Decision analytic cost-effectiveness model to compare prostate cryotherapy to androgen deprivation therapy for treatment of radiation recurrent prostate cancer

Focal therapy versus radical prostatectomy and external beam radiotherapy as primary treatment options for non-metastatic prostate cancer: results of a cost-effectiveness analysis

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.

A pharmacoeconomic evaluation of pharmaceutical treatment options for prostate cancer

INTRODUCTION

Prostate cancer is one of the most common neoplasms in men. For many years the mainstay of treatment was androgen deprivation therapy, but during last decade many novel agents have emerged, accompanied by increased costs for healthcare systems.

AREAS COVERED

In this literature review, the authors provide a pharmacoeconomic review of several pharmaceutical agents used in several disease stages, by summarizing evidence from cost-analysis, cost-effectiveness, cost-utility, cost-saving, cost-benefit and budgetary impact analysis studies.

EXPERT OPINION

The rapid development of therapeutic agents for prostate cancer has put a great budgetary burden on healthcare systems, since these drugs are prolonging survival and improving quality of life . Since existing data are now mature enough from a number of clinical trials with long-term follow-up, policy makers should propose not only the most clinically effective but also the most cost-effective agents, in order for every patient to gain access at least to some of these therapies. Docetaxel addition seems to be a cost-effective option, when compared to both abiraterone and enzalutamide (due to costs related to acquisition and side effects). Cabazitaxel is a strong candidate after docetaxel failure, while both denosumab and bisphosphonates are cost-effective for reducing skeletal-related events in metastatic disease.

The Scottish prostate cryotherapy service-the role of the clinical nurse specialist

This article outlines the role of the clinical nurse specialist in establishing a Scotland-wide national designated service for prostate cryotherapy for patients with radiation-recurrent prostate cancer. The service was established in 2009 and provides prostate cryotherapy across Scotland. This article reviews and discusses the challenges involved in setting up a new service for tertiary treatment as well as highlighting the key achievements of the service. The challenges have included introducing the cryotherapy procedure in a safe and quality assured manner, developing and refining the referral process, educating both primary and secondary care teams on salvage prostate cryotherapy as a treatment modality and surgical procedure, as well as managing of complications following salvage prostate cryotherapy. The article also outlines the achievements of both the service and the treatment as well as how the service has developed since 2009.

Salvage cryoablation for local recurrence of prostatic cancer after curative therapy

PURPOSE

The purpose of this study was to determine the efficacy of salvage cryotherapy for intra-prostatic and local extraprostatic recurrences after curative treatment of prostate adenocarcinoma.

MATERIAL AND METHOD

Twenty-eight men (mean age, 69±6 [SD] years; range: 51-82 years) treated with cryoablation for prostatic (N=21) or extraprostatic (N=7) recurrent prostate cancer after radiotherapy with or without associated prostatectomy were included. Technical success, complication and recurrences were reported. Biological recurrence was defined as an elevation ≥2ng/mL of prostate specific antigen (PSA) serum level after the treatment.

RESULTS

The mean follow-up was 18 months. Among the 21 patients with intraprostatic recurrence, 14 had successful cryotherapy with a mean decrease in serum prostate-specific antigen (PSA) levels of -5.7±2.6 (SD) ng/mL (range: -2.1 to -16.9ng/mL). Four patients (19%) had early progression and three patients (14%) had delayed biological recurrence (mean time: 15 months). Among the 7 patients with extraprostatic recurrence, 2/7 (291%) had successful cryotherapy with a decrease in PSA serum level of -2.7±1.6 (SD) ng/mL (range: -0.5--5.5ng/mL) and 4/7 (57%) had early biological recurrence after cryotherapy that required androgen deprivation therapy, whereas 1/7 (4%) was lost to follow-up. No major complications were observed for both intra- and extraprostatic recurrence.

CONCLUSION

Salvage cryoablation of locally recurrent prostate cancer after curative treatment is feasible and safe when the half prostate is treated. It could delay initiation of androgen deprivation therapy in these patients.

Health utility and health-related quality of life of Japanese prostate cancer patients according to progression status measured using EQ-5D-5L and FACT-P

PURPOSE

To obtain health utility data to allow for cost-effectiveness analysis in groups stratified by disease progression along with health-related quality of life (HRQoL) information in Japanese prostate cancer (PC) patients.

METHODS

In this cross-sectional observational study, EuroQol-5 Dimension- 5 Level (EQ-5D-5L), EuroQol Visual Analog Scale (EQ-VAS), and Functional Assessment of Cancer Therapy-Prostate (FACT-P) measures were used to examine utility, VAS scores, and disease-specific HRQoL, respectively. Scores obtained were statistically examined for the correlation among measures and domains. Parameter estimates of statistically significant factors were assessed using generalized linear models (GLM).

RESULTS

A total of 380 patients stratified by their disease progression status were analyzed. The numbers (%) of patients in groups stratified as having localized (L), localized progression (LP), distant metastatic (DM), and DM-castration-resistant PC (CRPC) were 275 (72.4), 40 (10.5), 27 (7.1), and 38 (10.0), respectively. EQ-5D-5L mean (standard deviation, SD) scores of L, LP, DM, and DM-CRPC in study participants were 0.87 (0.15), 0.86 (0.15), 0.85 (0.18), and 0.84 (0.17), respectively. The mean (SD) scores assessed by EQ-5D-5L, EQ-VAS, and FACT-P instruments were 0.86 (0.16), 74.6 (16.8), and 110.8 (19.6), respectively. Utility scores correlated well with FACT-P scores. Eastern Cooperative Oncology Group performance status had significant influences on all instruments' scores.

CONCLUSIONS

We obtained health utility and HRQoL scores of Japanese PC patients stratified by disease progression in detail. Our results will be useful for establishing cost-effectiveness analyses in Japanese PC settings.

Cost and cost-effectiveness studies in urologic oncology using large administrative databases

OBJECTIVE

Urologic cancers are not only among the most common types of cancers, but also among the most expensive cancers to treat in the United States. This study aimed to review the use of CEAs and other cost analyses in urologic oncology using large databases to better understand the value of management strategies of these cancers.

METHODS

A literature review on CEAs and other cost analyses in urologic oncology using large databases.

RESULTS

The options for and costs of diagnosing, treating, and following patients with urologic cancers can be expected to rise in the coming years. There are numerous opportunities in each urologic cancer to use CEAs to both lower costs and provide high-quality services. Improved cancer care must balance the integration of novelty with ensuring reasonable costs to patients and the health care system.

CONCLUSION

With the increasing focus cost containment, appreciating the value of competing strategies in caring for our patients is pivotal. Leveraging methods such as CEAs and harnessing large databases may help evaluate the merit of established or emerging strategies.

Avoidance of androgen deprivation therapy in radiorecurrent prostate cancer as a clinically meaningful endpoint for salvage cryoablation

BACKGROUND

To investigate the ability of salvage cryoablation of the prostate (SCAP) to delay the need for androgen deprivation therapy (ADT) in local recurrence after radiation therapy to the prostate using the Cryo-On-Line Database (COLD) registry.

METHODS

The COLD registry is comprised of a combination of retrospectively and prospectively collected data on patients undergoing primary and SCAP. Patients with local recurrence after radiation therapy were identified. Kaplan-Meier analysis was used to calculate ADT-free survival.

RESULTS

We identified 898 patients that have undergone SCAP in the COLD registry. Overall, the calculated 5-year ADT-free survival probability was 0.713. When stratified by D'Amico risk group, 264 high-risk patients (71.9%), 234 intermediate-risk (86.7%),and 228 low-risk (87.7%) were free of ADT post-SCAP. This correlates with a 5-year ADT-free survival of 60.7, 73.9, and 82.4%, respectively. Patients with post-SCAP PSA nadir of <0.2 ng/mL had a 5 year ADT-free survival of 87.1% compared to 48.7% with a PSA nadir ≥0.2 ng/mL. Pre-operative ADT use or full versus partial gland SCAP did not have an effect on ADT use post-operatively. In 118 (55.4%) of patients with post-operative biochemical recurrence, ADT was not used.

CONCLUSION

For patients with local recurrence after radiation, SCAP is an option that provides a high chance of avoiding or delaying ADT. The potential to delay ADT and its associated side effects should be a part of counseling sessions with the patient when discussing treatment options for locally recurrent prostate cancer after radiation. Avoidance of ADT is more clinically relevant than PSA elevation.

Time-Series Modeling and Simulation for Comparative Cost-Effective Analysis in Cancer Chemotherapy: An Application to Platinum-Based Regimens for Advanced Non-small Cell Lung Cancer

The purpose of this study was to propose a time-series modeling and simulation (M&S) strategy for probabilistic cost-effective analysis in cancer chemotherapy using a Monte-Carlo method based on data available from the literature. The simulation included the cost for chemotherapy, for pharmaceutical care for adverse events (AEs) and other medical costs. As an application example, we describe the analysis for the comparison of four regimens, cisplatin plus irinotecan, carboplatin plus paclitaxel, cisplatin plus gemcitabine (GP), and cisplatin plus vinorelbine, for advanced non-small cell lung cancer. The factors, drug efficacy explained by overall survival or time to treatment failure, frequency and severity of AEs, utility value of AEs to determine QOL, the drugs' and other medical costs in Japan, were included in the model. The simulation was performed and quality adjusted life years (QALY) and incremental cost-effectiveness ratios (ICER) were calculated. An index, percentage of superiority (%SUP) which is the rate of the increased cost vs. QALY-gained plots within the area of positive QALY-gained and also below some threshold values of the ICER, was calculated as functions of threshold values of the ICER. An M&S process was developed, and for the simulation example, the GP regimen was the most cost-effective, in case of threshold values of the ICER=&#36;70000/year, the %SUP for the GP are more than 50%. We developed an M&S process for probabilistic cost-effective analysis, this method would be useful for decision-making in choosing a cancer chemotherapy regimen in terms of pharmacoeconomic.

PSA nadir as a predictive factor for biochemical disease-free survival and overall survival following whole-gland salvage HIFU following radiotherapy failure

Background:

Treatment options for radio-recurrent prostate cancer are either androgen-deprivation therapy or salvage prostatectomy. Whole-gland high-intensity focussed ultrasound (HIFU) might have a role in this setting.

Methods:

An independent HIFU registry collated consecutive cases of HIFU. Between 2005 and 2012, we identified 50 men who underwent whole-gland HIFU following histological confirmation of localised disease following prior external beam radiotherapy (2005–2012). No upper threshold was applied for risk category, PSA or Gleason grade either at presentation or at the time of failure. Progression was defined as a composite with biochemical failure (Phoenix criteria (PSA>nadir+2 ng ml⁻¹)), start of systemic therapies or metastases.

Results:

Median age (interquartile range (IQR)), pretreatment PSA (IQR) and Gleason score (range) were 68 years (64–72), 5.9 ng ml⁻¹ (2.2–11.3) and 7 (6–9), respectively. Median follow-up was 64 months (49–84). In all, 24/50 (48%) avoided androgen-deprivation therapies. Also, a total of 28/50 (56%) achieved a PSA nadir <0.5 ng ml⁻¹, 15/50 (30%) had a nadir ⩾0.5 ng ml⁻¹ and 7/50 (14%) did not nadir (PSA non-responders). Actuarial 1, 3 and 5-year progression-free survival (PFS) was 72, 40 and 31%, respectively. Actuarial 1, 3 and 5-year overall survival (OS) was 100, 94 and 87%, respectively. When comparing patients with PSA nadir <0.5 ng ml⁻¹, nadir ⩾0.5 and non-responders, a statistically significant difference in PFS was seen (P<0.0001). Three-year PFS in each group was 57, 20 and 0%, respectively. Five-year OS was 96, 100 and 38%, respectively. Early in the learning curve, between 2005 and 2007, 3/50 (6%) developed a fistula. Intervention for bladder outlet obstruction was needed in 27/50 (54%). Patient-reported outcome measure questionnaires showed incontinence (any pad-use) as 8/26 (31%).

Conclusions:

In our series of high-risk patients, in whom 30–50% may have micro-metastases, disease control rates were promising in PSA responders, however, with significant morbidity. Additionally, post-HIFU PSA nadir appears to be an important predictor for both progression and survival. Further research on focal salvage ablation in order to reduce toxicity while retaining disease control rates is required.