부산대학교 도서관

Background Optimal 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. Methods A 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[pounds sterling]), estimated using EQ-5D-3L. Results Costs 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 ([pounds sterling]293,446 [95% CI [pounds sterling]282,811 to [pounds sterling]299,451] by D'Amico and [pounds sterling]292,736 [95% CI [pounds sterling]284,074 to [pounds sterling]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 ([pounds sterling]275,977 [95% CI [pounds sterling]258,630 to [pounds sterling]285,474] by D'Amico and [pounds sterling]271,933 [95% CI [pounds sterling]237,864 to [pounds sterling]287,784] by Grade group). This finding was supported by the sensitivity analysis. Prostatectomy had the greatest net benefit ([pounds sterling]290,487 [95% CI [pounds sterling]280,781 to [pounds sterling]296,281]) for men younger than 65 and radical radiotherapy ([pounds sterling]201,311 [95% CI [pounds sterling]195,161 to [pounds sterling]205,049]) for men older than 65, but sensitivity analysis showed considerable uncertainty in both findings. Conclusion Over 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 registration Current Controlled Trials number, ISRCTN20141297: http://isrctn.org (14/10/2002); ClinicalTrials.gov number, NCT02044172: http://www.clinicaltrials.gov (23/01/2014). Keywords: Prostate cancer, ProtecT trial, Lifetime cost-effectiveness, Active monitoring, Radiotherapy, Prostatectomy
Author(s): S. Sanghera[sup.1], S. Mohiuddin[sup.1,2], J. Coast[sup.1], K. Garfield[sup.1,3], S. Noble[sup.1], C. Metcalfe[sup.3], J. A. Lane[sup.3,4], E. L. Turner[sup.4], D. Neal[sup.5], F. C. Hamdy[sup.5], R. M. Martin[sup.4,6], J. L. Donovan[sup.2,4], [...]