Wallis Christopher J D, Morton Gerard, Jerath Angela, Satkunasviam Raj, Szumacher Ewa, Herschorn Sender, Kodama Ronald T, Kulkarni Girish S, Naimark David, Nam Robert K
Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.
MDM Policy Pract. 2017 May 19;2(1):2381468317709476. doi: 10.1177/2381468317709476. eCollection 2017 Jan-Jun.
Patients undergoing surgery for prostate cancer who have adverse pathological findings experience high rates of recurrence. While there are data supporting adjuvant radiotherapy compared to a wait-and-watch strategy to reduce recurrence rates, there are no randomized controlled trials comparing adjuvant radiotherapy with the other standard of care, salvage radiotherapy (radiotherapy administered at the time of recurrence). We constructed a health state transition (Markov) model employing two-dimensional Monte Carlo simulation using a lifetime horizon to compare the quality-adjusted survival associated with postoperative strategies using adjuvant or salvage radiotherapy. Prior to analysis, we calibrated and validated our model using the results of previous randomized controlled trials. We considered clinically important oncological health states from immediately postoperative to prostate cancer-specific death, commonly described complications from prostate cancer treatment, and other causes of mortality. Transition probabilities and utilities for disease states were derived from a literature search of MEDLINE and expert consensus. Salvage radiotherapy was associated with an increased quality-adjusted life expectancy (QALE) (58.3 months) as compared with adjuvant radiotherapy (53.7 months), a difference of 4.6 months (standard deviation 8.8). Salvage radiotherapy had higher QALE in 53% of hypothetical cohorts. There was a minimal difference in overall life expectancy (-0.1 months). Examining recurrence rates, our model showed validity when compared with available randomized controlled data. A salvage radiotherapy strategy appears to provide improved QALE for patients with adverse pathological findings following radical prostatectomy, compared with adjuvant radiotherapy. As these findings reflect, population averages, specific patient and tumor factors, and patient preferences remain central for individualized management.
接受前列腺癌手术且病理结果不良的患者复发率很高。虽然有数据支持辅助放疗与观察等待策略相比可降低复发率，但尚无随机对照试验将辅助放疗与另一种标准治疗方法挽救性放疗（复发时进行的放疗）进行比较。我们构建了一个健康状态转换（马尔可夫）模型，采用二维蒙特卡洛模拟，以终生为时间范围，比较采用辅助放疗或挽救性放疗的术后策略的质量调整生存期。在分析之前，我们使用先前随机对照试验的结果对模型进行了校准和验证。我们考虑了从术后即刻到前列腺癌特异性死亡的临床重要肿瘤健康状态、前列腺癌治疗常见的并发症以及其他死亡原因。疾病状态的转移概率和效用值来自对MEDLINE的文献检索和专家共识。与辅助放疗（53.7个月）相比，挽救性放疗的质量调整预期寿命（QALE）增加（58.3个月），相差4.6个月（标准差8.8）。在53%的假设队列中，挽救性放疗的QALE更高。总体预期寿命的差异最小（-0.1个月）。检查复发率时，与现有随机对照数据相比，我们的模型显示有效。与辅助放疗相比，挽救性放疗策略似乎能为根治性前列腺切除术后病理结果不良的患者提供更高的QALE。正如这些发现所反映的，人群平均值、特定患者和肿瘤因素以及患者偏好对于个体化管理仍然至关重要。
