Naser-Tavakolian Aurash, Venkataramana Abhishek, Spiegel Brennan, Almario Christopher, Kokorowski Paul, Freedland Stephen J, Anger Jennifer T, Leppert John T, Daskivich Timothy J
Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
The Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
Urol Oncol. 2023 Apr;41(4):205.e1-205.e10. doi: 10.1016/j.urolonc.2023.01.004. Epub 2023 Feb 1.
Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease.
We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments.
AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores.
LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.
预期寿命（LE）会影响前列腺癌（CaP）治疗的有效性和发病率，但其对成本效益的影响尚不清楚。我们试图评估预期寿命对临床局限性疾病的根治性前列腺切除术（RP）、放射治疗（RT）和主动监测（AS）成本效益的影响。
我们创建了一个马尔可夫模型，从医疗保险支付者的角度，计算低风险和中风险CaP在20年时间范围内RP、RT和AS的增量成本效益比（ICER）。死亡率结果因肿瘤风险和PCCI评分而异，PCCI评分是一种经过验证的预期寿命替代指标。我们在每个肿瘤风险亚组内对PCCI进行单因素敏感性分析，进行了1000次蒙特卡洛模拟，以比较各治疗方案之间的成本/质量调整生命年（QALY）。
对于预期寿命≤10年的男性（PCCI分别≥7和≥9），低风险和中风险疾病的AS优于RP和RT。然而，对于预期寿命较长的男性，AS未能优于RP和RT。对于低风险癌症且预期寿命>10年（PCCI 0 - 6）的男性，AS的有效性最高，但由于相对于RP成本较高而未能占优。对于中风险癌症且预期寿命>10年的男性，AS未能占优是因为相对于RP成本较高（PCCI 0 - 8）以及相对于RT有效性较低（PCCI 0 - 3）。在PCCI评分范围内，RP、RT和AS之间的QALY范围差异<13%（范围：0% - 12.9%），而成本差异高达521%（范围0.5% - 521%）。
预期寿命强烈调节CaP治疗的成本。这导致预期寿命≤10年的男性中AS优于RP和RT。然而，在预期寿命较长的男性中，AS主要由于其高累积成本而未能占优，这突出了对风险调整的AS方案的需求。
