Active surveillance for prostate cancer compared with immediate treatment: an economic analysis

Abstract

Background: The costs associated with a contemporary active surveillance strategy compared with immediate treatment for prostate cancer are not well characterized. The purpose of this study is to elucidate the health care costs of an active surveillance paradigm for prostate cancer.

Methods: A theoretical cohort of 120,000 men selecting active surveillance for prostate cancer was created. The number of men remaining on active surveillance and those exiting to each of 5 treatments over 5 years were simulated in a Markov model. Estimated total costs after 5 years of active surveillance with subsequent delayed treatment were compared with immediate treatment. Sensitivity analyses were performed to test the effect of various surveillance strategies and attrition rates. Additional analyses to include 10 years of follow-up were performed.

Results: The average simulated cost of treatment for 120,000 men initiating active surveillance with 5 years of follow-up and subsequent delayed treatment resulted in per patient cost savings of $16,042 (95% confidence interval [CI], $16,039-$16,046) relative to initial curative treatment. This represents a $1.9 billion dollar savings to the cohort. The strict costs of active surveillance exceeded those of brachytherapy in the ninth year of follow-up. A yearly biopsy within the active surveillance cohort increased costs by 22%, compared with every other year biopsy. At 10 years of follow-up, active surveillance still resulted in a cost benefit; however, the savings were reduced by 38% to $9944 (95% CI, $9941-$9948) per patient relative to initial treatment.

Conclusions: These data demonstrate that active surveillance represents a considerable cost savings over immediate treatment for prostate cancer in a theoretical cohort after 5 and 10 years of follow-up.

Figure 1

Costs of primary treatment and active surveillance (AS) are shown, with follow-up costs at every other year biopsy. ADT, androgen deprivation therapy; Brachy, brachy-therapy; IGRT, image-guided radiotherapy.

Figure 2

Total costs of active surveillance (AS) with delayed treatment after 5 years of follow-up are shown: (A) AS costs with exit within follow-up year 1; (B) AS costs with exit follow-up year 2; (C) AS costs with exit follow-up year 3; (D) AS costs with exit follow-up year 4; (E) AS costs with exit follow-up year 5. ADT, androgen deprivation therapy; Brachy, brachytherapy; IGRT, image-guided radiotherapy.