FCCC LOGO Faculty Publications
Zubek VB , Konski A
Cost Effectiveness of Risk-Prediction Tools in Selecting Patients for Immediate Post-Prostatectomy Treatment
Molecular Diagnosis & Therapy. 2009 ;13(1) :31-47
PMID: ISI:000265776700006   
Back to previous list
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 (R) 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 (R) test). Methods: The cost effectiveness of the Prostate Px (R) 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 lire years (QALYs) for the Prostate Px (R) test, nomogram, and Current practice were 8.11, 7.39, and 6.47, respectively. The expected costs were SUS 17 549, SUS 14 162, and SUS14 104 respectively. The incremental cost-effectiveness ratio of the Prostate Px (R) was SUS4704/QALY compared with the nomogram, and SUS2100/QALY compared with current practice. The incremental cost-effectiveness ratio of the nomogram was SUS63/QALY compared with current practice. These ratios are well below the common willingness-to-pay limit of SUS50 000/QALY. Expected effectiveness was highest for the Prostate Px (R) test, followed by the nomogram. Expected cost was slightly higher for Prostate Px (R) than for either alternative; nevertheless, the Prostate Px (R) 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 (R) 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 (R) 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 or 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.
ISI Document Delivery No.: 441NU Times Cited: 0 Cited Reference Count: 46 Cited References: *CURR CONTR TRIALS, RAD ANDR DEPR COMB L *EUROQOL GROUP, 1990, HLTH POLICY, V16, P199 *PDR STAFF, 2006, RED BOOK PHARM FUND *TUFTS NEW ENGL ME, 1998, PREF WEIGHTS 1998 20 ABRAMOWITZ MC, 2008, SEMIN RADIAT ONCOL, V18, P15 BAYOUMI AM, 2000, J NATL CANCER I, V92, P1731 BERGE V, 2007, SCAND J UROL NEPHROL, V41, P198, DOI 10.1080/00365590601016677 BOLLA M, 2005, LANCET, V366, P572 BRIGGS A, 1991, EC EVALUATION HLTH C, P172 BRIGGS A, 1998, PHARMACOECONOMICS, V13, P397 CALVERT NW, 2003, BRIT J CANCER, V88, P31, DOI 10.1038/sj.bjc.6600630 CATALONA WJ, 1998, J UROLOGY 2, V160, P2428 CORDONCARDO C, 2007, J CLIN INVEST, V117, P1876, DOI 10.1172/JCI31399 DOUBILET P, 1985, MED DECIS MAKING, V5, P157 FLEMING C, 1993, JAMA-J AM MED ASSOC, V269, P2650 GRAEFEN M, 2002, J CLIN ONCOL, V20, P951 GROSSFELD GD, 2002, J UROLOGY, V168, P530 HARRELL FE, 1982, JAMA-J AM MED ASSOC, V247, P2543 HORNBERGER J, 2005, AM J MANAG CARE, V11, P313 JEMAL A, 2008, CA-CANCER J CLIN, V58, P71, DOI 10.3322/CA.2007.0010 KATTAN MW, 1999, J CLIN ONCOL, V17, P1499 KONSKI A, 2005, INT J RADIAT ONCOL, V63, P788, DOI 10.1016/j.ijrobp.2005.03.010 KONSKI A, 2006, CANCER, V106, P51, DOI 10.1002/cncr.21575 KONSKI A, 2006, INT J RADIAT ONCOL, V66, P408, DOI 10.1016/j.ijrobp.2006.04.049 KRAHN M, 2003, MED CARE, V41, P153 KUNTZ K, 2001, EC EVALUATION HLTH C, P141 LIPSCOMB J, 1996, COST EFFECTIVENESS H, V1, P214 MAILLEFERT JF, 1999, J UROLOGY, V161, P1219 MEHTA SS, 2004, J UROLOGY, V171, P215, DOI 10.1097/01.ju.0000100087.83112.23 MESSING EM, 2006, LANCET ONCOL, V7, P472, DOI 10.1016/S1470-2045(06)70700-8 MOEREMANS K, 2004, VALUE HEALTH, V7, P472 MOUL JW, 2004, J UROLOGY, V171, P1141, DOI 10.1097/01.JU.0000113794.34810.D0 OEFELEIN MG, 2001, J UROLOGY, V166, P1724 PASS TM, 1981, MED DECIS MAKING, V1, P465 PIPER NY, 2002, PROSTATE CANCER P D, V5, P164 RAMSEY S, 2005, UROLOGY, V66, P835, DOI 10.1016/j.urology.2005.04.028 SCHER HI, 1999, J NATL CANCER I, V91, P244 SHARIAT SF, 2008, CANCER, V113, P3075, DOI 10.1002/cncr.23908 SHIPLEY WU, 2002, INT J RADIAT ONCOL, V54, P1302 STEPHENSON AJ, 2004, JAMA-J AM MED ASSOC, V291, P1325 STEPHENSON AJ, 2005, J CLIN ONCOL, V23, P7005, DOI 10.1200/JCO.2005.01.867 STOCH SA, 2001, J CLIN ENDOCR METAB, V86, P2787 SVATEK RS, 2006, CANCER EPIDEM BIOMAR, V15, P1485, DOI 10.1158/1055-9965.EPI-06-0221 THOMPSON IM, 2006, JAMA-J AM MED ASSOC, V296, P2329 TOWNSEND MF, 1997, CANCER, V79, P545 WIEGEL T, 2005, J CLIN ONCOL, V23, P381 Zubek, Valentina Bayer Konski, Andre ADIS INT LTD; 41 CENTORIAN DR, PRIVATE BAG 65901, MAIRANGI BAY, AUCKLAND 1311, NEW