TY - JOUR
T1 - Cost-Effectiveness of Metastasis-Directed Therapy in Oligorecurrent Hormone-Sensitive Prostate Cancer
AU - Parikh, Neil R.
AU - Chang, Eric M.
AU - Nickols, Nicholas G.
AU - Rettig, Matthew B.
AU - Raldow, Ann C.
AU - Steinberg, Michael L.
AU - Koontz, Bridget F.
AU - Vapiwala, Neha
AU - Deville, Curtiland
AU - Feng, Felix Y.
AU - Spratt, Daniel E.
AU - Reiter, Robert E.
AU - Phillips, Ryan
AU - Ost, Piet
AU - Tran, Phuoc T.
AU - Kishan, Amar U.
N1 - Funding Information:
A.U.K. reports research funding from the Prostate Cancer National Institutes of Health Specialized Programs of Research Excellence ( P50CA09213 ), the Radiological Society of North America (grant RSD1836 ), the STOP Cancer organization, the Jonsson Comprehensive Cancer Center, and the American Society of Radiation Oncology . N.G.N. reports research support from STOP Cancer and the Jonsson Comprehensive Cancer Center. A.U.K., N.G.N., P.T.T., F.Y.F., M.B.R., and D.E.S. report funding from the Prostate Cancer Foundation.
Funding Information:
A.U.K. reports research funding from the Prostate Cancer National Institutes of Health Specialized Programs of Research Excellence (P50CA09213), the Radiological Society of North America (grant RSD1836), the STOP Cancer organization, the Jonsson Comprehensive Cancer Center, and the American Society of Radiation Oncology. N.G.N. reports research support from STOP Cancer and the Jonsson Comprehensive Cancer Center. A.U.K., N.G.N., P.T.T., F.Y.F., M.B.R., and D.E.S. report funding from the Prostate Cancer Foundation. Disclosures: N.G.N. reports grants from Varian, Janssen, and Bayer; grants and personal fees from Progenics; and personal fees from Genes Science. M.B.R. reports grants from Novartis, Merck, Astellas, Medivation, and Progenics; grants and personal fees from Johnson & Johnson; personal fees from Bayer; and is a consultant for Constellation Pharmaceuticals. A.C.R. reports personal fees from Intelligent Automation. M.L.S. reports honoraria and travel support from ViewRay. B.F.K. has received research support from Janssen and has been on advisory boards for Blue Earth Diagnostics and Bayer. R.P. has received consulting fees and honoraria from RefleXion Medical, Inc.
Publisher Copyright:
© 2020 Elsevier Inc.
PY - 2020/11/15
Y1 - 2020/11/15
N2 - Purpose: Oligorecurrent prostate cancer has historically been treated with indefinite androgen deprivation therapy (ADT), although many patients and providers opt to defer this treatment at the time of recurrence given quality-of-life and/or comorbidity considerations. Recently, metastasis-directed therapy (MDT) has emerged as a potential intermediary between surveillance and immediate continuous ADT. Simultaneously, advanced systemic therapy in addition to ADT has also been shown to improve survival in metastatic hormone-sensitive disease. This study aimed to compare the cost-effectiveness of treating oligorecurrent patients with upfront MDT before standard-of-care systemic therapy. Methods and Materials: A Markov-based cost-effectiveness analysis was constructed comparing 3 strategies: (1) upfront MDT → salvage abiraterone acetate plus prednisone (AAP) + ADT → salvage docetaxel + ADT; (2) upfront AAP + ADT → salvage docetaxel + ADT; and (3) upfront docetaxel + ADT → salvage AAP + ADT. Transition probabilities and utilities were derived from the literature. Using a 10-year time horizon and willingness-to-pay threshold of $100,000/quality-adjusted life year (QALY), net monetary benefit values were subsequently calculated for each treatment strategy. Results: At 10 years, the base case revealed a total cost of $141,148, $166,807, and $136,154 with QALYs of 4.63, 4.89, and 4.00, respectively, reflecting a net monetary benefit of $322,240, $322,018, and $263,407 for upfront MDT, upfront AAP + ADT, and upfront docetaxel + ADT, respectively. In the probabilistic sensitivity analysis using a Monte Carlo simulation (1,000,000 simulations), upfront MDT was the cost-effective strategy in 53.6% of simulations. The probabilistic sensitivity analysis revealed 95% confidence intervals for cost ($75,914-$179,862, $124,431-$223,892, and $103,298-$180,617) and utility in QALYs (3.85-6.12, 3.91-5.86, and 3.02-5.22) for upfront MDT, upfront AAP + ADT, and upfront docetaxel + ADT, respectively. Conclusions: At 10 years, upfront MDT followed by salvage AAP + ADT, is comparably cost-effective compared with upfront standard-of-care systemic therapy and may be considered a viable treatment strategy, especially in patients wishing to defer systemic therapy for quality-of-life or comorbidity concerns. Additional studies are needed to determine whether MDT causes a sustained meaningful delay in disease natural history and whether any benefit exists in combining MDT with upfront advanced systemic therapy.
AB - Purpose: Oligorecurrent prostate cancer has historically been treated with indefinite androgen deprivation therapy (ADT), although many patients and providers opt to defer this treatment at the time of recurrence given quality-of-life and/or comorbidity considerations. Recently, metastasis-directed therapy (MDT) has emerged as a potential intermediary between surveillance and immediate continuous ADT. Simultaneously, advanced systemic therapy in addition to ADT has also been shown to improve survival in metastatic hormone-sensitive disease. This study aimed to compare the cost-effectiveness of treating oligorecurrent patients with upfront MDT before standard-of-care systemic therapy. Methods and Materials: A Markov-based cost-effectiveness analysis was constructed comparing 3 strategies: (1) upfront MDT → salvage abiraterone acetate plus prednisone (AAP) + ADT → salvage docetaxel + ADT; (2) upfront AAP + ADT → salvage docetaxel + ADT; and (3) upfront docetaxel + ADT → salvage AAP + ADT. Transition probabilities and utilities were derived from the literature. Using a 10-year time horizon and willingness-to-pay threshold of $100,000/quality-adjusted life year (QALY), net monetary benefit values were subsequently calculated for each treatment strategy. Results: At 10 years, the base case revealed a total cost of $141,148, $166,807, and $136,154 with QALYs of 4.63, 4.89, and 4.00, respectively, reflecting a net monetary benefit of $322,240, $322,018, and $263,407 for upfront MDT, upfront AAP + ADT, and upfront docetaxel + ADT, respectively. In the probabilistic sensitivity analysis using a Monte Carlo simulation (1,000,000 simulations), upfront MDT was the cost-effective strategy in 53.6% of simulations. The probabilistic sensitivity analysis revealed 95% confidence intervals for cost ($75,914-$179,862, $124,431-$223,892, and $103,298-$180,617) and utility in QALYs (3.85-6.12, 3.91-5.86, and 3.02-5.22) for upfront MDT, upfront AAP + ADT, and upfront docetaxel + ADT, respectively. Conclusions: At 10 years, upfront MDT followed by salvage AAP + ADT, is comparably cost-effective compared with upfront standard-of-care systemic therapy and may be considered a viable treatment strategy, especially in patients wishing to defer systemic therapy for quality-of-life or comorbidity concerns. Additional studies are needed to determine whether MDT causes a sustained meaningful delay in disease natural history and whether any benefit exists in combining MDT with upfront advanced systemic therapy.
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U2 - 10.1016/j.ijrobp.2020.06.009
DO - 10.1016/j.ijrobp.2020.06.009
M3 - Article
C2 - 32544574
AN - SCOPUS:85087928080
SN - 0360-3016
VL - 108
SP - 917
EP - 926
JO - International Journal of Radiation Oncology Biology Physics
JF - International Journal of Radiation Oncology Biology Physics
IS - 4
ER -