Cost-effectiveness of standard therapies for localized prostate cancer

According to a news item on the web site of the University of California, San Francisco, a new paper from a team lead by a UCSF researcher is, “The most comprehensive retrospective study ever conducted comparing how the major types of prostate cancer treatments stack up to each other in terms of saving lives and cost effectiveness.”

This new paper by Cooperberg et al., which appears in BJU International, offers a Markov model-based analysis of the costs and effectiveness of three different types of radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (dose-escalated three-dimensional conformal radiation, intensity-modulated radiation, brachytherapy, or some combination thereof). It is notable that it does not include any data on the cost-benefits of active surveillance or some other newer techniques such as stereotactic body radiation therapy (let alone things like proton beam radiation therapy or focal therapy of any type). To that extent, the practical value of the paper to the patient community is significantly limited.

Perhaps the most telling statement about the study’s findings is Dr. Cooperburg’s statement in the UCSF news item where he is quoted as saying that, “There is very little solid evidence that one [treatment approach] is better than another.”

Cooperburg and his colleagues were able to use accumulated data from > 230 published papers to construct a so-called Markov model which was designed to allow them to follow the outcomes of a series of hypothetical patients with low-, intermediate-, and high-risk prostate cancer over their lifetimes after primary treatment. At every treatment time-point, the patients might go into remission, have recurrent disease, need salvage treatment, have metastasis, die from their prostate cancer, or die from other causes.

The authors claim to be able to show that:

  • Differences among the various treatments options (when measured in terms of quality-adjusted life years of QALYs) were relatively modest.
    • Between 10.3 and 11.3 for low-risk patients
    • Between 9.6 and 10.5 for intermediate-risk patients
    • Between 7.8 and 9.3 for high-risk patients
  • Significant differences among surgical methods were not observed
  • Surgical methods “tended to be more effective than radiation therapy methods, with the exception of combined external beam radiation + brachytherapy for high-risk disease.”
  • Surgical methods were consistently less expensive than radiotherapeutic methods.
    • Costs ranged a low value of $19,901 (for robot-assisted prostatectomy for low-risk disease) to a high of $50,276 (for combined radiation therapy for high-risk disease).

The authors conclude that their analysis “found small differences in outcomes and substantial differences in payer and patient costs across treatment alternatives” and that their findings”may inform future policy discussions about strategies to improve efficiency of treatment selection for localized prostate cancer.”

4 Responses

  1. I expect that cost is going to become a major factor in what Medicare will be allowed to pay for the various treatment procedures. Already I noticed in a paper that Medicare has dropped what they will allow for proton beam therapy to, if I recollect correctly, $35,000 from a previous $50,000. These cuts are going to hit the PBT facilities pretty deeply into their pocketbooks after spending multi-millions to bring PBT to their facilities. And more and more we are learning that PBT results are no better than the less expensive IMRT/IGRT. Should be interesting on what the government will be doing regarding Medicare allowances for all treatment options … and other health insurers will likely follow suit.

  2. Apparently not having the entire original article available may lead to somewhat misleading conclusions.

    From what is available elsewhere, the cost for brachytherapy (without additional external radiation therapy) is only slightly higher than RALP.
    Unfortunately, the authors didn’t include cryotherapy in their study; cryotherapy seems to be less costly than any of the others and seems to be effective for low-risk cancer as well.

  3. However, whole gland cryotherapy is associated with high risk for significant side effects, and I am not so sure that it is necessarily similar in cost to RALP (although that may depend on where you go to have it, as is the case for all types of therapy).

  4. AUA quotes the cost of cryo to be about 50% of the cost of a “traditional treatment” (prostatectomy?); not sure how old this article is.

    Other references quote incontinence effects of cryoytherapy as comparable to those of other treatments; on the average, ED risks seem to be higher than those of other treatments.

    My main comment really just pointed out that Cryo was not included in the study (and, of course, neither was PBT).

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