Cost-Effectiveness of Active Surveillance, Radical Prostatectomy, and External Beam Radiotherapy for Localized Prostate Cancer: An Analysis of the ProtecT Trial.

Despite increasing emphasis on value-based care, the cost-effectiveness of prostate cancer (PCa) management options has not been compared using prospective clinical trial data. The prostate testing for cancer and treatment (ProtecT) trial demonstrated no difference in survival for patients randomized to active surveillance (AS), external beam radiotherapy (RT), or radical prostatectomy (RP). Herein, we compare the cost-effectiveness among the arms of ProtecT.

A Markov model compared the cost-effectiveness of AS, RP, and RT based on ProtecT outcomes; specifically, 6-year quality of life data and 10 year oncologic data. Costs were based on 2017 Medicare reimbursement while utility values were assigned from the literature. Univariable and multivariable sensitivity analyses were performed.

At 6 years after randomization, mean costs per patient were $12,143 (AS), $17,781 (RP), and $29,238 (RT). The incremental cost-effectiveness ratio relative to AS was $133,314/QALY for RP and $389,915/QALY for RT. At 10 years after randomization, both RP ($5,627/QALY) and RT ($78,291/QALY) were found to be more cost-effective than AS. The model was sensitive to the metastasis rate on AS, with a threshold of 2.4% at 10 years, below which AS was more cost-effective than RP. On multivariable sensitivity analysis at 10 years, using a willingness-to-pay threshold of $100,000/QALY, the most cost-effective strategy was RP in 45%, RT in 30%, and AS in 25% of model micro-simulations.

Although AS represents a cost-effective management strategy for localized PCa during the initial several years after diagnosis, the relative cost-effectiveness of treatment emerges with extended follow up.

The Journal of urology. 2019 May 21 [Epub ahead of print]

Vidit Sharma, Kevin M Wymer, Bijan J Borah, Daniel A Barocas, R Houston Thompson, R Jeffrey Karnes, Stephen A Boorjian

Department of Urology, Mayo Clinic , Rochester , MN , USA., Department of Health Services Research, Mayo Clinic , Rochester , MN , USA., Department of Urology, Vanderbilt University Medical Center , Nashville , TN , USA.