Postorchiectomy Surveillance Less Cost-Effective than Other Management Options

Phoebe Starr

March 2013, Vol 4, No 3 - Health Economics

Orlando, FL—Para-aortic radiotherapy, dog leg radiotherapy, and 1 cycle of carboplatin (Paraplatin) are cost-effective options for the treatment of patients with stage I testicular seminoma, but surveillance is not a cost-effective option, according to a cost analysis that factored in reimbursement costs for salvage bleomycin (Blenoxane), etoposide phosphate (Etopophos), and platinum (BEP) chemotherapy after a potential relapse. This analysis was presented at the 2013 Genitourinary Cancers Symposium.

When salvage BEP therapy was factored into the costs, surveillance alone was more costly and less effective compared with the other 3 strategies.

Approximately 50% of the estimated 8000 new cases of testicular seminoma annually are stage I, explained presenting investigator John Cox, MD, chief resident, Department of Radiation Oncology, University of Texas Medical Branch at Galveston. Approximately 80% to 85% of patients with stage I testicular seminoma who are managed with surveillance do not relapse, and therefore they do not require adjuvant therapy. For patients who relapse, para-aortic radiotherapy, dog leg radiotherapy, or cisplatin-based chemotherapy are effective treatments.

The goal of the cost analysis was to assess the costs that are associated with each management strategy in 2011 and in 2012, after the National Comprehensive Cancer Network (NCCN) changed its guidelines to reduce the use of imaging and laboratory tests during postorchiectomy surveillance follow-up. The NCCN 2012 guidelines remained unchanged for adjuvant radiation. The analysis also sought to assess the costs associated with the required 10-year follow-up for each strategy.

“Total reimbursement costs changed greatly for treatment and follow-up with imaging and markers from 2011 to 2012 for recommendations for 10 years of follow-up for both surveillance and single-agent carboplatin,” Dr Cox said.

The analysis used the expected 5-year failure rate of 18% for surveillance, 4% for para-aortic radiotherapy and for dog leg radiotherapy, and 5% for carboplatin. Medicare reimbursement rates were used to determine the actual reimbursement for each treatment course over a 10-year period.

Based on the current NCCN guidelines, the total Medicare reimbursement in 2012, when factoring in the cost of salvage therapy, was:

  • $10,643 for surveillance
  • $11,648 for para-aortic radiotherapy
  • $9662 for dog leg radiotherapy
  • $7870 for carboplatin.

In 2011, reimbursements for the 4 strategies, respectively, were $20,986; $11,517; $9394; and $20,365.

The incremental cost ratio for the default strategy of salvage chemotherapy with 3 cycles of BEP was calculated at $12,139.

No data on quality of life in these men with decades-long life expectancy and no quality-adjusted data were included in this study.

Dr Cox and colleagues plan to do further analyses of the costs and patient variables that are associated with adjuvant treatment modalities in this patient population. n