Abstract
BackgroundOptimal management strategies for clinically localised prostate cancer are debated. Using median 10-year data from the largest randomised controlled trial to date (ProtecT), the lifetime cost-effectiveness of three major treatments (radical radiotherapy, radical prostatectomy and active monitoring) was explored according to age and risk subgroups.MethodsA decision-analytic (Markov) model was developed and informed by clinical input. The economic evaluation adopted a UK NHS perspective and the outcome was cost per Quality-Adjusted Life Year (QALY) gained (reported in UK£), estimated using EQ-5D-3L.ResultsCosts and QALYs extrapolated over the lifetime were mostly similar between the three randomised strategies and their subgroups, but with some important differences. Across all analyses, active monitoring was associated with higher costs, probably associated with higher rates of metastatic disease and changes to radical treatments.When comparing the value of the strategies (QALY gains and costs) in monetary terms, for both low-risk prostate cancer subgroups, radiotherapy generated the greatest net monetary benefit (£293,446 [95% CI £282,811 to £299,451] by D’Amico and £292,736 [95% CI £284,074 to £297,719] by Grade group 1). However, the sensitivity analysis highlighted uncertainty in the finding when stratified by Grade group, as radiotherapy had 53% probability of cost-effectiveness and prostatectomy had 43%. In intermediate/high risk groups, using D’Amico and Grade group > = 2, prostatectomy generated the greatest net monetary benefit (£275,977 [95% CI £258,630 to £285,474] by D’Amico and £271,933 [95% CI £237,864 to £287,784] by Grade group). This finding was supported by the sensitivity analysis.Prostatectomy had the greatest net benefit (£290,487 [95% CI £280,781 to £296,281]) for men younger than 65 and radical radiotherapy (£201,311 [95% CI £195,161 to £205,049]) for men older than 65, but sensitivity analysis showed considerable uncertainty in both findings.ConclusionOver the lifetime, extrapolating from the ProtecT trial, radical radiotherapy and prostatectomy appeared to be cost-effective for low risk prostate cancer, and radical prostatectomy for intermediate/high risk prostate cancer, but there was uncertainty in some estimates. Longer ProtecT trial follow-up is required to reduce uncertainty in the model.Trial registrationCurrent Controlled Trials number, ISRCTN20141297: http://isrctn.org (14/10/2002); ClinicalTrials.gov number, NCT02044172: http://www.clinicaltrials.gov (23/01/2014).
Highlights
Optimal management strategies for clinically localised prostate cancer are debated
Prostate Testing for Cancer and Treatment (ProtecT) trial The ProtecT trial methods and median 10-year outcomes are reported in detail elsewhere [3, 7] At a median of 10-years’ follow up, the ProtecT trial reported no evidence of differences in prostate-cancer specific mortality [8] between the three management strategies, but the rate of disease progression (evidence of clinical progression (T3 or T4 or the initiation of long-term androgen deprivation therapy (ADT)) and metastases in the prostatectomy and radiotherapy group was half that of men in the active monitoring group (6% compared with 2–3%) [9]
Age thresholds Over a lifetime, both Quality-adjusted life years (QALYs) gained and costs were greater in men who were younger than 65 years than men older than 65 years
Summary
Optimal management strategies for clinically localised prostate cancer are debated. Due to the typically slow natural progression of the disease, many men with prostate cancer die of other causes, which has led to an international debate about the optimal disease management strategy [2]. NICE recommend offering a choice of treatment (active surveillance, prostatectomy and radiotherapy) for men with low risk, localised prostate cancer. For men with intermediate risk, localised prostate cancer, NICE recommend that radical treatment (either surgery or radiotherapy) be offered, but active surveillance should be considered for men who do not want radical treatment. Evidence from a direct comparison of the long-term cost-effectiveness of radical prostatectomy, radical radiotherapy and active monitoring for men with localised prostate cancer was not available for all men with localised prostate cancer or by risk stratification, and the recommendations were based on limited direct evidence of costeffectiveness
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