Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease.
We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments.
AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores.
LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.
Urologic oncology. 2023 Feb 01 [Epub ahead of print]
Aurash Naser-Tavakolian, Abhishek Venkataramana, Brennan Spiegel, Christopher Almario, Paul Kokorowski, Stephen J Freedland, Jennifer T Anger, John T Leppert, Timothy J Daskivich
Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA., The Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA., Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA., Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Section of Urology, Durham VA Medical Center, Durham, NC., Department of Urology, UC San Diego Health, La Jolla, CA., Division of Urology, Stanford University, Stanford CA., Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: .