Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA.
Department of Radiation Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Cancer. 2022 Nov 1;128(21):3815-3823. doi: 10.1002/cncr.34450. Epub 2022 Sep 7.
Patients with high-risk prostate cancer (HRPC) have multiple accepted treatment options. Because there is no overall survival benefit of one option over another, appropriate treatment must consider patient life expectancy, quality of life, and cost.
The authors compared quality-adjusted life years (QALYs) and cost effectiveness among treatment options for HRPC using a Markov model with three treatment arms: (1) external-beam radiotherapy (EBRT) delivered with 20 fractions, (2) EBRT with 23 fractions followed by low-dose-rate (LDR) brachytherapy boost, or (3) radical prostatectomy alone. An exploratory analysis considered a simultaneous integrated boost according to the FLAME trial (ClinicalTrials.gov identifier NCT01168479).
Treatment strategies were compared using the incremental cost-effectiveness ratio (ICER). EBRT with LDR brachytherapy boost was a cost-effective strategy (ICER, $20,929 per QALY gained). These results were most sensitive to variations in the biochemical failure rate. However, the results still demonstrated cost effectiveness for the brachytherapy boost paradigm, regardless of any tested parameter ranges. Probabilistic sensitivity analysis demonstrated that EBRT with LDR brachytherapy was favored in 52% of 100,000 Monte Carlo iterations. In an exploratory analysis, EBRT with a simultaneous integrated boost was also a cost-effective strategy, resulting in an ICER of $62,607 per QALY gained; however, it was not cost effective compared with EBRT plus LDR brachytherapy boost.
EBRT with LDR brachytherapy boost may be a cost-effective treatment strategy compared with EBRT alone and radical prostatectomy for HRPC, demonstrating high-value care. The current analysis suggests that a reduction in biochemical failure alone can result in cost-effective care, despite no change in overall survival.
高危前列腺癌（HRPC）患者有多种可接受的治疗选择。由于一种选择相对于另一种选择没有总体生存获益，因此适当的治疗必须考虑患者的预期寿命、生活质量和成本。
作者使用具有三个治疗臂的马尔可夫模型比较了 HRPC 治疗选择的质量调整生命年（QALY）和成本效益：（1）用 20 个分数进行外照射放射治疗（EBRT），（2）用 23 个分数进行 EBRT 后进行低剂量率（LDR）近距离放射治疗（Brachytherapy）增强，或（3）单独根治性前列腺切除术。根据 FLAME 试验（ClinicalTrials.gov 标识符 NCT01168479）进行了同时综合增强的探索性分析。
使用增量成本效益比（ICER）比较了治疗策略。EBRT 联合 LDR 近距离放射治疗是一种具有成本效益的策略（ICER，每获得 1 个 QALY 增加 20,929 美元）。这些结果对生化失败率的变化最为敏感。但是，无论任何测试参数范围如何，这些结果仍然表明了近距离放射治疗增强范式的成本效益。概率敏感性分析表明，在 100,000 次蒙特卡罗迭代的 52％中，EBRT 联合 LDR 近距离放射治疗更为有利。在探索性分析中，EBRT 联合同时综合增强也是一种具有成本效益的策略，导致每获得 1 个 QALY 增加 62,607 美元的 ICER；然而，与 EBRT 联合 LDR 近距离放射治疗增强相比，它并不具有成本效益。
与单独 EBRT 和根治性前列腺切除术相比，EBRT 联合 LDR 近距离放射治疗可能是一种具有成本效益的治疗策略，为 HRPC 提供了高价值的治疗。目前的分析表明，尽管总生存没有改变，但仅降低生化失败率就可以实现具有成本效益的治疗。
