Presentation Authors: Kevin Wymer*, Vidit Sharma, Bijan Borah, Rochester, MN, James Catto, Sheffield, United Kingdom, R. Houston Thompson, R. Jeffrey Karnes, Stephen Boorjian, Rochester, MN
Introduction: 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 with primarily low/intermediate risk PCa randomized to active surveillance (AS), external beam radiotherapy (RT), or radical prostatectomy (RP). While AS had the lowest complication rate, AS also had a higher rate of metastasis compared to RT or RP. We herein compared the cost-effectiveness among the management arms of ProtecT.
Methods: A Markov decision analytic model was created to compare the cost-effectiveness of AS, RP, and RT based on ProtecT outcomes; specifically, 6 year quality of life data (perioperative complications, urinary, sexual, and bowel symptoms) and 10 year oncologic data (biochemical recurrence, metastases, and all-cause mortality). Costs were based on 2017 Medicare reimbursement rates. Utility values were assigned from the literature. Univariate sensitivity and multivariable Monte Carlo sensitivity analyses were performed.
Results: At 6 years after randomization, mean costs per patient were $11,957 (AS), $17,781 (RP), and $29,238 (RT). RP and RT each resulted in a gain of 0.05 quality adjusted life years (QALYs) relative to AS (4.90 and 4.90 versus 4.85, respectively). Accordingly, the incremental cost-effectiveness ratio relative to AS was $133,314/QALY for RP and $389,915/QALY for RT. The model was sensitive to the annual metastasis rate on AS, with a threshold of 0.7%/year, above which RP was more cost-effective than AS. On multivariable sensitivity analysis, at a willingness-to-pay (WTP) threshold of $100,000/QALY, the most cost-effective strategy was AS in 46%, RP in 44%, and RT in 10% of simulations. At a WTP threshold of $150,000/QALY, the most cost-effective strategy was RP in 44%, AS in 39%, and RT in 17% of simulations (Figure).
Conclusions: Based on oncologic and quality of life data from ProtecT, AS is a cost-effective strategy for localized PCa, while, for patients undergoing definitive local treatment, RP is more cost-effective than RT. Future study is warranted as ProtecT data matures.