ASCO GU 2019: Value-Based Decision-Making for Castrate-Sensitive Prostate Cancer

San Francisco, CA ( In this second talk of the session on quality and value for optimizing advanced prostate cancer treatment, Dr. Chen gave a presentation on value-based decision making for castration-sensitive prostate cancer.

He took a humorous, albeit apropos, approach to explaining the concept of value-based decision making. He pointed out, as many in the audience already knew, that today is Valentine’s Day. He put a play on words and called the scenario GUSFASCO (or GU ASCO fiasco).

In this GUSFASCO situation, many of the attendees are separated from their loved ones on Valentine’s day. They have a few options, and have to weigh each of the options.
UroToday ASCOGU2019 Value Based Decision Making for CSPC
Option 1: Make a phone call to wish loved one Happy Valentine’s day.
  • It’s cheap – essentially no cost
  • It’s effectiveness is low, essentially 5 relationship points
Option 2: Make phone call and send flowers
  • It’s slightly more expensive, approximately $50
  • However, its more effective, maybe worth 55 relationship points
  • This incremental value, defined as cost/effectiveness, is about $1/point
Option 3: Buying a diamond ring as an apology
  • It’s much more expensive, ~$4000
  • However, it is the most effect, ~75 relationship points
  • Its incremental value, unfortunately, is ~200/point
Ultimately, the decision to choose one option over the other is based on each individual’s willingness to pay (WTP) – or amount cutoff per unit of effectiveness that they are willing to pay. Each household or individual has competing financial interests that will affect the WTP level – bills, food, vacation, etc.

For example, if the WTP is set at $10/point, then flowers are the best option, rather than the ring:

UroToday ASCOGU2019 costeffectiveness

Important caveats:

  • If the value of diamonds suddenly drop (similar to a drug becoming generic), then it may fall under the WTP cutoff
  • If the individual is a wealthier situation and has the financial ability to spend unlimited money, then the ring may still be the best option

Ultimately, value-based decision making is based on:

  • Effectiveness
    • Survival outcomes
    • Quality of Life (QoL)
    • Combination of the two into QALY – quality of life adjusted life years
  • Understanding that there are competing obligations and limited resources

So, taking this to a real-life scenario with metastatic castration-sensitive prostate cancer, where ADT+docetaxel or ADT+abiraterone are the recommended treatments, he compared the data for both options:

  • Docetaxel
    • Current data puts the incremental benefit of docetaxel at $34,732/QALY – which is under the $100,000/QALY usually used in the United States as a cost-effective cutoff
    • However, different countries have a different WTP cutoff – a recent study demonstrated that while docetaxel was considered cost-effective in the US, Brazil, and UK, it was not in China (WTP ~$20K/QALY)
  • Abiraterone
    • Abiraterone is much more expensive
    • However, it is also more effective (for low and high volume disease)
    • Current data puts the incremental benefit at $295,000/QALY – which is well above the $100,000/QALY cutoff
    • However, if it were to become generic (as has been potentially promised), and costs are dropped below $3000/month, then the incremental cost may be <$100,000/QALY – and suddenly it becomes cost-effective

His conclusions were as follows:
UroToday ASCOGU2019 valuebaseddecisionmaking

Presented by: Ronald C. Chen, MD, MPH, University of North Carolina at Chapel Hill, Chapel Hill, NC 

Written by: Thenappan Chandrasekar, MD, Clinical Instructor, Thomas Jefferson University, @tchandra_uromd, @JEFFUrology, at the 2019 American Society of Clinical Oncology Genitourinary Cancers Symposium, (ASCO GU) #GU19, February 14-16, 2019 - San Francisco, CA

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