Postprostatectomy Radiation Therapy

An Evidence-based Review

Mark V Mishra; Colin E Champ; Robert B Den; Eli D Scher; Xinglei Shen; Edouard J Trabulsi; Costas D Lallas; Karen E Knudsen; Adam P Dicker; Timothy N Showalter

Disclosures

Future Oncol. 2011;7(12):1429-1440. 

In This Article

Is ART Cost Effective?

With national costs of PC treatment nearing $12 billion,[43] coupled with recent national efforts to decrease the cost of healthcare, it is becoming increasingly important to take cost considerations into account when making treatment decisions.

Several analyses have recently been performed to determine the number (of patients) needed-to-treat to result in at least one patient who benefits from ART. Based on the results of the EORTC study, it is estimated that two patients are required to be treated with ART in order to prevent one biochemical failure over 5 years.[44] In the SWOG study, where a benefit for metastasis-free and overall survival was seen, it is estimated that one in 9.1 and one in 12.2 patients treated with ART will derive an overall survival or metastasis-free survival benefit at 12 years, respectively.[44] In another needed-to-treat analysis, the effectiveness of ART versus SRT was compared. The authors of this study demonstrated a benefit of ART over SRT if there were no treatment complications. However, SRT was found to be advantageous when taking into account a moderate RT side-effect profile.[45]

A more recent study was performed to design an analytic model to estimate the costs of ART versus observation for patients with APFs following a RP.[46] In this study, the cost per PSA success was utilized as the primary measure of effectiveness. Costs were estimated using 2010 Medicare reimbursement rates for conventional 3D conformal RT (non-IMRT). The patient population in the study was 242 out of 431 patients who participated in the SWOG 8794 study who had a documented PSA of ≤0.2 ng/ml. The total cost of ART was found to be $15,900 compared with $9876 for patients in the observation group. Thus, the mean incremental cost for ART over observation was $6023. Over a period of 10 years, the cost per additional PSA success achieved with ART versus observation was estimated to be $26,983. The authors concluded that ART is a cost-effective strategy for managing eligible patients.

In another study, the cost and utility of a variety of different PC treatments were examined. Costs were estimated based upon 2006 reimbursement rates. Utility was defined as a measure of patient preferences as assessed using a European quality of life instrument (EQ-5D) completed 6 months following end of RT. The cost of ART utilizing IMRT was estimated to be $27080 with a utility value of 0.909. By contrast, the utility value of ADT was 0.74.[44,47]

In a different study, a Markov model was constructed to determine and compare the clinical and quality-adjusted life year (QALY) outcomes of patients treated with ART versus those treated with SRT following a RP.[48] After adjusting for patients with high-risk features who would never require RT, patients treated with observation plus SRT yielded better QALYs at 10 years as compared with those treated with ART (6.80 and 6.13 QALYs, respectively). Thus, the authors concluded that observation with close monitoring with serial PSAs may be the optimal treatment method for patients who are likely to be compliant with follow-up.

Thus, postoperative RT (ART or SRT) appears to be a cost-effective treatment strategy. The issue of how SRT and ART compare in terms of cost–effectiveness can be more fully assessed once Phase III trials comparing the two treatment approaches are completed.

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