Cost-effectiveness Analysis of Active Surveillance Strategies for Men with Low-risk Prostate Cancer
Cost-effectiveness Analysis of Active Surveillance Strategies for Men with Low-risk Prostate Cancer
复制标题
DOI：
10.1016/j.eururo.2018.10.055
复制
发表时间：
2019-06-01
期刊：
影响因子：
23.4
通讯作者：
Kuntz, Karen M.
中科院分区：
文献类型：
--
作者：
Sathianathen, Niranjan J.;Konety, Badrinath R.;Kuntz, Karen M.
背景：主动监测(AS)已成为低风险前列腺癌男性患者推荐的治疗策略。然而，关于要进行的测试及其频率方面的最佳随访计划仍存在相当大的不确定性。目的：评估不同的随访策略与观察等待(WW)或立即治疗相比的成本和收益。设计、设置和参与者：为假想的50岁新诊断为低风险前列腺癌的男性队列，开发了一个状态转移马尔可夫模型来模拟前列腺癌的自然历史(即，没有测试或干预)。在确诊后，假设性地对男性进行管理，采取立即治疗、警惕等待或几种策略中的一种。根据PRIAS方案(1年、4年、7年和10年，然后每5年)，采用经直肠超声引导活检或磁共振成像(MRI)进行随访，按计划每年、每两年、每3年进行一次。结果测量和统计分析：我们测量了贴现的质量调整寿命年(QALY)、贴现的终生医疗成本(2017美元)和增量成本-效果比(ICER)。结果和局限性：与WW相比，基于MRI的监测每5年执行一次，将质量调整后的生存率提高4.47个月，并使用标准的成本-效果指标代表了联邦医疗保险报销率下的高价值医疗保健。对于每个测试间隔，基于活检的策略不如相应的基于MRI的策略有效且成本更低。以MRI为基础的监测间隔更频繁，ICERs大于80万美元/QALY，根据标准指标不会被认为是具有成本效益的。我们的结果对两种活检模式在发现临床重大癌症方面的诊断准确性和成本都很敏感。结论：对于选择保守治疗低风险前列腺癌的男性来说，将MRI纳入医疗保险报销率的监测方案和降低重复测试的强度可能是具有成本效益的选择。患者总结：我们的研究模拟了低风险前列腺癌患者在接受不同随访计划的观察等待、立即治疗或主动监测的结果。我们发现，对低风险疾病的保守管理可以优化健康结果和成本。此外，我们还表明，根据核磁共振成像(MRI)的成本，降低主动监视随访的强度并将磁共振成像(MRI)纳入监视方案可能具有成本效益。(C)2018年欧洲泌尿外科协会。爱思唯尔出版，版权所有。
Background: Active surveillance (AS) has become the recommended management strategy for menwith low-risk prostate cancer. However, there is considerable uncertainty about the optimal follow-up schedule in terms of the tests to perform and their frequency.Objective: To assess the costs and benefits of different AS follow-up strategies compared to watchful waiting (WW) or immediate treatment.Design, setting, and participants: A state-transition Markov model was developed to simulate the natural history (ie, no testing or intervention) of prostate cancer for a hypothetical cohort of 50-yr-old men newly diagnosed with low-risk prostate cancer. Following diagnosis, men were hypothetically managed with immediate treatment, watchful waiting, or one of several AS strategies. AS follow-up was performed either with transrectal ultrasound-guided biopsy or magnetic resonance imaging (MRI) which was scheduled annually, biennially, every 3 yrs, according to the PRIAS protocol (yrs 1, 4, 7, and 10, and then every 5 yr) or every 5 yr. Diagnosis of higher-grade or -stage disease while on AS resulted in curative treatment.Outcome measurements and statistical analysis: We measured discounted quality-adjusted life years (QALYs), discounted lifetime medical costs (2017 US$), and incremental cost-effectiveness ratios (ICERs).Results and limitations: Compared to WW, MRI-based surveillance performed every 5 yr improved quality-adjusted survival by 4.47 quality-adjustedmonths and represented high-value health care at the Medicare reimbursement rate using standard cost-effectiveness metrics. Biopsy-based strategies were less effective and less costly than the corresponding MRI-based strategies for each testing interval. MRI-based surveillance at more frequent intervals had ICERs greater than $800 000 per QALY and would not be considered cost-effective according to standard metrics. Our results were sensitive to the diagnostic accuracy and costs of both biopsy modes in detecting clinically significant cancer.Conclusions: Incorporation of MRI into surveillance protocols at Medicare reimbursement rates and decreasing the intensity of repeat testing may be cost-effective options for men opting for conservative management of low-risk prostate cancer.Patient summary: Our study modeled outcomes for men with low-risk prostate cancer undergoing watchful waiting, immediate treatment, or active surveillance with different follow-up schedules. We found that conservative management of low-risk disease optimizes health outcomes and costs. Furthermore, we showed that decreasing the intensity of active surveillance follow-up and incorporating magnetic resonance imaging (MRI) into surveillance protocols can be cost-effective, depending on the MRI costs. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.