Chicago, IL—Active surveillance is a cost-effective option for low-risk clinically localized prostate cancer.
The number of quality-adjusted lifeyears (QALYs) was highest with active surveillance compared with radical prostatectomy, radiation therapy, brachytherapy, and proton beam therapy, according to data presented by Julia H. Hayes, MD, instructor in medicine at Harvard Medical School, and attending physician at Dana-Farber Cancer Institute, Boston, MA, during a poster presentation at the 2010 meeting of the American Society of Clinical Oncology.
“In the age of PSA [prostate-specific antigen] screening, more than 50% of men with clinical localized disease are overtreated, meaning that they are treated unnecessarily, and treatment is associated with significant side effects,” she said.
Dr Hayes used a Markov Monte Carlo model to estimate costs and QALYs of 5 different therapeutic strategies for clinically localized, low-risk prostate cancer. The model considered active surveillance (a policy of following men closely and treating them at the first sign of progression with intent to cure) or immediate treatment with any 1 of the following: radical prostatectomy, intensity-modulated radiation therapy (IMRT), brachytherapy, or proton beam therapy. Costs included Medicare reimbursement rates for treatment and costs associated with side effects, treatment, visits, biopsies, and patient time costs in 2008 US dollars. Cost and QALYs were discounted at 3% annually.
The model assumed equivalent prostate cancer–related outcomes, and then the risk of dying from prostate cancer was varied.
For a 65-year-old man, brachytherapy was the least expensive treatment option when considering total costs ($25,606), whereas proton beam therapy was the most expensive ($53,828). Active surveillance was associated with the highest quality-adjusted life expectancy (QALE), at 8.58 QALYs. Compared with radical prostatectomy, active surveillance provided an additional 9.1 months of QALE, at an incremental cost-effectiveness ratio of $2729 per QALY.
Brachytherapy and IMRT had similar QALE benefit, but IMRT cost $21,050 compared with $10,174 for brachytherapy.
“The reason that active surveillance cost more than brachytherapy was because everybody who progressed on active surveillance, which was about 60% of men over the course of their lives, went on to IMRT, and IMRT cost about $20,000 and brachytherapy cost about $10,000,” said Dr Hayes.
“If we assumed that men on active surveillance got brachytherapy or radical prostatectomy, it actually became the most effective and least expensive,” he said.
For a 55-year-old man, active surveillance provided an additional 4.7 months of QALYs compared with radical prostatectomy, at an incremental cost-effectiveness ratio of $829 per QALY.
Active surveillance remained the most effective strategy, even if the risk of disease progression doubled, the risk of symptoms on active surveillance doubled, and the risk of side effects of treatment was reduced by half (from 53% to 26%).
The risk of prostate cancer–specific death on active surveillance would have to be 60% higher than after initial treatment (16% vs 9%) to eliminate the QALE advantage of active surveillance compared with immediate treatment. “You would have to almost double the risk of dying from prostate cancer on active surveillance in order to make initial treatment favored in terms of QALE,” Dr Hayes said.
