (Basel) 2022; 14:cancers14174088. [PMID: 36077625 PMCID: PMC9454560 DOI: 10.3390/cancers14174088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Prostate cancer has huge health and societal impacts, and there is no clear consensus on the most effective and efficient treatment strategy for this disease, particularly for localized prostate cancer. We have reviewed the scientific literature describing the economic burden and cost-effectiveness of different treatment strategies for localized prostate cancer in OECD countries. We initially identified 315 articles, studying 13 of them in depth (those that met the inclusion criteria), comparing the social perspectives of cost, time period, geographical area, and severity. The economic burden arising from prostate cancer due to losses in productivity and increased caregiver load is noticeable, but clinical decision-making is carried out with more subjective variability than would be advisable. The direct cost of the intervention was the main driver for the treatment of less severe cases of prostate cancer, whereas for more severe cases, the most important determinant was the loss in productivity. Newer, more affordable radiotherapy strategies may play a crucial role in the future treatment of early prostate cancer. The interpretation of our results depends on conducting thorough sensitivity analyses. This approach may help better understand parameter uncertainty and the methodological choices discussed in health economics studies. Future results of ongoing clinical trials that are considering genetic characteristics in assessing treatment response of patients with localized prostate cancer may shed new light on important clinical and pharmacoeconomic decisions.
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9
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Degeling K, Corcoran NM, Pereira-Salgado A, Hamid AA, Siva S, IJzerman MJ. Lifetime Health and Economic Outcomes of Active Surveillance, Radical Prostatectomy, and Radiotherapy for Favorable-Risk Localized Prostate Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1737-1745. [PMID: 34838271 DOI: 10.1016/j.jval.2021.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/18/2021] [Accepted: 06/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To estimate the lifetime health and economic outcomes of selecting active surveillance (AS), radical prostatectomy (RP), or radiation therapy (RT) as initial management for low- or favorable-risk localized prostate cancer. METHODS A discrete-event simulation model was developed using evidence from published randomized trials. Health outcomes were measured in life-years and quality-adjusted life-years (QALYs). Costs were included from a public payer perspective in Australian dollars. Outcomes were discounted at 5% over a lifetime horizon. Probabilistic and scenario analyses quantified parameter and structural uncertainty. RESULTS A total of 60% of patients in the AS arm eventually received radical treatment (surgery or radiotherapy) compared with 90% for RP and 91% for RT. Although AS resulted in fewer treatment-related complications, it led to increased clinical progression (AS 40.7%, RP 17.6%, RT 19.9%) and metastatic disease (AS 13.4%, RP 6.1%, RT 7.0%). QALYs were 10.88 for AS, 11.10 for RP, and 11.13 for RT. Total costs were A$17 912 for AS, A$15 609 for RP, and A$15 118 for RT. At a willingness to pay of A$20 000/QALY, RT had a 61.4% chance of being cost-effective compared to 38.5% for RP and 0.1% for AS. CONCLUSIONS Although AS resulted in fewer and delayed treatment-related complications, it was not found to be a cost-effective strategy for favorable-risk localized prostate cancer over a lifetime horizon because of an increase in the number of patients developing metastatic disease. RT was the dominant strategy yielding higher QALYs at lower cost although differences compared with RP were small.
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Affiliation(s)
- Koen Degeling
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Niall M Corcoran
- Department of Surgery, The University of Melbourne, Melbourne, Australia; Department of Urology, Frankston Hospital, Frankston, Australia; Division of Urology, Royal Melbourne Hospital, Melbourne, Australia
| | - Amanda Pereira-Salgado
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Anis A Hamid
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Maarten J IJzerman
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
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Beitel-White N, Aycock KN, Manuchehrabadi N, Zhao Y, Imran KM, Coutermarsh-Ott S, Allen IC, Lorenzo MF, Davalos RV. Properties of tissue within prostate tumors and treatment planning implications for ablation therapies. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:1539-1542. [PMID: 34891577 DOI: 10.1109/embc46164.2021.9630534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Irreversible electroporation (IRE) is a promising alternative therapy for the local treatment of prostate tumors. The procedure involves the direct insertion of needle electrodes into the target zone, and subsequent delivery of short but high-voltage pulses. Successful outcomes rely on adequate exposure of the tumor to a threshold electrical field. To aid in predicting this exposure, computational models have been developed, yet often do not incorporate the appropriate tissue-specific properties. This work aims to quantify electrical conductivity behavior during IRE for three types of tissue present in the target area of a prostate cancer ablation: the tumor tissue itself, the surrounding healthy tissue, and potential areas of necrosis within the tumor. Animal tissues were used as a stand-in for primary samples. The patient-derived prostate tumor tissue showed very similar responses to healthy porcine prostate tissue. An examination of necrotic tissue inside the tumors revealed a large difference, however, and a computational model showed that a necrotic core with differing electrical properties can cause unexpected inhomogeneities within the treatment region.
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Sanghera S, Mohiuddin S, Coast J, Garfield K, Noble S, Metcalfe C, Lane JA, Turner EL, Neal D, Hamdy FC, Martin RM, Donovan JL. Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial. BMC Cancer 2020; 20:971. [PMID: 33028256 PMCID: PMC7542698 DOI: 10.1186/s12885-020-07276-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 08/09/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Optimal management strategies for clinically localised prostate cancer are debated. Using median 10-year data from the largest randomised controlled trial to date (ProtecT), the lifetime cost-effectiveness of three major treatments (radical radiotherapy, radical prostatectomy and active monitoring) was explored according to age and risk subgroups. METHODS A decision-analytic (Markov) model was developed and informed by clinical input. The economic evaluation adopted a UK NHS perspective and the outcome was cost per Quality-Adjusted Life Year (QALY) gained (reported in UK£), estimated using EQ-5D-3L. RESULTS Costs and QALYs extrapolated over the lifetime were mostly similar between the three randomised strategies and their subgroups, but with some important differences. Across all analyses, active monitoring was associated with higher costs, probably associated with higher rates of metastatic disease and changes to radical treatments. When comparing the value of the strategies (QALY gains and costs) in monetary terms, for both low-risk prostate cancer subgroups, radiotherapy generated the greatest net monetary benefit (£293,446 [95% CI £282,811 to £299,451] by D'Amico and £292,736 [95% CI £284,074 to £297,719] by Grade group 1). However, the sensitivity analysis highlighted uncertainty in the finding when stratified by Grade group, as radiotherapy had 53% probability of cost-effectiveness and prostatectomy had 43%. In intermediate/high risk groups, using D'Amico and Grade group > = 2, prostatectomy generated the greatest net monetary benefit (£275,977 [95% CI £258,630 to £285,474] by D'Amico and £271,933 [95% CI £237,864 to £287,784] by Grade group). This finding was supported by the sensitivity analysis. Prostatectomy had the greatest net benefit (£290,487 [95% CI £280,781 to £296,281]) for men younger than 65 and radical radiotherapy (£201,311 [95% CI £195,161 to £205,049]) for men older than 65, but sensitivity analysis showed considerable uncertainty in both findings. CONCLUSION Over the lifetime, extrapolating from the ProtecT trial, radical radiotherapy and prostatectomy appeared to be cost-effective for low risk prostate cancer, and radical prostatectomy for intermediate/high risk prostate cancer, but there was uncertainty in some estimates. Longer ProtecT trial follow-up is required to reduce uncertainty in the model. TRIAL REGISTRATION Current Controlled Trials number, ISRCTN20141297: http://isrctn.org (14/10/2002); ClinicalTrials.gov number, NCT02044172: http://www.clinicaltrials.gov (23/01/2014).
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Affiliation(s)
- S Sanghera
- Health Economics Bristol (HEB), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK.
| | - S Mohiuddin
- Health Economics Bristol (HEB), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol, Bristol, BS1 2NT, UK
| | - J Coast
- Health Economics Bristol (HEB), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - K Garfield
- Health Economics Bristol (HEB), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, BS8 2PS, UK
| | - S Noble
- Health Economics Bristol (HEB), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK
| | - C Metcalfe
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, BS8 2PS, UK
| | - J A Lane
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, BS8 2PS, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - E L Turner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - D Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 7DQ, UK
| | - F C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 7DQ, UK
| | - R M Martin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
- National Institute for Health Research (NIHR) Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, BS8 2PS, UK
| | - J L Donovan
- NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol, Bristol, BS1 2NT, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
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Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, Wade J, Noble S, Garfield K, Young G, Davis M, Peters TJ, Turner EL, Martin RM, Oxley J, Robinson M, Staffurth J, Walsh E, Blazeby J, Bryant R, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Gnanapragasam V, Hughes O, Kockelbergh R, Kynaston H, Paul A, Paez E, Powell P, Prescott S, Rosario D, Rowe E, Neal D. Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT. Health Technol Assess 2020; 24:1-176. [PMID: 32773013 PMCID: PMC7443739 DOI: 10.3310/hta24370] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments. OBJECTIVES To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years. DESIGN A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up. SETTING Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK. PARTICIPANTS Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment. INTERVENTIONS The interventions were active monitoring, radical prostatectomy and radical radiotherapy. TRIAL PRIMARY OUTCOME MEASURE Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants. SECONDARY OUTCOME MEASURES Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes. RESULTS There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy). LIMITATIONS A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed. CONCLUSIONS At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years. TRIAL REGISTRATION Current Controlled Trials ISRCTN20141297. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - J Athene Lane
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Malcolm Mason
- School of Medicine, University of Cardiff, Cardiff, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Julia Wade
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Grace Young
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Davis
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma L Turner
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Mary Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Eleanor Walsh
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Andrew Doble
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | | | - Owen Hughes
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edgar Paez
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Philip Powell
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen Prescott
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Derek Rosario
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - David Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Academic Urology Group, University of Cambridge, Cambridge, UK
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