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Randomized Controlled Trial
. 2020 Oct 7;20(1):971.
doi: 10.1186/s12885-020-07276-4.

Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial

S Sanghera  1 , S Mohiuddin  2   3 , J Coast  2 , K Garfield  2   4 , S Noble  2 , C Metcalfe  4 , J A Lane  4   5 , E L Turner  5 , D Neal  6 , F C Hamdy  6 , R M Martin  5   7 , J L Donovan  3   5 ; ProtecT study group
Collaborators, Affiliations
Randomized Controlled Trial

Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial

S Sanghera et al. BMC Cancer. .

Abstract

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£), 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 (£293,446 [95% CI £282,811 to £299,451] by D'Amico and £292,736 [95% CI £284,074 to £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 (£275,977 [95% CI £258,630 to £285,474] by D'Amico and £271,933 [95% CI £237,864 to £287,784] by Grade group). This finding was supported by the sensitivity analysis. Prostatectomy had the greatest net benefit (£290,487 [95% CI £280,781 to £296,281]) for men younger than 65 and radical radiotherapy (£201,311 [95% CI £195,161 to £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: Active monitoring; Lifetime cost-effectiveness; Prostate cancer; Prostatectomy; ProtecT trial; Radiotherapy.

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Conflict of interest statement

SS, KG, SN, CM, JAL, FCH, DN and JLD had financial support from NIHR HTA and RMM and ET from CRUK for the submitted work; All other authors declare no conflict of interest.

Figures

Fig. 1
Fig. 1
Schematic diagram of the Markov model
Fig. 2
Fig. 2
Cost-effectiveness acceptability curves for all analyses
See this image and copyright information in PMC

References

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    1. Lane JA, Donovan JL, Davis M, et al. Active monitoring, radical prostatectomy, or radiotherapy for localised prostate cancer: study design and diagnostic and baseline results of the ProtecT randomised phase 3 trial. Lancet Oncol. 2014;15:1109–1118. doi: 10.1016/S1470-2045(14)70361-4. - DOI - PubMed
    1. D’Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280(11):969–974. doi: 10.1001/jama.280.11.969. - DOI - PubMed
    1. NICE . Prostate cancer: diagnosis and management. London: National Institute for Health and Care Excellence; 2019. - PubMed

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