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Kang SK, Mali RD, Prabhu V, Ferket BS, Loeb S. Active Surveillance Strategies for Low-Grade Prostate Cancer: Comparative Benefits and Cost-effectiveness. Radiology 2021; 300:594-604. [PMID: 34254851 DOI: 10.1148/radiol.2021204321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Active surveillance (AS) is the recommended treatment option for low-risk prostate cancer (PC). Surveillance varies in MRI, frequency of follow-up, and the Prostate Imaging Reporting and Data System (PI-RADS) score that would repeat biopsy. Purpose To compare the effectiveness and cost-effectiveness of AS strategies for low-risk PC with versus without MRI. Materials and Methods This study developed a mathematical model to evaluate the cost-effectiveness of surveillance strategies in a simulation of men with a diagnosis of low-risk PC. The following strategies were compared: watchful waiting, prostate-specific antigen (PSA) and annual biopsy without MRI, and PSA testing and MRI with varied PI-RADS thresholds for biopsy. MRI strategies differed regarding scheduling and use of PI-RADS score of at least 3, or a PI-RADS score of at least 4 to indicate the need for biopsy. Life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were calculated by using microsimulation. Sensitivity analysis was used to assess the impact of varying parameter values on results. Results For the base case of 60-year-old men, all strategies incorporating prostate MRI extended QALYs and life-years compared with watchful waiting and non-MRI strategies. Annual MRI strategies yielded 16.19 QALYs, annual biopsy with no MRI yielded 16.14 QALYs, and watchful waiting yielded 15.94 QALYs. Annual MRI with PI-RADS score of at least 3 or of at least 4 as the biopsy threshold and annual MRI with biopsy even after MRI with negative findings offered similar QALYs and the same unadjusted life expectancy: 23.05 life-years. However, a PI-RADS score of at least 4 yielded 42% fewer lifetime biopsies. With a cost-effectiveness threshold of $100 000 per QALY, annual MRI with biopsy for lesions with PI-RADS scores of 4 or greater was most cost-effective (incremental cost-effectiveness ratio, $67 221 per QALY). Age, treatment type, risk of initial grade misclassification, and quality-of-life impact of procedural complications affected results. Conclusion The use of active surveillance (AS) with biopsy decisions guided by findings from annual MRI reduces the number of biopsies while preserving life expectancy and quality of life. Biopsy in lesions with PI-RADS scores of 4 or greater is likely the most cost-effective AS strategy for men with low-risk prostate cancer who are younger than 70 years. © RSNA, 2021 Online supplemental material is available for this article. An earlier incorrect version appeared online. This article was corrected on July 13, 2021.
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Affiliation(s)
- Stella K Kang
- From the Departments of Radiology (S.K.K., R.D.M., V.P.), Population Health (S.K.K., S.L.), and Urology (S.L.), New York University Grossman School of Medicine, 660 First Ave, Room 333, New York, NY 10016; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F.); and Manhattan VA Medical Center, New York, NY (S.L.)
| | - Rahul D Mali
- From the Departments of Radiology (S.K.K., R.D.M., V.P.), Population Health (S.K.K., S.L.), and Urology (S.L.), New York University Grossman School of Medicine, 660 First Ave, Room 333, New York, NY 10016; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F.); and Manhattan VA Medical Center, New York, NY (S.L.)
| | - Vinay Prabhu
- From the Departments of Radiology (S.K.K., R.D.M., V.P.), Population Health (S.K.K., S.L.), and Urology (S.L.), New York University Grossman School of Medicine, 660 First Ave, Room 333, New York, NY 10016; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F.); and Manhattan VA Medical Center, New York, NY (S.L.)
| | - Bart S Ferket
- From the Departments of Radiology (S.K.K., R.D.M., V.P.), Population Health (S.K.K., S.L.), and Urology (S.L.), New York University Grossman School of Medicine, 660 First Ave, Room 333, New York, NY 10016; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F.); and Manhattan VA Medical Center, New York, NY (S.L.)
| | - Stacy Loeb
- From the Departments of Radiology (S.K.K., R.D.M., V.P.), Population Health (S.K.K., S.L.), and Urology (S.L.), New York University Grossman School of Medicine, 660 First Ave, Room 333, New York, NY 10016; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F.); and Manhattan VA Medical Center, New York, NY (S.L.)
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Nuijten M, Dainelli L, Rasouli B, Araujo Torres K, Perugini M, Marczewska A. A Meal Replacement Program for the Treatment of Obesity: A Cost-Effectiveness Analysis from the Swiss Payer's Perspective. Diabetes Metab Syndr Obes 2021; 14:3147-3160. [PMID: 34267531 PMCID: PMC8275158 DOI: 10.2147/dmso.s284855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/04/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Obesity is a disease associated with high direct medical costs and high indirect costs resulting from productivity loss. The high prevalence of obesity generates the need for payers to identify cost-effective weight loss approaches. Among various weight management techniques, the OPTI (Optifast®) program is a clinically recognised total meal replacement diet that can lead to significant weight loss and reduction in complications. This study's objective is to assess OPTI program's cost-effectiveness in Switzerland in comparison to "no intervention" and pharmacotherapy. METHODS An event-driven decision-analytic model was used to estimate the payer's cost savings through the reimbursement of OPTI program over a 1-year period as well as a lifetime in Switzerland. The analysis was performed on a broad population of people with obesity with a body mass index (BMI) higher than 30 kg/m2 following the OPTI program vs two comparators (liraglutide and "no intervention"). The model incorporated a higher risk of complications due to an increased BMI and their related healthcare costs. Data sources included published literature, clinical trials, official Swiss price/tariff lists and national population statistics. The primary perspective was that of a Swiss payer. Scenario analyses - for example, for patients with existing complications (such as myocardial infarction, stroke, type 2 diabetes mellitus) or severe obesity - were conducted to test the robustness of the results. RESULTS The OPTI program results in cost savings of CHF 20,886 (€ 18,724) and CHF 15,382 (€ 13,790) per person compared with "no intervention" and liraglutide 3 mg, respectively. In addition, OPTI program led to 1.133 and 0.734 quality-adjusted life years (QALYs) gained respectively against its comparators. Scenario analyses showed similar outcomes with cost savings and QALYs gained. CONCLUSION OPTI program is a dominant strategy compared to "no intervention" and liraglutide 3 mg as it leads to both cost savings and QALY gain. Therefore, reimbursing the OPTI program for patients with obesity would be cost-effective for Swiss payers.
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Affiliation(s)
- Mark Nuijten
- Health Economics and Valuation, A2M, Amsterdam, the Netherlands
| | - Livia Dainelli
- Global Market Access & Pricing, Nestlé Health Science, Vevey, Switzerland
| | - Bahareh Rasouli
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Moreno Perugini
- Commercial and Medical Affairs, Pharmaceuticals, Nestlé Health Science, Bridgewater, MA, USA
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Oliveira RARD, Mourão TC, Santana TBM, Favaretto RDL, Zequi SDC, Guimarães GC. Cost-Effectiveness Analysis of Prostate Cancer Screening in Brazil. Value Health Reg Issues 2021; 26:89-97. [PMID: 34146776 DOI: 10.1016/j.vhri.2021.02.002] [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: 10/28/2020] [Revised: 02/01/2021] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Prostate cancer is one of the most common malignancies among men worldwide. Prostate-specific antigen (PSA) screening shows uncertain benefits and harms from clinical and economic perspectives, resulting in an important impact on healthcare systems. Because of nonstandardized studies and substantial differences among populations, data are still inconclusive. OBJECTIVE The objective of this study was to carry out long-term cost-effectiveness and cost-utility analysis on the PSA-screened population from the service provider's perspective in the Brazilian population. METHODS We performed a cost-effectiveness and cost-utility analysis using clinical outcomes obtained from 9692 men enrolled in the PSA screening program. Prostate cancer treatments, 5-year follow-up outcomes, and all related costs were examined. Data were compared with a nonscreened prostate cancer population to calculate incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). ICER and ICUR were compared with the Brazilian-established willingness-to-pay (WTP) threshold (WTP = R$ 114 026.55). RESULTS A total of 251 of 9692 men had a diagnosis of prostate cancer (2.6%), of which 90% had localized disease. Two hundred and five patients were treated as follows: surgery (45.37%); radiation therapy (11.22%); radiation plus androgen deprivation therapy (21.95%); active surveillance (13.17%); exclusive androgen deprivation therapy (7.32%); and watchful waiting (0.98%). Two simulated cohorts were compared based on screening and nonscreening groups. Values obtained were-ICER of R$ 44 491.39 per life saved and ICUR of R$ 10 851.56 per quality-adjusted life year (QALY) gained-below the Brazilian WTP threshold and showed cost-effectiveness and cost-utility advantages. CONCLUSION According to the Brazilian WTP, PSA screening is a cost-effective policy from a hospital and long-term perspective and should have more standardized studies developed in different populations and economies.
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Affiliation(s)
- Renato Almeida Rosa de Oliveira
- Urology Department, Beneficência Portuguesa de São Paulo, São Paulo, Brazil; Instituto de Urologia, Oncologia e Cirurgia Robótica, São Paulo, Brazil.
| | - Thiago Camelo Mourão
- Urology Department, Beneficência Portuguesa de São Paulo, São Paulo, Brazil; Instituto de Urologia, Oncologia e Cirurgia Robótica, São Paulo, Brazil
| | - Thiago Borges Marques Santana
- Urology Department, Beneficência Portuguesa de São Paulo, São Paulo, Brazil; Instituto de Urologia, Oncologia e Cirurgia Robótica, São Paulo, Brazil
| | - Ricardo de Lima Favaretto
- Urology Department, Beneficência Portuguesa de São Paulo, São Paulo, Brazil; Instituto de Urologia, Oncologia e Cirurgia Robótica, São Paulo, Brazil
| | | | - Gustavo Cardoso Guimarães
- Instituto de Urologia, Oncologia e Cirurgia Robótica, São Paulo, Brazil; Surgical Oncology Department, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Magnani CJ, Bievre N, Baker LC, Brooks JD, Blayney DW, Hernandez-Boussard T. Real-world Evidence to Estimate Prostate Cancer Costs for First-line Treatment or Active Surveillance. EUR UROL SUPPL 2020; 23:20-29. [PMID: 33367287 PMCID: PMC7751921 DOI: 10.1016/j.euros.2020.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Prostate cancer is the most common cancer in men and second leading cause of cancer-related deaths. Changes in screening guidelines, adoption of active surveillance (AS), and implementation of high-cost technologies have changed treatment costs. Traditional cost-effectiveness studies rely on clinical trial protocols unlikely to capture actual practice behavior, and existing studies use data predating new technologies. Real-world evidence reflecting these changes is lacking. Objective To assess real-world costs of first-line prostate cancer management. Design setting and participants We used clinical electronic health records for 2008-2018 linked with the California Cancer Registry and the Medicare Fee Schedule to assess costs over 24 or 60 mo following diagnosis. We identified surgery or radiation treatments with structured methods, while we used both structured data and natural language processing to identify AS. Outcome measurements and statistical analysis Our results are risk-stratified calculated cost per day (CCPD) for first-line management, which are independent of treatment duration. We used the Kruskal-Wallis test to compare unadjusted CCPD while analysis of covariance log-linear models adjusted estimates for age and Charlson comorbidity. Results and limitations In 3433 patients, surgery (54.6%) was more common than radiation (22.3%) or AS (23.0%). Two years following diagnosis, AS ($2.97/d) was cheaper than surgery ($5.67/d) or radiation ($9.34/d) in favorable disease, while surgery ($7.17/d) was cheaper than radiation ($16.34/d) for unfavorable disease. At 5 yr, AS ($2.71/d) remained slightly cheaper than surgery ($2.87/d) and radiation ($4.36/d) in favorable disease, while for unfavorable disease surgery ($4.15/d) remained cheaper than radiation ($10.32/d). Study limitations include information derived from a single healthcare system and costs based on benchmark Medicare estimates rather than actual payment exchanges. Patient summary Active surveillance was cheaper than surgery (-47.6%) and radiation (-68.2%) at 2 yr for favorable-risk disease, which decreased by 5 yr (-5.6% and -37.8%, respectively). Surgery was less costly than radiation for unfavorable risk for both intervals (-56.1% and -59.8%, respectively).
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Affiliation(s)
| | - Nicolas Bievre
- Department of Statistics, Stanford University, Stanford, CA, USA
| | - Laurence C Baker
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - James D Brooks
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Douglas W Blayney
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA.,Stanford Cancer Institute, School of Medicine, Stanford University, CA, USA.,Clinical Excellence Research Center, School of Medicine, Stanford University, CA, USA
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Hueting TA, Cornel EB, Korthorst RA, Pleijhuis RG, Somford DM, van Basten JPA, van der Palen JAM, Koffijberg H. Optimizing the risk threshold of lymph node involvement for performing extended pelvic lymph node dissection in prostate cancer patients: a cost-effectiveness analysis. Urol Oncol 2020; 39:72.e7-72.e14. [PMID: 33121913 DOI: 10.1016/j.urolonc.2020.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 08/24/2020] [Accepted: 09/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extended pelvic lymph node dissection (ePLND) may be omitted in prostate cancer (CaP) patients with a low predicted risk of lymph node involvement (LNI). The aim of the current study was to quantify the cost-effectiveness of using different risk thresholds for predicted LNI in CaP patients to inform decision making on omitting ePLND. METHODS Five different thresholds (2%, 5%, 10%, 20%, and 100%) used in practice for performing ePLND were compared using a decision analytic cohort model with the 100% threshold (i.e., no ePLND) as reference. Compared outcomes consisted of quality-adjusted life years (QALYs) and costs. Baseline characteristics for the hypothetical cohort were based on an actual Dutch patient cohort containing 925 patients who underwent ePLND with risks of LNI predicted by the Memorial Sloan Kettering Cancer Center web-calculator. The best strategy was selected based on the incremental cost effectiveness ratio when applying a willingness to pay (WTP) threshold of €20,000 per QALY gained. Probabilistic sensitivity analysis was performed with Monte Carlo simulation to assess the robustness of the results. RESULTS Costs and health outcomes were lowest (€4,858 and 6.04 QALYs) for the 100% threshold, and highest (€10,939 and 6.21 QALYs) for the 2% threshold, respectively. The incremental cost effectiveness ratio for the 2%, 5%, 10%, and 20% threshold compared with the first threshold above (i.e., 5%, 10%, 20%, and 100%) were €189,222/QALY, €130,689/QALY, €51,920/QALY, and €23,187/QALY respectively. Applying a WTP threshold of €20.000 the probabilities for the 2%, 5%, 10%, 20%, and 100% threshold strategies being cost-effective were 0.0%, 0.3%, 4.9%, 30.3%, and 64.5% respectively. CONCLUSION Applying a WTP threshold of €20.000, completely omitting ePLND in CaP patients is cost-effective compared to other risk-based strategies. However, applying a 20% threshold for probable LNI to the Briganti 2012 nomogram or the Memorial Sloan Kettering Cancer Center web-calculator, may be a feasible alternative, in particular when higher WTP values are considered.
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Affiliation(s)
- Tom A Hueting
- Department of Health Technology & Services Research, Technical Medical Centre, University of Twente, Enschede.
| | - Erik B Cornel
- Department of urology, Ziekenhuisgroep Twente, Hengelo
| | | | - Rick G Pleijhuis
- Department of internal medicine, University Medical Center Groningen, Groningen, Netherlands
| | | | | | - Job A M van der Palen
- Faculty of behavioural, management and social sciences, research methodology, measurement and data analysis, University of Twente, Enschede. Medisch Spectrum Twente, Enschede
| | - Hendrik Koffijberg
- Department of Health Technology & Services Research, Technical Medical Centre, University of Twente, Enschede
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Noble SM, Garfield K, Lane JA, Metcalfe C, Davis M, Walsh EI, Martin RM, Turner EL, Peters TJ, Thorn JC, Mason M, Bollina P, Catto JWF, Doherty A, Gnanapragasam V, Hughes O, Kockelbergh R, Kynaston H, Paul A, Paez E, Rosario DJ, Rowe E, Oxley J, Staffurth J, Neal DE, Hamdy FC, Donovan JL. The ProtecT randomised trial cost-effectiveness analysis comparing active monitoring, surgery, or radiotherapy for prostate cancer. Br J Cancer 2020; 123:1063-1070. [PMID: 32669672 PMCID: PMC7524753 DOI: 10.1038/s41416-020-0978-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 06/08/2020] [Accepted: 06/25/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND There is limited evidence relating to the cost-effectiveness of treatments for localised prostate cancer. METHODS The cost-effectiveness of active monitoring, surgery, and radiotherapy was evaluated within the Prostate Testing for Cancer and Treatment (ProtecT) randomised controlled trial from a UK NHS perspective at 10 years' median follow-up. Prostate cancer resource-use collected from hospital records and trial participants was valued using UK reference-costs. QALYs (quality-adjusted-life-years) were calculated from patient-reported EQ-5D-3L measurements. Adjusted mean costs, QALYs, and incremental cost-effectiveness ratios were calculated; cost-effectiveness acceptability curves and sensitivity analyses addressed uncertainty; subgroup analyses considered age and disease-risk. RESULTS Adjusted mean QALYs were similar between groups: 6.89 (active monitoring), 7.09 (radiotherapy), and 6.91 (surgery). Active monitoring had lower adjusted mean costs (£5913) than radiotherapy (£7361) and surgery (£7519). Radiotherapy was the most likely (58% probability) cost-effective option at the UK NICE willingness-to-pay threshold (£20,000 per QALY). Subgroup analyses confirmed radiotherapy was cost-effective for older men and intermediate/high-risk disease groups; active monitoring was more likely to be the cost-effective option for younger men and low-risk groups. CONCLUSIONS Longer follow-up and modelling are required to determine the most cost-effective treatment for localised prostate cancer over a man's lifetime. 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)
- Sian M Noble
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - Kirsty Garfield
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - J Athene Lane
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Michael Davis
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Richard M Martin
- Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research, Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Emma L Turner
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna C Thorn
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Malcolm Mason
- The School of Medicine, University of Cardiff, Cardiff, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, Edinburgh, UK
| | - James W F Catto
- The Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - Vincent Gnanapragasam
- The Academic Urology Group, University of Cambridge, Cambridge, UK
- Cambridge Urology Translational Research and Clinical Trials Office, Cambridge, UK
| | - Owen Hughes
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals Leicester, Leicester, UK
| | | | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edgar Paez
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Derek J Rosario
- Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Edward Rowe
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - John Staffurth
- The School of Medicine, University of Cardiff, Cardiff, UK
| | - David E Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Olsson H, Nordström T, Jäderling F, Egevad L, Vigneswaran HT, Annerstedt M, Grönberg H, Eklund M, Lantz A. Incorporating Magnetic Resonance Imaging and Biomarkers in Active Surveillance Protocols - Results From the Prospective Stockholm3 Active Surveillance Trial (STHLM3AS). J Natl Cancer Inst 2020; 113:632-640. [PMID: 32866231 PMCID: PMC8096373 DOI: 10.1093/jnci/djaa131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/05/2020] [Accepted: 08/20/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Active surveillance (AS) for men with low-risk prostate cancer (PC) can lead to patient morbidity and healthcare overutilization. The aim of this study was to evaluate an AS protocol using the Stockholm3 test and magnetic resonance imaging (MRI) to reduce biopsy intensity. METHODS We conducted a prospective multicenter study of 280 invited men from a contemporary screening study (STHLM3), with Gleason Score (GS) 3 + 3 PC on a current AS protocol. Patients underwent prostate-MRI and blood sampling for analysis of the Stockholm3 test including protein biomarkers, genetic variants, and clinical variables to predict risk of GS ≥3 + 4 PC followed by systematic biopsies and targeted biopsies (for Prostate Imaging Reporting and Data System version 2 ≥3 lesions) in all men. Primary outcomes were reclassification to GS ≥3 + 4 PC and clinically significant PC (csPCa), including unfavorable intermediate risk PC or higher based on National Comprehensive Cancer Network guidelines. RESULTS Adding MRI-targeted biopsies to systematic biopsies increased sensitivity of GS ≥3 + 4 PC compared with systematic biopsies alone (relative sensitivity [RS] = 1.52, 95% confidence interval [CI] = 1.28 to 1.85). Performing biopsies in only MRI positive increased sensitivity of GS ≥3 + 4 PC (RS = 1.30, 95% CI = 1.04 to 1.67) and reduced number of biopsy procedures by 49.3% while missing 7.2% GS ≥3 + 4 PC and 1.4% csPCa. Excluding men with negative Stockholm3 test reduced the number of MRI investigations at follow-up by 22.5% and biopsies by 56.8% while missing 6.9% GS ≥3 + 4 PC and 1.3% csPCa. CONCLUSION Including MRI and targeted/systematic biopsies in the follow-up for men on AS increased sensitivity of PC reclassification. Incorporation of risk prediction models including biomarkers may reduce the need for MRI use in men with low-risk PC.
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Affiliation(s)
- Henrik Olsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Nordström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Sciences, Danderyd's Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Jäderling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Radiology, Capio St Göran Hospital, Stockholm, Sweden
| | - Lars Egevad
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Hari T Vigneswaran
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Henrik Grönberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna Lantz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Vernooij RW, Lancee M, Cleves A, Dahm P, Bangma CH, Aben KK. Radical prostatectomy versus deferred treatment for localised prostate cancer. Cochrane Database Syst Rev 2020; 6:CD006590. [PMID: 32495338 PMCID: PMC7270852 DOI: 10.1002/14651858.cd006590.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Prostate cancer is a common cancer but is oftentimes slow growing. When confined to the prostate, radical prostatectomy (RP), which involves removal of the prostate, offers potential cure that may come at the price of adverse events. Deferred treatment, involving observation and palliative treatment only (watchful waiting (WW)) or close monitoring and delayed local treatment with curative intent as needed in the setting of disease progression (active monitoring (AM)/surveillance (AS)) might be an alternative. This is an update of a Cochrane Review previously published in 2010. OBJECTIVES To assess effects of RP compared with deferred treatment for clinically localised prostate cancer. SEARCH METHODS We searched the Cochrane Library (including CDSR, CENTRAL, DARE, and HTA), MEDLINE, Embase, AMED, Web of Science, LILACS, Scopus, and OpenGrey. Additionally, we searched two trial registries and conference abstracts of three conferences (EAU, AUA, and ASCO) until 3 March 2020. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared RP versus deferred treatment in patients with localised prostate cancer, defined as T1-2, N0, M0 prostate cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of references and extracted data from included studies. The primary outcome was time to death from any cause; secondary outcomes were: time to death from prostate cancer; time to disease progression; time to metastatic disease; quality of life, including urinary and sexual function; and adverse events. We assessed the certainty of evidence per outcome using the GRADE approach. MAIN RESULTS: We included four studies with 2635 participants (average age between 60 to 70 years). Three multicentre RCTs, from Europe and USA, compared RP with WW (n = 1537), and one compared RP with AM (n = 1098). Radical prostatectomy versus watchful waiting RP probably reduces the risk of death from any cause (hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.70-0.90; 3 studies with 1537 participants; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1000 men in the RP group compared to 839 deaths per 1000 men in the WW group. RP probably also lowers the risk of death from prostate cancer (HR 0.57, 95% CI 0.44-0.73; 2 studies with 1426 participants; moderate-certainty evidence). Based on prostate cancer-specific mortality at 29 years, this corresponds to 195 deaths from prostate cancer per 1000 men in the RP group compared with 316 deaths from prostate cancer per 1000 men in the WW group. RP may reduce the risk of progression (HR 0.43, 95% CI 0.35-0.54; 2 studies with 1426 participants; I² = 54%; low-certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1000 men for the RP group compared with 684 progressions per 1000 men for the WW group) and probably reduces the risk of developing metastatic disease (HR 0.56, 95% CI 0.46-0.70; 2 studies with 1426 participants; I² = 0%; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1000 men for RP compared with 431 metastatic diseases per 1000 men for WW. General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio (RR) 1.0, 95% CI 0.85-1.16; low-certainty evidence), corresponding to 344 patients with high quality of life per 1000 men for the RP group compared with 344 patients with high quality of life per 1000 men for the WW group. Rates of urinary incontinence may be considerably higher (RR 3.97, 95% CI 2.34-6.74; low-certainty evidence), corresponding to 173 incontinent men per 1000 in the RP group compared with 44 incontinent men per 1000 in the WW group, as are rates of erectile dysfunction (RR 2.67, 95% CI 1.63-4.38; low-certainty evidence), corresponding to 389 erectile dysfunction events per 1000 for the RP group compared with 146 erectile dysfunction events per 1000 for the WW group, both at 10 years' follow-up. Radical prostatectomy versus active monitoring Based on one study including 1098 participants with 10 years' follow-up, there are probably no differences between RP and AM in time to death from any cause (HR 0.93, 95% CI 0.65-1.33; moderate-certainty evidence). Based on overall mortality at 10 years, this corresponds to 101 deaths per 1000 men in the RP group compared with 108 deaths per 1000 men in the AM group. Similarly, risk of death from prostate cancer probably is not different between the two groups (HR 0.63, 95% CI 0.21-1.89; moderate-certainty evidence). Based on prostate cancer-specific mortality at 10 years, this corresponds to nine prostate cancer deaths per 1000 men in the RP group compared with 15 prostate cancer deaths per 1000 men in the AM group. RP probably reduces the risk of progression (HR 0.39, 95% CI 0.27-0.56; moderate-certainty evidence; at 10 years, this corresponds to 86 progressions per 1000 men for RP compared with 206 progressions per 1000 men for AM) and the risk of developing metastatic disease (RR 0.39, 95% CI 0.21-0.73; moderate-certainty evidence; at 10 years, this corresponds to 24 metastatic diseases per 1000 men for the RP group compared with 61 metastatic diseases per 1000 men for the AM group).The general quality of life during follow-up was not different between the treatment groups. However, urinary function (mean difference (MD) 8.60 points lower, 95% CI 11.2-6.0 lower) and sexual function (MD 14.9 points lower, 95% CI 18.5-11.3 lower) on the Expanded Prostate Cancer Index Composite-26 (EPIC-26) instrument, were worse in the RP group. AUTHORS' CONCLUSIONS Based on long-term follow-up, RP compared with WW probably results in substantially improved oncological outcomes in men with localised prostate cancer but also markedly increases rates of urinary incontinence and erectile dysfunction. These findings are largely based on men diagnosed before widespread PSA screening, thereby limiting generalisability. Compared to AM, based on follow-up to 10 years, RP probably has similar outcomes with regard to overall and disease-specific survival yet probably reduces the risks of disease progression and metastatic disease. Urinary function and sexual function are probably decreased for the patients treated with RP.
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Affiliation(s)
- Robin Wm Vernooij
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Michelle Lancee
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Anne Cleves
- Velindre NHS Trust, Cardiff University Library Services, Cardiff, UK
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chris H Bangma
- Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Katja Kh Aben
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
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9
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Harat A, Harat M, Martinson M. A Cost-Effectiveness and Quality of Life Analysis of Different Approaches to the Management and Treatment of Localized Prostate Cancer. Front Oncol 2020; 10:103. [PMID: 32117753 PMCID: PMC7026676 DOI: 10.3389/fonc.2020.00103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/20/2020] [Indexed: 01/22/2023] Open
Abstract
The aim of this study was to compare the cost-effectiveness and quality-adjusted life years (QALYs) of active monitoring (AM), radical prostatectomy (PR), and external-beam radiotherapy with neoadjuvant hormone therapy (RT) for localized prostate cancer. Microsimulations of radical prostatectomy, 3D-conformal radiotherapy, or active monitoring were performed using Medicare reimbursement schedules and clinical trial results for a target population of men aged 50–69 years with newly diagnosed localized prostate cancer (T1-T2, NX, M0) over a time horizon of 10 years. Quality-adjusted life years (QALYs) and costs were assessed and sensitivity analyses performed. Monte Carlo simulations revealed that the mean cost for AM, PR, and RT were $15,654, $18,791, and $30,378, respectively, and QALYs were 6.96, 7.44, and 7.9 years, respectively. The incremental cost-effectiveness ratio (ICER) was $6,548 for PR over AM and $68,339 for RT over PR. Results were sensitive to the number of years of follow-up and procedure cost. With relaxed assumptions for AM, the ICER of PR and RT met the societal willingness to pay (WTP) threshold of $50,000 per QALY. Compared with AM, PR was highly cost-effective. RT and PR for localized prostate cancer can be cost-effective, but RT must offer increased QALYs or decreased procedural costs to be cost-effective compared to PR. Newer and cheaper radiotherapy strategies like stereotactic body radiotherapy may play a crucial role in future early prostate cancer management.
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Affiliation(s)
- Aleksandra Harat
- Department of Social and Medical Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maciej Harat
- Department of Oncology and Brachytherapy, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Department of Radiotherapy, Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
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10
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Chang EM, Punglia RS, Steinberg ML, Raldow AC. Cost Effectiveness of the Oncotype DX Genomic Prostate Score for Guiding Treatment Decisions in Patients With Early Stage Prostate Cancer. Urology 2019; 126:89-95. [DOI: 10.1016/j.urology.2018.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
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11
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Lorent M, Maalmi H, Tessier P, Supiot S, Dantan E, Foucher Y. Meta-analysis of predictive models to assess the clinical validity and utility for patient-centered medical decision making: application to the CAncer of the Prostate Risk Assessment (CAPRA). BMC Med Inform Decis Mak 2019; 19:2. [PMID: 30616621 PMCID: PMC6323757 DOI: 10.1186/s12911-018-0727-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 12/21/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The Cancer of the Prostate Risk Assessment (CAPRA) score was designed and validated several times to predict the biochemical recurrence-free survival after a radical prostatectomy. Our objectives were, first, to study the clinical validity of the CAPRA score, and, second, to assess its clinical utility for stratified medicine from an original patient-centered approach. METHODS We proposed a meta-analysis based on a literature search using MEDLINE. Observed and predicted biochemical-recurrence-free survivals were compared to assess the calibration of the CAPRA score. Discriminative capacities were evaluated by estimating the summary time-dependent ROC curve. The clinical utility of the CAPRA score was evaluated according to the following stratified decisions: active monitoring for low-risk patients, prostatectomy for intermediate-risk patients, or radio-hormonal therapy for high risk patients. For this purpose, we assessed CAPRA's clinical utility in terms of its ability to maximize time-dependent utility functions (i.e. Quality-Adjusted Life-Years - QALYs). RESULTS We identified 683 manuscripts and finally retained 9 studies. We reported good discriminative capacities with an area under the SROCt curve at 0.73 [95%CI from 0.67 to 0.79], while graphical calibration seemed acceptable. Nevertheless, we also described that the CAPRA score was unable to discriminate between the three medical alternatives, i.e. it did not allow an increase in the number of life years in perfect health (QALYs) of patients with prostate cancer. CONCLUSIONS We confirmed the prognostic capacities of the CAPRA score. In contrast, we were not able to demonstrate its clinical usefulness for stratified medicine from a patient-centered perspective. Our results also highlighted the confusion between clinical validity and utility. This distinction should be better considered in order to develop predictive tools useful in practice.
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Affiliation(s)
- Marine Lorent
- SPHERE (methodS in Patient-centered outcomes & HEalth ResEarch) U1246, INSERM, Nantes University, Tours University, Nantes, France
| | - Haïfa Maalmi
- Division of Clinical Epidemiology and Aging Research, Heidelberg University, Heidelberg, Germany
| | - Philippe Tessier
- SPHERE (methodS in Patient-centered outcomes & HEalth ResEarch) U1246, INSERM, Nantes University, Tours University, Nantes, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de l’Ouest René Gauducheau, Saint Herblain, France
- INSERM UMR892, Nantes University, Nantes, France
| | - Etienne Dantan
- SPHERE (methodS in Patient-centered outcomes & HEalth ResEarch) U1246, INSERM, Nantes University, Tours University, Nantes, France
| | - Yohann Foucher
- SPHERE (methodS in Patient-centered outcomes & HEalth ResEarch) U1246, INSERM, Nantes University, Tours University, Nantes, France
- Nantes University Hospital, Nantes, France
- IRS2, SPHERE U1246, 22 boulevard Bénoni Goullin, 44200 Nantes, France
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12
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A comprehensive analysis of cost of an active surveillance cohort compared to radical prostatectomy as primary treatment for prostate cancer. World J Urol 2018; 37:1297-1303. [DOI: 10.1007/s00345-018-2500-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022] Open
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13
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Glaser SM, Kalash R, Bongiorni DR, Roberts MS, Balasubramani GK, Jacobs BL, Beriwal S, Heron DE, Greenberger JS. Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer. In Vivo 2018; 32:113-120. [PMID: 29275307 PMCID: PMC5892645 DOI: 10.21873/invivo.11212] [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: 10/10/2017] [Revised: 11/19/2017] [Accepted: 11/29/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Prostate cancer can be treated with radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (BT). These modalities have similar cancer-related outcomes. We used an innovative method to analyze the cost of such treatment. MATERIALS AND METHODS We queried our Institution's Insurance Division [University of Pittsburgh Medical Center (UPMC) Health Plan] beneficiaries from 2003-2008, who were diagnosed with prostate cancer and also queried the UPMC tumor registry for all patients with prostate cancer treated at our Institution. In a de-identified manner, data from the Health Plan and Tumor Registry were merged. RESULTS A total of 354 patients with non-metastatic disease with treatment initiated within 9 months of diagnosis were included (RP=236, EBRT=55, and BT=63). Radiotherapy-treated patients tended to be older, higher-risk, and have more comorbidities. Unadjusted median total health care expenditures during the first year after diagnosis were: RP: $16,743, EBRT: $47,256, and BT: $23,237 (p<0.0005). A propensity score-matched model comparing RP and EBRT demonstrated median total health care expenditures during year one: RP: $8,189, EBRT: $10,081; p=0.48. In a propensity-matched model comparing RP and BT, the median total health care expenditures during year one were: RP: $18,143, BT: $26,531; p=0.015 and per year during years 2 through 5 from diagnosis were: RP: $5,913, BT: $6,110; p=0.68. CONCLUSION This pilot study demonstrates the feasibility of combining healthcare costs from the payer's perspective with clinical data from a Tumor Registry within an IDFS and represents a novel approach to investigating the economic impact of cancer treatment.
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Affiliation(s)
- Scott M Glaser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Ronny Kalash
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Dante R Bongiorni
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Mark S Roberts
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Goundappa K Balasubramani
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Joel S Greenberger
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A.
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14
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Lao C, Edlin R, Rouse P, Brown C, Holmes M, Gilling P, Lawrenson R. The cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer. BMC Cancer 2017; 17:529. [PMID: 28789623 PMCID: PMC5549326 DOI: 10.1186/s12885-017-3522-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 08/01/2017] [Indexed: 01/07/2023] Open
Abstract
Background Radical prostatectomy is the most common treatment for localised prostate cancer in New Zealand. Active surveillance was introduced to prevent overtreatment and reduce costs while preserving the option of radical prostatectomy. This study aims to evaluate the cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy. Methods Markov models were constructed to estimate the life-time cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer patients aged 45–70 years, using national datasets in New Zealand and published studies including the SPCG-4 study. This study was from the perspective of the Ministry of Health in New Zealand. Results Radical prostatectomy is less costly than active surveillance in men aged 45–55 years with low risk localised prostate cancer, but more costly for men aged 60–70 years. Scenario analyses demonstrated significant uncertainty as to the most cost-effective option in all age groups because of the unavailability of good quality of life data for men under active surveillance. Uncertainties around the likelihood of having radical prostatectomy when managed with active surveillance also affect the cost-effectiveness of active surveillance against radical prostatectomy. Conclusions Active surveillance is less likely to be cost-effective compared to radical prostatectomy for younger men diagnosed with low risk localised prostate cancer. The cost-effectiveness of active surveillance compared to radical prostatectomy is critically dependent on the ‘trigger’ for radical prostatectomy and the quality of life in men on active surveillance. Research on the latter would be beneficial. Electronic supplementary material The online version of this article (doi:10.1186/s12885-017-3522-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chunhuan Lao
- National Institute of Demographic and Economic Analysis, The University of Waikato, Level 3 Hockin building, Waikato Hospital, Hamilton, 3240, New Zealand.
| | - Richard Edlin
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Paul Rouse
- The University of Auckland Business School, The University of Auckland, Auckland, New Zealand
| | - Charis Brown
- National Institute of Demographic and Economic Analysis, The University of Waikato, Hamilton, New Zealand
| | - Michael Holmes
- Urology Department, Waikato Hospital, Hamilton, New Zealand
| | - Peter Gilling
- Department of Urology, Tauranga Hospital, Tauranga, New Zealand
| | - Ross Lawrenson
- National Institute of Demographic and Economic Analysis, The University of Waikato, Hamilton, New Zealand
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15
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McArthur GA, Mohr P, Ascierto PA, Arance A, Banos Hernaez A, Kaskel P, Weichenthal M, Shinde R, Stevinson K. Health Care Resource Utilization and Associated Costs Among Metastatic Cutaneous Melanoma Patients Treated with Ipilimumab (INTUITION Study). Oncologist 2017; 22:951-962. [PMID: 28526721 PMCID: PMC5553953 DOI: 10.1634/theoncologist.2016-0272] [Citation(s) in RCA: 7] [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: 07/11/2016] [Accepted: 02/02/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND There are limited real-world data on health care resource utilization (HCRU) among advanced melanoma patients. The objective of this study was to describe HCRU and health care costs associated with the management of advanced melanoma patients receiving ipilimumab. METHODS This retrospective multinational, observational study included advanced melanoma patients from Australia, Germany, Italy, and Spain who had received at least 1 dose of ipilimumab. Data extracted from medical charts included inpatient admissions, outpatient visits, surgical procedures, laboratory investigations, radiation therapy, imaging studies, and concomitant medications. Cost estimates were based on unit costs from country-specific standard reimbursement sources. Subgroup analyses were performed for BRAF mutation status and ipilimumab refractory patients, who had disease progression within 24 weeks of their last dose of ipilimumab. RESULTS Mean age of 362 enrolled patients was 60.6 years (standard deviation [SD] 14.4). During a median follow-up period of 30.2 weeks, 57% of patients were admitted to hospital and 16% underwent surgery. Health care resource utilization rates varied substantially across countries and were highest in Germany. Concomitant medications to treat adverse events were commonly used. Subgroup analyses showed higher utilization rates among ipilimumab refractory and BRAF mutant patients. Mean weekly total costs associated with HCRU were lower in the pre-progression period (€107; 95% confidence interval (CI): 79-145) than in the post-progression period (€216; 95% CI: 180-259). CONCLUSION Health care resource utilization pattern and associated costs among patients treated with ipilimumab varied greatly among countries and between pre- and post-progression periods. There is a high economic burden associated with ipilimumab refractory melanoma. IMPLICATIONS FOR PRACTICE Metastatic melanoma patients treated with the anti-CTLA-4 inhibitor ipilimumab have a high utilization of various types of health care services, such as inpatient hospital stays or doctor visits. There are differences across countries regarding patterns of health care utilization and economic burden of the disease. Health care services are used more frequently after patients experience progression of their disease. The study highlights that better therapies leading to durable response in patients with metastatic melanoma have the potential to decrease health care costs and patient burden in terms of hospitalizations and other health care services.
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Affiliation(s)
| | - Peter Mohr
- Elbe-Klinikum Buxtehude, Buxtehude, Germany
| | | | - Ana Arance
- Hospital Clinic Barcelona, Barcelona, Spain
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16
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Hutchinson R, Lotan Y. Cost consideration in utilization of multiparametric magnetic resonance imaging in prostate cancer. Transl Androl Urol 2017; 6:345-354. [PMID: 28725576 PMCID: PMC5503976 DOI: 10.21037/tau.2017.01.13] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The screening, evaluation and management of prostate cancer changed significantly in the last decade. The recommendations regarding prostate cancer screening continue to evolve with new revelations about existing data sets and longer followup of landmark trials. Robotics has gained the vast majority of the marketplace for surgically managed prostate cancer in rapid fashion. The need for intervention in low risk prostate cancer has been closely examined and more men are being expectantly managed than ever before. Amidst all these changes, prostate magnetic resonance imaging (MRI) has emerged as a disruptive technology. Through the use of dynamic contrast-enhanced and diffusion weighted series, prostate tumors that were previously not visible have become identifiable and quantifiable. The ability of MRI to improve staging and identification of clinically significant disease has resulted in increased utilization for different aspects of prostate cancer care. The best studied use is in men with a prior negative transrectal ultrasound guided (TRUS) prostate biopsy and the performance characteristics in this role match well with the clinical question raised. The role for MRI in initial biopsy, in pre-surgical planning before prostatectomy and in men on active surveillance is less well defined. A primary concern in the use of MRI is that of cost. MRI units are expensive, both in initial outlay and ongoing use. The availability of MRI varies widely between countries and even within regions of the same country. Different healthcare models have different approaches for allocating the use of expensive resources, including MRI, in times when they are scarce. Prostate MRI can be used at multiple points in the management algorithm of prostate cancer and each implies different cost concerns. In this review we present an overview of current research in cost and cost efficacy for the use of MRI in the management of prostate cancer. By examining what is known and highlighting areas of ongoing research we hope to provide the reader with a solid foundation for understanding these complex, ever-changing issues.
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Affiliation(s)
- Ryan Hutchinson
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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17
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de Carvalho TM, Heijnsdijk EAM, de Koning HJ. When should active surveillance for prostate cancer stop if no progression is detected? Prostate 2017; 77:962-969. [PMID: 28419541 DOI: 10.1002/pros.23352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/14/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND A significant proportion of screen-detected men with prostate cancer may be overdiagnosed. Active Surveillance (AS) has emerged as a way to mitigate this problem, by delaying treatment of men, who are at low-risk until this becomes necessary. However, it is not known after how much time or biopsy rounds should patients stop AS and transition to conservative management (CM), if no progression is detected. METHODS We used a microsimulation model with natural history of prostate cancer based on ERSPC and SEER data. We modeled referral to treatment while in AS, based on Johns Hopkins treatment-free survival data. We projected lifetime costs and effects of AS (and radical treatment, if progression is detected) under different biopsy follow-up schedules compared to CM, where radical treatment only occurs when men would be clinically diagnosed in absence of screening. RESULTS For men with low-risk disease in younger age groups (55-65), AS is cost-effective for up to 7 yearly biopsy rounds. For men older than 65, even one biopsy round results in quality adjusted life years (QALYs) lost, though it may result in QALYs gained for men without previous screening. For men with intermediate-risk disease AS is cost-effective even for men in 65-75 age group. CONCLUSIONS The benefit of AS when compared to CM is strongly dependent on life expectancy and disease risk. Clinicians should take this into account when selecting men to AS, deciding on biopsy frequency and when to stop AS surveillance rounds and transition to CM.
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Affiliation(s)
- Tiago M de Carvalho
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Harry J de Koning
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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18
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Dijkstra S, Govers TM, Hendriks RJ, Schalken JA, Van Criekinge W, Van Neste L, Grutters JPC, Sedelaar JPM, van Oort IM. Cost-effectiveness of a new urinary biomarker-based risk score compared to standard of care in prostate cancer diagnostics - a decision analytical model. BJU Int 2017; 120:659-665. [PMID: 28370948 DOI: 10.1111/bju.13861] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of a new urinary biomarker-based risk score (SelectMDx; MDxHealth, Inc., Irvine, CA, USA) to identify patients for transrectal ultrasonography (TRUS)-guided biopsy and to compare this with the current standard of care (SOC), using only prostate-specific antigen (PSA) to select for TRUS-guided biopsy. MATERIALS AND METHODS A decision tree and Markov model were developed to evaluate the cost-effectiveness of SelectMDx as a reflex test vs SOC in men with a PSA level of >3 ng/mL. Transition probabilities, utilities and costs were derived from the literature and expert opinion. Cost-effectiveness was expressed in quality-adjusted life years (QALYs) and healthcare costs of both diagnostic strategies, simulating the course of patients over a time horizon representing 18 years. Deterministic sensitivity analyses were performed to address uncertainty in assumptions. RESULTS A diagnostic strategy including SelectMDx with a cut-off chosen at a sensitivity of 95.7% for high-grade prostate cancer resulted in savings of €128 and a gain of 0.025 QALY per patient compared to the SOC strategy. The sensitivity analyses showed that the disutility assigned to active surveillance had a high impact on the QALYs gained and the disutility attributed to TRUS-guided biopsy only slightly influenced the outcome of the model. CONCLUSION Based on the currently available evidence, the reduction of over diagnosis and overtreatment due to the use of the SelectMDx test in men with PSA levels of >3 ng/mL may lead to a reduction in total costs per patient and a gain in QALYs.
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Affiliation(s)
- Siebren Dijkstra
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim M Govers
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rianne J Hendriks
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack A Schalken
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim Van Criekinge
- Department of Mathematical Modelling, Statistics and Bioinformatics, Ghent University, Ghent, Belgium
| | - Leander Van Neste
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Janneke P C Grutters
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
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19
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Lokman U, Erickson AM, Vasarainen H, Rannikko AS, Mirtti T. PTEN Loss but Not ERG Expression in Diagnostic Biopsies Is Associated with Increased Risk of Progression and Adverse Surgical Findings in Men with Prostate Cancer on Active Surveillance. Eur Urol Focus 2017; 4:867-873. [PMID: 28753869 DOI: 10.1016/j.euf.2017.03.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 02/15/2017] [Accepted: 03/07/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Active surveillance (AS) is an option for men with low-risk prostate cancer (PCa). PTEN and ERG have been considered as potential biomarkers of PCa progression and survival. OBJECTIVE To study the role of ERG and PTEN status in the Prostate Cancer Research International: Active Surveillance (PRIAS) trial diagnostic biopsies (DBxs) in predicting surveillance discontinuation and adverse surgical findings in subsequent radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS A total of 231 patients were recruited to the PRIAS between 2007 and 2013 in Helsinki. DBx tissue for immunohistochemistry (IHC) was available from 190 patients. Tissue microarrays (TMAs) were constructed from 57 specimens of subsequent RPs. DBxs containing grade group (GG) 1 PCa and RP TMA sections were stained with ERG and PTEN antibodies, and scored as either negative or positive. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Outcomes were followed up by biopsy GG upgrade (GG ≥ 2) and protocol-based treatment change, as well as adverse findings in RP (GG ≥ 3 or pathological stage≥3). Clinical variables and biomarker status in DBx were correlated in Cox regression analysis and cumulative survival in Kaplan-Meier analysis, and finally, Gray's competing risk analysis was performed and nonprotocol-based discontinuation was considered as a competing event. RESULTS AND LIMITATIONS In both uni- and multivariate Cox regression analyses, only the number of positive cores in the DBx, the number of rebiopsy sessions, and PTEN status at diagnosis were significantly associated with rebiopsy GG upgrade, treatment change, and adverse histopathology in RP. In Kaplan-Meier analysis, PTEN loss was associated with a shorter time to GG upgrade and treatment change. Patients with PTEN loss had a higher probability for protocol-based discontinuation but not for competing risk factors compared with patients with intact PTEN. Biopsy ERG status was concordant with RP TMA ERG status, while PTEN was not. Limitations include a retrospective analysis of prospective cohort data. CONCLUSIONS PTEN status at diagnosis is a potential biomarker for identifying patients with PCa on AS with a high risk for progression or adverse findings on subsequent RP. PATIENT SUMMARY A simple diagnostic biopsy-based analysis of PTEN status may help identify patients with high risk for prostate cancer progression.
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Affiliation(s)
- Utku Lokman
- Department of Urology, Helsinki University Hospital, Helsinki, Finland
| | - Andrew M Erickson
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Hanna Vasarainen
- Department of Urology, Helsinki University Hospital, Helsinki, Finland
| | - Antti S Rannikko
- Department of Urology, Helsinki University Hospital, Helsinki, Finland
| | - Tuomas Mirtti
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland; Department of Pathology (HUSLAB) and Medicum, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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Cost-Effectiveness Comparison of Imaging-Guided Prostate Biopsy Techniques: Systematic Transrectal Ultrasound, Direct In-Bore MRI, and Image Fusion. AJR Am J Roentgenol 2017; 208:1058-1063. [PMID: 28225639 DOI: 10.2214/ajr.16.17322] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Three commonly used prostate biopsy approaches are systematic transrectal ultrasound guided, direct in-bore MRI guided, and image fusion guided. The aim of this study was to calculate which strategy is most cost-effective. MATERIALS AND METHODS A decision tree and Markov model were developed to compare cost-effectiveness. Literature review and expert opinion were used as input. A strategy was deemed cost-effective if the costs of gaining one quality-adjusted life year (incremental cost-effectiveness ratio) did not exceed the willingness-to-pay threshold of €80,000 (≈$85,000 in January 2017). A base case analysis was performed to compare systematic transrectal ultrasound- and image fusion-guided biopsies. Because of a lack of appropriate literature regarding the accuracy of direct in-bore MRI-guided biopsy, a threshold analysis was performed. RESULTS The incremental cost-effectiveness ratio for fusion-guided biopsy compared with systematic transrectal ultrasound-guided biopsy was €1386 ($1470) per quality-adjusted life year gained, which was below the willingness-to-pay threshold and thus assumed cost-effective. If MRI findings are normal in a patient with clinically significant prostate cancer, the sensitivity of direct in-bore MRI-guided biopsy has to be at least 88.8%. If that is the case, the incremental cost-effectiveness ratio is €80,000 per quality-adjusted life year gained and thus cost-effective. CONCLUSION Fusion-guided biopsy seems to be cost-effective compared with systematic transrectal ultrasound-guided biopsy. Future research is needed to determine whether direct in-bore MRI-guided biopsy is the best pathway; in this study a threshold was calculated at which it would be cost-effective.
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Keller A, Gericke C, Whitty JA, Yaxley J, Kua B, Coughlin G, Gianduzzo T. A Cost-Utility Analysis of Prostate Cancer Screening in Australia. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:95-111. [PMID: 27757918 DOI: 10.1007/s40258-016-0278-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES The Göteborg randomised population-based prostate cancer screening trial demonstrated that prostate-specific antigen (PSA)-based screening reduces prostate cancer deaths compared with an age-matched control group. Utilising the prostate cancer detection rates from this study, we investigated the clinical and cost effectiveness of a similar PSA-based screening strategy for an Australian population of men aged 50-69 years. METHODS A decision model that incorporated Markov processes was developed from a health system perspective. The base-case scenario compared a population-based screening programme with current opportunistic screening practices. Costs, utility values, treatment patterns and background mortality rates were derived from Australian data. All costs were adjusted to reflect July 2015 Australian dollars (A$). An alternative scenario compared systematic with opportunistic screening but with optimisation of active surveillance (AS) uptake in both groups. A discount rate of 5 % for costs and benefits was utilised. Univariate and probabilistic sensitivity analyses were performed to assess the effect of variable uncertainty on model outcomes. RESULTS Our model very closely replicated the number of deaths from both prostate cancer and background mortality in the Göteborg study. The incremental cost per quality-adjusted life-year (QALY) for PSA screening was A$147,528. However, for years of life gained (LYGs), PSA-based screening (A$45,890/LYG) appeared more favourable. Our alternative scenario with optimised AS improved cost utility to A$45,881/QALY, with screening becoming cost effective at a 92 % AS uptake rate. Both modelled scenarios were most sensitive to the utility of patients before and after intervention, and the discount rate used. CONCLUSION PSA-based screening is not cost effective compared with Australia's assumed willingness-to-pay threshold of A$50,000/QALY. It appears more cost effective if LYGs are used as the relevant outcome, and is more cost effective than the established Australian breast cancer screening programme on this basis. Optimised utilisation of AS increases the cost effectiveness of prostate cancer screening dramatically.
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Affiliation(s)
- Andrew Keller
- University of Queensland, Brisbane, QLD, Australia.
- Wesley Research Institute, The Wesley Private Hospital, Brisbane, QLD, Australia.
| | - Christian Gericke
- University of Queensland, Brisbane, QLD, Australia
- Wesley Research Institute, The Wesley Private Hospital, Brisbane, QLD, Australia
| | | | - John Yaxley
- The Wesley Private Hospital, Brisbane, QLD, Australia
| | - Boon Kua
- The Wesley Private Hospital, Brisbane, QLD, Australia
| | | | - Troy Gianduzzo
- University of Queensland, Brisbane, QLD, Australia
- The Wesley Private Hospital, Brisbane, QLD, Australia
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22
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Venkatesh S, Pasternak JD, Beninato T, Drake FT, Kluijfhout WP, Liu C, Gosnell JE, Shen WT, Clark OH, Duh QY, Suh I. Cost-effectiveness of active surveillance versus hemithyroidectomy for micropapillary thyroid cancer. Surgery 2017; 161:116-126. [DOI: 10.1016/j.surg.2016.06.076] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/01/2016] [Accepted: 06/16/2016] [Indexed: 11/25/2022]
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23
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Brandes A, Koerber F, Schwarzkopf L, Hunger M, Rogowski WH, Waidelich R. Costs of conservative management of early-stage prostate cancer compared to radical prostatectomy-a claims data analysis. BMC Health Serv Res 2016; 16:664. [PMID: 27863486 PMCID: PMC5116165 DOI: 10.1186/s12913-016-1886-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 10/29/2016] [Indexed: 11/30/2022] Open
Abstract
Background Due to widespread PSA testing incidence rates of localized prostate cancer increase but curative treatment is often not required. Overtreatment imposes a substantial economic burden on health care systems. We compared the direct medical costs of conservative management and radical therapy for the management of early-stage prostate cancer in routine care. Methods An observational study design is chosen based on claims data of a German statutory health insurance fund for the years 2008–2011. Three hundred fifty-three age-matched men diagnosed with prostate cancer and treated with conservative management and radical prostatectomy, are included. Individuals with diagnoses of metastases or treatment of advanced prostate cancer are excluded. In an excess cost approach direct medical costs are considered from an insured community perspective for in- and outpatient care, pharmaceuticals, physiotherapy, and assistive technologies. Generalized linear models adjust for comorbidity by Charlson comorbidity score and recycled predictions method calculates per capita costs per treatment strategy. Results After follow-up of 2.5 years per capita costs of conservative management are €6611 lower than costs of prostatectomy ([−9734;−3547], p < 0.0001). Complications increase costs of assistive technologies by 30% (p = 0.0182), but do not influence any other costs. Results are robust to cost outliers and incidence of prostate cancer diagnosis. The short time horizon does not allow assessing long-term consequences of conservative management. Conclusions At a time horizon of 2.5 years, conservative management is preferable to radical prostatectomy in terms of costs. Claims data analysis is limited in the selection of comparable treatment groups, as clinical information is scarce and bias due to non-randomization can only be partly mitigated by matching and confounder adjustment. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1886-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alina Brandes
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Florian Koerber
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Larissa Schwarzkopf
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Matthias Hunger
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Wolf H Rogowski
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany. .,Institute of Public Health and Nursing Research, Health Sciences, University of Bremen, Bremen, Germany.
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24
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Gordon LG, James R, Tuffaha HW, Lowe A, Yaxley J. Cost‐effectiveness analysis of multiparametric MRI with increased active surveillance for low‐risk prostate cancer in Australia. J Magn Reson Imaging 2016; 45:1304-1315. [DOI: 10.1002/jmri.25504] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 09/21/2016] [Indexed: 12/31/2022] Open
Affiliation(s)
| | - Robbie James
- Griffith University, Centre for Applied Health Economics, Nathan CampusBrisbane Australia
| | - Haitham W. Tuffaha
- Griffith University, Centre for Applied Health Economics, Nathan CampusBrisbane Australia
| | - Anthony Lowe
- Prostate Cancer Foundation of Australia, St LeonardsSydney Australia
- Griffith University, Menzies Health Institute QueenslandSouthport Australia
| | - John Yaxley
- The Wesley Hospital, AuchenflowerBrisbane Australia
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25
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Becerra V, Ávila M, Jimenez J, Cortes-Sanabria L, Pardo Y, Garin O, Pont A, Alonso J, Cots F, Ferrer M. Economic evaluation of treatments for patients with localized prostate cancer in Europe: a systematic review. BMC Health Serv Res 2016; 16:541. [PMID: 27716267 PMCID: PMC5048403 DOI: 10.1186/s12913-016-1781-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 09/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Our objective was to assess the efficiency of treatments in patients with localized prostate cancer, by synthesizing available evidence from European economic evaluations through systematic review. METHODS Articles published 2000-2015 were searched in MEDLINE, EMBASE and NHS EED (Prospero protocol CRD42015022063). Two authors independently selected studies for inclusion and extracted the data. A third reviewer resolved discrepancies. We included European economic evaluations or cost comparison studies, of any modality of surgery or radiotherapy treatments, regardless the comparator/s. Drummond's Checklist was used for quality assessment. RESULTS After reviewing 8,789 titles, 13 European eligible studies were included: eight cost-utility, two cost-effectiveness, one cost-minimization, and two cost-comparison analyses. Of them, five compared interventions with expectant management, four contrasted robotic with non robotic-assisted surgery, three assessed new modalities of radiotherapy, and three compared radical prostatectomy with brachytherapy. All but two studies scored ≥8 in the quality checklist. Considering scenario and comparator, three interventions were qualified as dominant strategies (active surveillance, robotic-assisted surgery and IMRT), and six were cost-effective (radical prostatectomy, robotic-assisted surgery, IMRT, proton therapy, brachytherapy, and 3DCRT). However, QALY gains in most of them were small. For interventions considered as dominant strategies, QALY gain was 0.013 for active surveillance over radical prostatectomy; and 0.007 for robotic-assisted over non-robotic techniques. The highest QALY gains were 0.57-0.86 for radical prostatectomy vs watchful waiting, and 0.72 for brachytherapy vs conventional radiotherapy. CONCLUSIONS Currently, relevant treatment alternatives for localized prostate cancer are scarcely evaluated in Europe. Very limited available evidence supports the cost-effectiveness of radical prostatectomy over watchful waiting, brachytherapy over radical prostatectomy, and new treatment modalities over traditional procedures. Relevant disparities were detected among studies, mainly based on effectiveness. These apparently contradictory results may be reflecting the difficulty of interpreting small differences between treatments regarding QALY gains.
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Affiliation(s)
- Virginia Becerra
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - Mónica Ávila
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Jorge Jimenez
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Laura Cortes-Sanabria
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, IMSS, Guadalajara, México
| | - Yolanda Pardo
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Olatz Garin
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Angels Pont
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Jordi Alonso
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Francesc Cots
- Epidemiology and Evaluation Department, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Health Services Research on Chronic Patients Network (Red de Investigación en Servicios de Salud en Enfermedades Crónicas [REDISSEC]), Barcelona, Spain
| | - Montse Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain. .,Universitat Pompeu Fabra, Barcelona, Spain. .,Universitat Autònoma de Barcelona, Bellaterra, Spain.
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26
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Sanyal C, Aprikian AG, Cury FL, Chevalier S, Dragomir A. Management of localized and advanced prostate cancer in Canada: A lifetime cost and quality-adjusted life-year analysis. Cancer 2016; 122:1085-96. [PMID: 26828716 DOI: 10.1002/cncr.29892] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/18/2015] [Accepted: 12/21/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND To the authors' knowledge, the literature to date lacks studies examining lifetime costs and quality-adjusted life-years (QALYs) of prostate cancer (PCa) management strategies that integrate localized and advanced disease. The objective of the current study was to assess lifetime costs and QALYs associated with contemporary PCa management strategies across risk groups by integrating localized and advanced disease. METHODS The authors' validated Markov chain Monte Carlo model was used to predict lifetime direct costs and QALYs. The health states modeled were active surveillance, initial treatments (radical prostatectomy or radiotherapy), PCa recurrence, PCa recurrence free, metastatic castration-resistant prostate cancer, and death (cause specific/other causes). Data regarding treatment distribution, state transition probabilities, adverse effects of management options, costs, utilities, and disutilities were derived from the published literature. RESULTS The total cost per patient for the overall cohort increased from $18,503 at 5 years to $28,032 and $39,143, respectively, at 10 years and 15 years. Furthermore, the results indicated the influence of risk group on total cost, with the high-risk group accruing the maximum per patient cost followed by the intermediate-risk and low-risk groups. Active surveillance was found to confer the most QALYs (12.5 years) and was the least costly strategy ($18,452) for individuals at low risk. For all risk groups, radical prostatectomy was less costly and conferred modestly more QALYs compared with intensity-modulated radiotherapy modalities. CONCLUSIONS Public health care systems in Canada and elsewhere are operating under budget constraints to allocate finite resources. The findings of the current study might inform discussions concerning budget planning to provide health care services.
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Affiliation(s)
| | - Armen G Aprikian
- Department of Urology, McGill University, Montreal, Quebec, Canada.,Research Institute of McGill University Health Center, Montreal, Quebec, Canada
| | - Fabio L Cury
- Department of Urology, McGill University, Montreal, Quebec, Canada.,Division of Radiation Oncology, McGill University Health Center, Montreal, Quebec, Canada
| | - Simone Chevalier
- Department of Urology, McGill University, Montreal, Quebec, Canada.,Research Institute of McGill University Health Center, Montreal, Quebec, Canada
| | - Alice Dragomir
- Department of Urology, McGill University, Montreal, Quebec, Canada.,Research Institute of McGill University Health Center, Montreal, Quebec, Canada
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Hutchinson RC, Costa DN, Lotan Y. The economic effect of using magnetic resonance imaging and magnetic resonance ultrasound fusion biopsy for prostate cancer diagnosis. Urol Oncol 2015; 34:296-302. [PMID: 26725249 DOI: 10.1016/j.urolonc.2015.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/23/2015] [Accepted: 10/26/2015] [Indexed: 01/24/2023]
Abstract
Prostate magnetic resonance imaging (MRI) is a maturing imaging modality that has been used to improve detection and staging of prostate cancer. The goal of this review is to evaluate the economic effect of the use of MRI and MRI fusion in the diagnosis of prostate cancer. A literature review was used to identify articles regarding efficacy and cost of MRI and MRI-guided biopsies. There are currently a limited number of studies evaluating cost of incorporating MRI into clinical practice. These studies are primarily models projecting cost estimates based on meta-analyses of the literature. There is considerable variance in the effectiveness of MRI-guided biopsies, both cognitive and fusion, based on user experience, type of MRI (3T vs. 1.5T), use of endorectal coil and type of scoring system for abnormalities such that there is still potential for improvement in accuracy. There is also variability in assumed costs of incorporating MRI into clinical practice. The addition of MRI to the diagnostic algorithm for prostate cancer has caused a shift in how we understand the disease and in what tumors are found on initial and repeat biopsies. Further risk stratification may allow more men to pursue noncurative therapy, which in and of itself is cost-effective in properly selected men. As prostate cancer care comes under increasing scrutiny on a national level, there is pressure on providers to be more accurate in their diagnoses. This in turn can lead to additional testing including Multiparametric MRI, which adds upfront cost. Whether the additional cost of prostate MRI is warranted in detection of prostate cancer is an area of intense research.
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Affiliation(s)
- Ryan C Hutchinson
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Daniel N Costa
- Department of Radiology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Yair Lotan
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX.
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Rogowski W, Payne K, Schnell-Inderst P, Manca A, Rochau U, Jahn B, Alagoz O, Leidl R, Siebert U. Concepts of 'personalization' in personalized medicine: implications for economic evaluation. PHARMACOECONOMICS 2015; 33:49-59. [PMID: 25249200 PMCID: PMC4422179 DOI: 10.1007/s40273-014-0211-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
CONTEXT This study assesses if, and how, existing methods for economic evaluation are applicable to the evaluation of personalized medicine (PM) and, if not, where extension to methods may be required. METHODS A structured workshop was held with a predefined group of experts (n = 47), and was run using a modified nominal group technique. Workshop findings were recorded using extensive note taking, and summarized using thematic data analysis. The workshop was complemented by structured literature searches. RESULTS The key finding emerging from the workshop, using an economic perspective, was that two distinct, but linked, interpretations of the concept of PM exist (personalization by 'physiology' or 'preferences'). These interpretations involve specific challenges for the design and conduct of economic evaluations. Existing evaluative (extra-welfarist) frameworks were generally considered appropriate for evaluating PM. When 'personalization' is viewed as using physiological biomarkers, challenges include representing complex care pathways; representing spillover effects; meeting data requirements such as evidence on heterogeneity; and choosing appropriate time horizons for the value of further research in uncertainty analysis. When viewed as tailoring medicine to patient preferences, further work is needed regarding revealed preferences, e.g. treatment (non)adherence; stated preferences, e.g. risk interpretation and attitude; consideration of heterogeneity in preferences; and the appropriate framework (welfarism vs. extra-welfarism) to incorporate non-health benefits. CONCLUSIONS Ideally, economic evaluations should take account of both interpretations of PM and consider physiology and preferences. It is important for decision makers to be cognizant of the issues involved with the economic evaluation of PM to appropriately interpret the evidence and target future research funding.
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Affiliation(s)
- Wolf Rogowski
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany,
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