Is combined androgen blockade with bicalutamide cost-effective compared with combined androgen blockade with flutamide?

Systematic Review of Cost-Effectiveness Models in Prostate Cancer: Exploring New Developments in Testing and Diagnosis

OBJECTIVES

Recent innovations in prostate cancer diagnosis include new biomarkers and more accurate biopsy methods. This study assesses the evidence base on cost-effectiveness of these developments (eg, Prostate Health Index and magnetic resonance imaging [MRI]-guided biopsy) and identifies areas of improvement for future cost-effectiveness models.

METHODS

A systematic review using the National Health Service Economic Evaluation Database, MEDLINE, Embase, Health Technology Assessment databases, National Institute for Health and Care Excellence guidelines, and United Kingdom National Screening Committee guidance was performed, between 2009 and 2021. Relevant data were extracted on study type, model inputs, modeling methods and cost-effectiveness conclusions, and results narratively synthesized.

RESULTS

A total of 22 model-based economic evaluations were included. A total of 11 compared the cost-effectiveness of new biomarkers to prostate-specific antigen testing alone and all found biomarkers to be cost saving. A total of 8 compared MRI-guided biopsy methods to transrectal ultrasound-guided methods and found MRI-guided methods to be most cost-effective. Newer detection methods showed a reduction in unnecessary biopsies and overtreatment. The most cost-effective follow-up strategy in men with a negative initial biopsy was uncertain. Many studies did not model for stage or grade of cancer, cancer progression, or the entire testing and treatment pathway. Few fully accounted for uncertainty.

CONCLUSIONS

This review brings together the cost-effectiveness literature for novel diagnostic methods in prostate cancer, showing that most studies have found new methods to be more cost-effective than standard of care. Several limitations of the models were identified, however, limiting the reliability of the results. Areas for further development include accurately modeling the impact of early diagnostic tests on long-term outcomes of prostate cancer and fully accounting for uncertainty.

Evaluation of the Cost-effectiveness of Infection Control Strategies to Reduce Hospital-Onset Clostridioides difficile Infection

Importance

Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile.

Objective

To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles.

Design, Setting, and Participants

This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature.

Interventions

Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers.

Main Outcomes and Measures

Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY).

Results

In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively.

Conclusions and Relevance

The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.

Prostate cancer mortality and metastasis under different biopsy frequencies in North American active surveillance cohorts

BACKGROUND

Active surveillance (AS) is an accepted means of managing low-risk prostate cancer. Because of the rarity of downstream events, data from existing AS cohorts cannot yet address how differences in surveillance intensity affect metastasis and mortality. This study projected the comparative benefits of different AS schedules in men diagnosed with prostate cancer who had Gleason score (GS) ≤6 disease and risk profiles similar to those in North American AS cohorts.

METHODS

Times of GS upgrading were simulated based on AS data from the University of Toronto, Johns Hopkins University, the University of California at San Francisco, and the Canary Pass Active Surveillance Cohort. Times to metastasis and prostate cancer death, informed by models from the Scandinavian Prostate Cancer Group 4 trial, were projected under biopsy surveillance schedules ranging from watchful waiting to annual biopsies. Outcomes included the risk of metastasis, the risk of death, remaining life-years (LYs), and quality-adjusted LYs.

RESULTS

Compared with watchful waiting, AS biopsies reduced the risk of prostate cancer metastasis and prostate cancer death at 20 years by 1.4% to 3.3% and 1.0% to 2.4%, respectively; and 5-year biopsies reduced the risk of metastasis and prostate cancer death by 1.0% to 2.4% and 0.6% to 1.6%, respectively. There was little difference between annual and 5-year biopsy schedules in terms of LYs (range of differences, 0.04-0.16 LYs) and quality-adjusted LYs (range of differences, -0.02 to 0.09 quality-adjusted LYs).

CONCLUSIONS

Among men diagnosed with GS ≤6 prostate cancer, obtaining a biopsy every 3 or 4 years appears to be an acceptable alternative to more frequent biopsies. Reducing surveillance intensity for those who have a low risk of progression reduces the number of biopsies while preserving the benefit of more frequent schedules.

An Economic Analysis of Strategies to Control Clostridium Difficile Transmission and Infection Using an Agent-Based Simulation Model

Background

A number of strategies exist to reduce Clostridium difficile (C. difficile) transmission. We conducted an economic evaluation of “bundling” these strategies together.

Methods

We constructed an agent-based computer simulation of nosocomial C. difficile transmission and infection in a hospital setting. This model included the following components: interactions between patients and health care workers; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. Six interventions were introduced alone and "bundled" together: (a) aggressive C. difficile testing; (b) empiric isolation and treatment of symptomatic patients; (c) improved adherence to hand hygiene and (d) contact precautions; (e) improved use of soap and water for hand hygiene; and (f) improved environmental cleaning. Our analysis compared these interventions using values representing 3 different scenarios: (1) base-case (BASE) values that reflect typical hospital practice, (2) intervention (INT) values that represent implementation of hospital-wide efforts to reduce C. diff transmission, and (3) optimal (OPT) values representing the highest expected results from strong adherence to the interventions. Cost parameters for each intervention were obtained from published literature. We performed our analyses assuming low, normal, and high C. difficile importation prevalence and transmissibility of C. difficile.

Results

INT levels of the “bundled” intervention were cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in all importation prevalence and transmissibility scenarios. OPT levels of intervention were cost-effective for normal and high importation prevalence and transmissibility scenarios. When analyzed separately, hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were the interventions that had the greatest impact on both cost and effectiveness.

Conclusions

A combination of available interventions to prevent CDI is likely to be cost-effective but the cost-effectiveness varies for different levels of intensity of the interventions depending on epidemiological conditions such as C. difficile importation prevalence and transmissibility.

Is fidaxomicin worth the cost? An economic analysis

BACKGROUND

In May 2011, the Food and Drug Administration approved fidaxomicin for the treatment of Clostridium difficile infection (CDI). It has been found to be noninferior to vancomycin; however, its cost-effectiveness for the treatment of CDI remains undetermined.

METHODS

We developed a decision analytic simulation model to determine the economic value of fidaxomicin for CDI treatment from the third-party payer perspective. We looked at CDI treatment in these 3 cases: (1) no fidaxomicin, (2) only fidaxomicin, and (3) fidaxomicin based on strain typing results.

RESULTS

The incremental cost-effectiveness ratio for fidaxomicin based on screening given current conditions was >$43.7 million per quality-adjusted life-year and using only fidaxomicin was dominated (ie, more costly and less effective) by the other 2 treatment strategies explored. The fidaxomicin strategy tended to remain dominated, even at lower costs. With approximately 50% of CDI due to the NAP1/BI/027 strain, a course of fidaxomicin would need to cost ≤$150 to be cost-effective in the treatment of all CDI cases and between $160 and $400 to be cost-effective for those with a non-NAP1/BI/027 strain (ie, treatment based on strain typing).

CONCLUSIONS

Given the current cost and NAP1/BI/027 accounting for approximately 50% of isolates, using fidaxomicin as a first-line treatment for CDI is not cost-effective. However, typing and treatment with fidaxomicin based on strain may be more promising depending on the costs of fidaxomicin.

Quality-of-life effects of prostate-specific antigen screening

BACKGROUND

After 11 years of follow-up, the European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a 29% reduction in prostate-cancer mortality among men who underwent screening for prostate-specific antigen (PSA) levels. However, the extent to which harms to quality of life resulting from overdiagnosis and treatment counterbalance this benefit is uncertain.

METHODS

On the basis of ERSPC follow-up data, we used Microsimulation Screening Analysis (MISCAN) to predict the number of prostate cancers, treatments, deaths, and quality-adjusted life-years (QALYs) gained after the introduction of PSA screening. Various screening strategies, efficacies, and quality-of-life assumptions were modeled.

RESULTS

Per 1000 men of all ages who were followed for their entire life span, we predicted that annual screening of men between the ages of 55 and 69 years would result in nine fewer deaths from prostate cancer (28% reduction), 14 fewer men receiving palliative therapy (35% reduction), and a total of 73 life-years gained (average, 8.4 years per prostate-cancer death avoided). The number of QALYs that were gained was 56 (range, -21 to 97), a reduction of 23% from unadjusted life-years gained. To prevent one prostate-cancer death, 98 men would need to be screened and 5 cancers would need to be detected. Screening of all men between the ages of 55 and 74 would result in more life-years gained (82) but the same number of QALYs (56).

CONCLUSIONS

The benefit of PSA screening was diminished by loss of QALYs owing to postdiagnosis long-term effects. Longer follow-up data from both the ERSPC and quality-of-life analyses are essential before universal recommendations regarding screening can be made. (Funded by the Netherlands Organization for Health Research and Development and others.).

The potential economic value of screening hospital admissions for Clostridium difficile

Asymptomatic Clostridium difficile carriage has a prevalence reported as high as 51-85 %; with up to 84 % of incident hospital-acquired infections linked to carriers. Accurately identifying carriers may limit the spread of Clostridium difficile. Since new technology adoption depends heavily on its economic value, we developed an analytic simulation model to determine the cost-effectiveness screening hospital admissions for Clostridium difficile from the hospital and third party payer perspectives. Isolation precautions were applied to patients testing positive, preventing transmission. Sensitivity analyses varied Clostridium difficile colonization rate, infection probability among secondary cases, contact isolation compliance, and screening cost. Screening was cost-effective (i.e., incremental cost-effectiveness ratio [ICER] ≤ $50,000/QALY) for every scenario tested; all ICER values were ≤ $256/QALY. Screening was economically dominant (i.e., saved costs and provided health benefits) with a ≥10.3 % colonization rate and ≥5.88 % infection probability when contact isolation compliance was ≥25 % (hospital perspective). Under some conditions screening led to cost savings per case averted (range, $53-272). Clostridium difficile screening, coupled with isolation precautions, may be a cost-effective intervention to hospitals and third party payers, based on prevalence. Limiting Clostridium difficile transmission can reduce the number of infections, thereby reducing its economic burden to the healthcare system.

Combined androgen blockade with bicalutamide for advanced prostate cancer: long-term follow-up of a phase 3, double-blind, randomized study for survival

BACKGROUND

A previously reported, double-blind, randomized, multicenter phase 3 trial in 205 patients with stage C/D prostate cancer compared combined androgen blockade (CAB) with luteinizing hormone-releasing hormone agonist (LHRH-A) plus bicalutamide 80 mg versus LHRH-A plus bicalutamide-matching placebo (LHRH-A monotherapy). The analysis at a median follow-up of 2.4 years indicated that CAB significantly (P<.001) prolonged the time to progression and the time to treatment failure. In the current report, survival data from a long-term follow-up (median, 5.2 years) were analyzed.

METHODS

All deaths irrespective of cause and all prostate cancer-specific deaths were recorded. The data were analyzed using Cox regression analysis and the log-rank test.

RESULTS

At a median follow-up of 5.2 years, a significant overall survival advantage was observed in favor of CAB over LHRH-A monotherapy (Cox regression analysis: hazard ratio, 0.78; 95% confidence interval, 0.60-0.99; P=.0498; log-rank test: P=.0425). The difference in cause-specific survival between the 2 groups was not significant. The achievement of a prostate-specific antigen (PSA) nadir concentration<or=1 ng/mL was a prognostic factor for improved survival. More patients attained PSA nadir concentrations<or=1 ng/mL with CAB compared with patients who received LHRH-A monotherapy (81.4% vs 33.7%; P<.001).

CONCLUSIONS

CAB with bicalutamide 80 mg offered a significant overall survival benefit compared with LHRH-A monotherapy without reducing tolerability in patients with locally advanced or metastatic prostate cancer.

Cost effectiveness of risk-prediction tools in selecting patients for immediate post-prostatectomy treatment

BACKGROUND AND OBJECTIVE

Ideally, tests that predict the risk of cancer recurrence should be capable of guiding treatment decisions that are both therapeutically effective and cost effective. This paper evaluates the cost effectiveness of two tools that identify patients at high risk for biochemical (prostate-specific antigen) recurrence of prostate cancer after prostatectomy, the hypothesis being that accurate classification of high-risk patients will allow more appropriate use of secondary (adjuvant/salvage) treatment and may improve on current clinical practice. These risk-prediction tools are the Kattan postoperative nomogram, which uses clinicopathologic features, and the Prostate Px test, which employs additional morphometric and immunofluorescence features of the prostate specimen to predict risk of biochemical recurrence. These tools were trained on patients treated at the Memorial Sloan-Kettering Cancer Center (996 patients for the nomogram, 342 patients for the Prostate Px test).

METHODS

The cost effectiveness of the Prostate Px test, the Kattan postoperative nomogram, and current clinical practice were compared using a decision analytic model. The modeled treatment for low-risk patients was watchful waiting. The modeled treatments for high-risk patients were local radiation, hormonal therapy, and watchful waiting. Costs, utilities, and transition probabilities were obtained from the literature. Costs and effects were discounted at 3% per year. The time span modeled was 10 years after prostatectomy. Monte Carlo simulation was performed to estimate cost and effectiveness; sensitivity analysis was performed to examine the impact of uncertainty in the parameter values.

RESULTS

The expected quality-adjusted life years (QALYs) for the Prostate Px test, nomogram, and current practice were 8.11, 7.39, and 6.47, respectively. The expected costs were $US17 549, $US14 162, and $US14 104, respectively. The incremental cost-effectiveness ratio of the Prostate Px was $US4704/QALY compared with the nomogram, and $US2100/QALY compared with current practice. The incremental cost-effectiveness ratio of the nomogram was $US63/QALY compared with current practice. These ratios are well below the common willingness-to-pay limit of $US50 000/QALY. Expected effectiveness was highest for the Prostate Px test, followed by the nomogram. Expected cost was slightly higher for Prostate Px than for either alternative; nevertheless, the Prostate Px was cost effective compared with both the nomogram and current practice. The nomogram was cost effective compared with current practice. The acceptable cost effectiveness of the Prostate Px test and the nomogram compared with current practice were not sensitive to changes in the values used to inform the model within clinically plausible ranges. The superior performance of both Prostate Px test and nomogram over current practice resulted from identifying high-risk patients likely to benefit from adjuvant treatment, while sparing the low-risk patients the added cost and toxicity of treatment.

CONCLUSION

Incorporation of risk-prediction tools in the initial management of patients after prostatectomy resulted in increased QALYs at an acceptable increase in cost relative to current practice.

Combined androgen blockade in advanced prostate cancer: looking back to move forward

In 1989, Crawford and colleagues suggested that combined androgen blockade with castration plus antiandrogen therapy provided significantly improved survival compared with castration alone. Since then, some studies have supported these results, whereas others have not. To resolve this discrepancy, the Prostate Cancer Trialists' Collaborative Group conducted a metaanalysis of 27 randomized trials to evaluate whether combined androgen blockade has benefits compared with castration alone. The results published in 2000 showed that combined androgen blockade using a nonsteroidal antiandrogen treatment (nilutamide or flutamide) improved survival compared with castration alone, whereas combined androgen blockade using a steroidal antiandrogen agent (cyproterone acetate) reduced survival compared with castration alone. In 2004, an analysis was carried out to evaluate the nonsteroidal antiandrogen agent bicalutamide in the combined androgen blockade setting, by incorporating the data from a trial of combined androgen blockade with bicalutamide versus combined androgen blockade with flutamide with the Prostate Cancer Trialists' Collaborative Group metaanalysis data for combined androgen blockade with flutamide versus castration. This analysis showed that combined androgen blockade with bicalutamide was associated with a 20% reduction in the risk of death compared with castration alone. The survival benefit associated with combined androgen blockade using a nonsteroidal antiandrogen agent should be weighed against the potential for increased toxicity and expense compared with castration alone. Studies have shown that bicalutamide has a better tolerability profile than flutamide or nilutamide. Furthermore, cost-benefit analyses of combined androgen blockade with bicalutamide suggest it is a cost-effective option versus castration alone and versus combined androgen blockade with flutamide. In summary, the present evidence suggests that combined androgen blockade with a nonsteroidal antiandrogen agent should be a first-line therapy option in patients with advanced disease.

Pharmacoeconomics of available treatment options for metastatic prostate cancer

The resources devoted to managing metastatic prostate cancer are enormous, yet little attention has been given to directly measuring the economic consequences of treatment alternatives. The purpose of this article was to evaluate the pharmacoeconomics of available treatments for metastatic prostate cancer, including hormone-sensitive disease, androgen-independent prostate cancer and locally advanced/progressive disease. We identified 58 articles addressing economic issues related to metastatic prostate cancer. Treatment alternatives with considerably different costs are available in many areas of disease management, most notably, medical androgen deprivation therapy (ADT) versus surgical castration; combined androgen blockage (CAB) versus monotherapy for initial treatment of hormone-sensitive disease; as well as bisphosphonates and bone-targeted radioisotopes for palliation. The few available pharmacoeconomic studies indicate that the additional costs are not supported by clear and compelling evidence of differences in survival or quality-of-life (QOL) outcomes. Our review revealed that authors often use considerably different assumptions about efficacy and survival outcomes in their analyses, which may be due to the inconsistency of available clinical evidence. Although there have been many clinical trials comparing various therapies, we identified only three trials that included economic assessments. Thus, few sources of economic data are available and most pharmacoeconomic studies rely on information mined from indirect sources. We note that, while there has been considerable enthusiasm about the role of docetaxel regimens in the past 2 years, no study has yet examined the costs of these therapies. Survival remains poor for metastatic disease, thus QOL is the primary consideration for many therapies. However, QOL for treatment of metastatic disease is poorly measured and, in most analyses, the impact of therapy on QOL was inferred based on speculation by the authors. Given the large cost burdens of these treatments, it is essential that we more fully understand the true QOL gains potentially offered by more expensive therapies. The economic studies of advanced prostate cancer highlight several aspects of clinical care that are filled with considerable uncertainty and remain guided by forces other than optimal resource allocation. It is essential that we address the weaknesses in our understanding of the economic consequences of therapies for prostate cancer, and find ways to include economic information into the process of determining optimal therapy.

Primer: using decision analysis to improve clinical decision making in urology

Many clinical decisions in urology involve uncertainty about the course of disease or the effectiveness of treatment. Many decisions also involve trade-offs; for example, an improvement in patient survival at the cost of an increased risk of treatment-related adverse effects. Decision analysis is a formal, quantitative method for systematically comparing the benefits and harms of alternative clinical strategies under circumstances of uncertainty. The basic steps in performing a decision analysis are to define the clinical scenario or problem, identify the clinical strategies to be considered in the decision, enumerate all of the important sequelae of each strategy and their associated probabilities, define the outcome of interest, and assign a value to each possible outcome. Health outcomes can be defined in a number of ways, including quality-adjusted survival. A key aspect of decision analysis is allowing the values of particular health outcomes to vary from patient to patient, depending on individual preferences. Decision analysis has already been used to assess a variety of prevention, screening and treatment decisions in urology, and there is much potential for its future application. Greater incorporation of decision-analytic techniques into urology research and clinical practice might improve decision making, and thereby improve patient outcomes.