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QALY of guideline-recommended prostate cancer treatments study by ESTRO

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Posted 7/1/2013 7:19 PM (GMT 0)
I just came across a study presented at the European Society for Radiotherapy and Oncology (ESTRO) April 19-23, 2013 in Geneva, Switzerland, that analyzed research findings from six recent overview studies involving 55,000 patients.  The investigators involved evaluated disease progression and outcomes, and associated costs extrapolated over a 10-year period.  I have requested a copy of the full study and am waiting for that; in the meantime they did send me the abstract:

Abstract: PD-0371

Comparative cost / QALY of guideline-recommended prostate cancertreatments: a UK cost perspective

Purpose/Objective
 To estimate the expected comparative costs/Quality Adjusted Life Year (QALY) gained of the guideline recommended treatments Active Surveillance (AS), Radical Prostatectomy (RP), Brachytherapy (BT), EBRT and appropriate combinations hereof incl. Androgen Deprivation Therapy (ADT) in patients with low, intermediate or high risk prostate cancer over a time horizon of 10 years from an UK-NHS cost perspective.

Materials and Methods

A decision analytic model was developed considering survival, health related quality of life and costs associated with 1) initial treatment and 2) management of relapse, local recurrence, metastasis, and 3) treatment-associated complications and morbidities. The wide range of appropriate treatments to be compared for low, intermediate and high risk prostate cancers were based on NICE, EAU, AUA and NCCN guidelines. Survival, relapse, recurrence, metastasis and complication rates, as well as health-related quality of life and cost data were based on systematic reviews of the published literature and expert opinions where required. Probabilistic sensitivity analysis, using 10000 Monte Carlo simulations, quantified the joint decision uncertainty surrounding model outcomes at the prevailing threshold of £20k-30k/QALY.

Results
In low risk prostate cancer, AS has the highest probability for being cost-effective (C/E), i.e. 70%. When AS is unacceptable to a patient, BT dominates EBRT by generating more QALYs/patient (+0,06) at lower cost (-£14k) over 10-years. EBRT is C/Evs. RP as shown by the incremental C/E ratio of £7k/QALY which is far below the WTP threshold. In intermediate risk, EBRT+BT is the dominating treatment (5,02QALYs at £14.7k; 65% probability C/E), followed by BT as monotherapy (4,98QALYs at £16.9k; 35% probability C/E). RP generates the lowest QALYs at relatively high costs (4,06 QALYs, £28.8k). In high risk, all mono and combination radiation treatments dominate RP which generates 3,96 QALYs at £35.4 over 10 years/patient. EBRT+BT (4,7 QALYs, £35.1k) is most C/E compared to monoradiation treatments by generating more QALYs at only slightly higher total costs. BT (4,65 QALYs, £32.5k) dominates EBRT (4,62 QALYs, £32.5k) and EBRT+ADT(4,47 QALYs, £37.7k).

Conclusions
Across risk groups, RP is likely to perform worse than radiation treatments in terms of expected costs/QALY. In intermediate and high risk prostate cancer, EBRT+BT is expected to provide highest QALYs at acceptable or lower cost than monoradiation treatments and RP. In low risk prostate cancer, AS is preferred in terms of QALYs, while BT dominates EBRT and RP in terms of costs/QALYs.

 

Co-authors

L.M.G. Steuten1, V.P. Retel2.
1PANAXEA bv / University of Twente, Enschede, The Netherlands.
2Netherlands Cancer Institute, Amsterdam, The Netherlands.

 QALY by nature includes cost factor, which I have put secondarily to treatment outcomes - none the less an interesting study.

 
Posted 7/1/2013 8:30 PM (GMT 0)
Not really surprised at these findings. Be interesting to see what others here think of the results.
Posted 7/2/2013 1:00 PM (GMT 0)
So I guess by posting again I'm "bumping" this one - surprised that there have been no other posts besides Purg's. . .

In addition to the abstract in my original post, I received this summary from Elekta:

• Better outcomes can be achieved for prostate cancer patients using brachytherapy compared to surgery, according to a new study conducted by PANAXEA, The University of Twente, Netherlands. The study was funded by a research grant provided by Elekta.

• The study, presented at the European Society for Radiotherapy and Oncology (ESTRO) April 19-23, 2013, Geneva, Switzerland analyzed research findings from six recent overview studies, involving 55,000 patients. Investigators evaluated disease progression, associated costs and outcomes extrapolated over a 10-year period from a UK NHS cost perspective.

• The researchers found that in patients in whom the prostate cancer remains localized, brachytherapy is more cost effective and offers better quality of life outcomes – either as monotherapy in low-risk patients in which “active surveillance” is not favored, or in combination with external beam radiation therapy (EBRT) for higher risk patients.

• Brachytherapy is underused in the UK, where only four to five percent of patients are treated with it compared with eight percent in Germany and 25 percent in the United States. (reference 3 from the press release)

• Around 50 percent of prostate cancer patients in the UK are treated using surgery 4, which is associated with an increased risk of incontinence and impotence compared to radiotherapy treatments.2

“Prostate cancer is the most common cancer in men and UK survival rates are lower than in comparable countries such as Norway and Sweden,” says principle investigator, Lotte Steuten, Associate Professor of Health Technology Assessment at University of Twente. “Brachytherapy is offered as an out-patient procedure, which means shorter recovery times than with surgery and our findings show that it is more cost effective. We urge all practitioners involved in the care of people with prostate cancer to consider these results and how they can achieve the best outcomes for their patients as well as cost effectiveness for the health care system.”
Posted 7/2/2013 2:55 PM (GMT 0)
Yooper,

The primary target audience for that study seems to be the movers and shakers in the UK national health service. I think it makes a strong case and their premise -- that public health in the UK would be better served by more emphasis on brachytherapy for prostate cancer -- deserves to be considered.

For individuals in the UK the case is a bit weaker. The health service creates the atmosphere in which patients seek medical care, and in which doctors offer it. It may be that until adjustments are made in the bureaucracy to make brachytherapy more widely available, including more and better-trained practitioners, that it will continue to be a poor choice for some, perhaps most, individuals in the UK.

As for what it means to individuals in the rest of the world, it gets a bit wobbly. There are too many places were expert opinion was used to establish parameters and where assumptions were made about men's priorities, for it to be particularly compelling for individuals seeking treatment. I generally advise men considering their treatment options to consider brachytherapy. I will continue to do so. But it remains an individual decision.
Posted 7/2/2013 8:09 PM (GMT 0)
I'd be interested to see the full study. Great info as always Yooper. I was going to do BT myself and then found an excellent SBRT team here at Mercy Hospital in St. Louis. I do think sometimes guys are pushed into decisions without looking into things for themselves. The urologist that did my biopsy wanted me to make an appointment for surgery without even discussing any other options. I still believe surgery is an answer for many guys, but EVERY guy should be able to make up his own mind.

Mike
Posted 7/2/2013 8:16 PM (GMT 0)
Given the above, I am really at a loss to understand why LDR, or HDR, brachytherapy isn't offered at hospitals more often.
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