Aug. 27, 2019
Prostate cancer is the most common cancer in men. Over the last several years, there has been an increased acknowledgment of the indolent nature of some prostate cancers. As a result, active surveillance (AS) of prostate cancer is recommended to many patients with very low-risk and low-risk cancers, and is endorsed as a management option by the American Urological Association. At the same time, radical prostatectomy (RP) and radiation therapy (RT) remain standard treatments for patients with prostate cancer at increased risk of disease progression.
Nevertheless, the optimal treatment approach ― and in particular from a health care system standpoint, the most cost-effective management strategy ― for men with prostate cancer remains to be determined.
Urologic oncologist Stephen A. Boorjian, M.D., and a research team at Mayo Clinic's campus in Rochester, Minnesota, recently utilized data from a large randomized trial known as the Prostate Testing for Cancer and Treatment (ProtecT) trial to conduct an analysis of the cost-effectiveness of the common prostate cancer management strategies.
Previous authors have evaluated the cost-effectiveness of various prostate cancer treatments, but these analyses have been limited by the availability of high-quality and prospective data with long follow-up.
The ProtecT trial randomized 1,643 men ages 50 to 69 to AS, RP or RT. After 10 years of follow-up, prostate-cancer-specific survival was not statistically different between each of the treatment groups. However, the rate of disease progression was significantly higher in the AS group. Results of the ProtecT trial were published in the New England Journal of Medicine in 2016.
To assess cost-effectiveness, the research team used the available 10-year oncologic outcome and six-year quality of life (QOL) data available in the ProtecT trial. The six-year QOL data was extrapolated to 10-year data for analysis. Researchers used cost data from Medicare and utility values already available in the literature.
Key outcomes
The key outcomes assessed in the cost-effectiveness study were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). ICER is a representation of the difference in cost between treatments relative to the difference in QALYs between treatments. QALYs attempt to take into account treatment side effects such as urinary or sexual symptoms and disease state burdens such as metastatic disease.
During the first six years of follow-up, AS was found to be cost-effective relative to RP and RT. However, after six years, RP and RT became more cost-effective than AS. Researchers attributed this outcome to the lower metastatic rate with radical treatment, the ongoing costs of repeat biopsies, and the fact that the number of patients on AS who eventually underwent radical treatment increased over time.
After six years, the mean cost per patient for AS, RP and RT was $12,143, $17,781 and $29,238, respectively. The ICERs for RP and RT (relative to AS) were $127,752/QALY and $381,894/QALYs.
However, after 10 years of follow-up, AS becomes the least cost-effective treatment. Relative to AS, the ICER for RP was $5,627/QALYs and the ICER for RT was $78,291/QALYs.
The conclusions put forth as a result of this important cost-effectiveness study may have a significant impact on the way various prostate cancer treatments are viewed by urologists and the public alike. Vidit Sharma, M.D., a urologic oncology fellow at Mayo Clinic in Rochester, Minnesota, comments: "Interestingly, ProtecT was largely interpreted by the media as being against prostate cancer treatment. However, the present cost-effectiveness study revealed that, after a detailed analysis of the results, ProtecT actually supports the upfront treatment of more-aggressive prostate cancers and the surveillance of less aggressive prostate cancers."
Dr. Boorjian summarizes the importance of the team's recent work: "Active surveillance is a very good treatment decision for many patients with prostate cancer. However, it is important to consider the risk of adverse pathology, development of metastatic disease and any individual patient's life expectancy. Therefore, each patient with prostate cancer requires a personalized and informed decision. Given increasing and appropriate pressure to manage costs, these treatment decisions have become increasingly complex."
Results of the Mayo Clinic study were published in the Journal of Urology in 2019.
For more information
Hamdy FC, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. New England Journal of Medicine. 2016;375:1415.
Sharma V, et al. Cost-effectiveness of active surveillance, radical prostatectomy, and external beam radiotherapy for localized prostate cancer: An analysis of the ProtecT trial. Journal of Urology. In press.