Department of Urology, University of Minnesota, Minneapolis, MN, USA; Department of Surgery, Urology Unit, University of Melbourne and Olivia Newton-John Cancer Research Institute Austin Health, Melbourne, Australia.
Department of Urology, University of Minnesota, Minneapolis, MN, USA.
Eur Urol. 2019 Jun;75(6):910-917. doi: 10.1016/j.eururo.2018.10.055. Epub 2018 Nov 10.
Active surveillance (AS) has become the recommended management strategy for men with low-risk prostate cancer. However, there is considerable uncertainty about the optimal follow-up schedule in terms of the tests to perform and their frequency.
To assess the costs and benefits of different AS follow-up strategies compared to watchful waiting (WW) or immediate treatment.
DESIGN, SETTING, AND PARTICIPANTS: A state-transition Markov model was developed to simulate the natural history (ie, no testing or intervention) of prostate cancer for a hypothetical cohort of 50-yr-old men newly diagnosed with low-risk prostate cancer. Following diagnosis, men were hypothetically managed with immediate treatment, watchful waiting, or one of several AS strategies. AS follow-up was performed either with transrectal ultrasound-guided biopsy or magnetic resonance imaging (MRI) which was scheduled annually, biennially, every 3yrs, according to the PRIAS protocol (yrs 1, 4, 7, and 10, and then every 5yr) or every 5yr. Diagnosis of higher-grade or -stage disease while on AS resulted in curative treatment.
We measured discounted quality-adjusted life years (QALYs), discounted lifetime medical costs (2017 US$), and incremental cost-effectiveness ratios (ICERs).
Compared to WW, MRI-based surveillance performed every 5yr improved quality-adjusted survival by 4.47 quality-adjusted months and represented high-value health care at the Medicare reimbursement rate using standard cost-effectiveness metrics. Biopsy-based strategies were less effective and less costly than the corresponding MRI-based strategies for each testing interval. MRI-based surveillance at more frequent intervals had ICERs greater than $800000 per QALY and would not be considered cost-effective according to standard metrics. Our results were sensitive to the diagnostic accuracy and costs of both biopsy modes in detecting clinically significant cancer.
Incorporation of MRI into surveillance protocols at Medicare reimbursement rates and decreasing the intensity of repeat testing may be cost-effective options for men opting for conservative management of low-risk prostate cancer.
Our study modeled outcomes for men with low-risk prostate cancer undergoing watchful waiting, immediate treatment, or active surveillance with different follow-up schedules. We found that conservative management of low-risk disease optimizes health outcomes and costs. Furthermore, we showed that decreasing the intensity of active surveillance follow-up and incorporating magnetic resonance imaging (MRI) into surveillance protocols can be cost-effective, depending on the MRI costs.
主动监测（AS）已成为低危前列腺癌患者的推荐管理策略。然而，在执行测试及其频率方面，对于最佳随访方案仍存在相当大的不确定性。
评估与观察等待（WW）或即刻治疗相比，不同 AS 随访策略的成本效益。
设计、设置和参与者：开发了一个状态转移马尔可夫模型，以模拟假设队列中 50 岁新诊断为低危前列腺癌男性的前列腺癌自然史（即不进行任何检测或干预）。诊断后，假设男性接受即刻治疗、观察等待或几种 AS 策略之一进行管理。AS 随访通过经直肠超声引导活检或 MRI 进行，根据 PRIAS 方案（第 1、4、7 和 10 年，然后每 5 年）或每 5 年进行年度、每两年或每 3 年进行一次。在 AS 过程中诊断出高级别或更晚期疾病时，采用治愈性治疗。
与 WW 相比，每 5 年进行一次 MRI 监测可提高 4.47 个质量调整生存月，并在使用标准成本效益指标的 Medicare 报销率下代表高价值的医疗保健。与相应的 MRI 为基础的策略相比，基于活检的策略在每个检测间隔的效果较差，成本较低。更频繁的 MRI 监测间隔的 ICER 超过 800000 美元/QALY，根据标准指标，不会被认为具有成本效益。我们的结果对活检模式在检测临床显著癌症方面的诊断准确性和成本敏感。
在 Medicare 报销率下将 MRI 纳入监测方案，并降低重复检测的强度，可能是选择对低危前列腺癌进行保守治疗的男性的一种具有成本效益的选择。
我们的研究对接受观察等待、即刻治疗或不同随访计划的主动监测的低危前列腺癌男性进行了结果建模。我们发现，低危疾病的保守管理可优化健康结果和成本。此外，我们表明，降低主动监测随访的强度并将磁共振成像（MRI）纳入监测方案可以具有成本效益，具体取决于 MRI 成本。
