Cost-effectiveness Analysis of Active Surveillance Strategies for Men with Low-risk Prostate Cancer

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.