The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer.

Naser-Tavakolian A, Venkataramana A, Spiegel B, Almario C, Kokorowski P, Freedland SJ, Anger JT, Leppert JT, Daskivich TJ. The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer. Urologic oncology. 2023 Apr 1; 41(4):205.e1-205.e10.

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Abstract:

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.