RESUMEN
Treatment choices for metastatic prostate cancer are complex and can involve men balancing survival versus quality of life. The present study aims to elicit patient preferences with respect to the attributes of treatments for metastatic prostate cancer through a discrete choice experiment (DCE) questionnaire. Men with recently diagnosed localized prostate cancer were asked to envisage that they had metastatic disease when completing a survey. As expected, men with prostate cancer placed considerable importance on gains in survival; however, avoiding side effects of treatment was also clearly important. Survival gains should be considered alongside side effects when discussing treatment options in metastatic disease.
Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/secundario , Antagonistas de Andrógenos/uso terapéutico , Anilidas/uso terapéutico , Antineoplásicos Hormonales/uso terapéutico , Flutamida/uso terapéutico , Nitrilos/uso terapéutico , Satisfacción del Paciente , Neoplasias de la Próstata/tratamiento farmacológico , Compuestos de Tosilo/uso terapéutico , Adenocarcinoma/economía , Adenocarcinoma/psicología , Anciano , Antagonistas de Andrógenos/administración & dosificación , Antagonistas de Andrógenos/efectos adversos , Antagonistas de Andrógenos/economía , Anilidas/administración & dosificación , Anilidas/efectos adversos , Anilidas/economía , Antineoplásicos Hormonales/administración & dosificación , Antineoplásicos Hormonales/efectos adversos , Antineoplásicos Hormonales/economía , Conducta de Elección , Estudios Transversales , Diarrea/inducido químicamente , Diarrea/psicología , Esquema de Medicación , Costos de los Medicamentos , Quimioterapia/psicología , Disfunción Eréctil/inducido químicamente , Disfunción Eréctil/psicología , Flutamida/administración & dosificación , Flutamida/efectos adversos , Flutamida/economía , Ginecomastia/inducido químicamente , Ginecomastia/psicología , Encuestas Epidemiológicas , Hematuria/inducido químicamente , Hematuria/psicología , Humanos , Esperanza de Vida , Masculino , Persona de Mediana Edad , Nitrilos/administración & dosificación , Nitrilos/efectos adversos , Nitrilos/economía , Aceptación de la Atención de Salud , Neoplasias de la Próstata/economía , Neoplasias de la Próstata/psicología , Compuestos de Tosilo/administración & dosificación , Compuestos de Tosilo/efectos adversos , Compuestos de Tosilo/economíaRESUMEN
BACKGROUND: In Radiation Therapy Oncology Group (RTOG) trial 92-02, after men received neoadjuvant hormone cytoreduction and radiotherapy for locally advanced prostate carcinoma, they were randomized to receive either 2 years of long-term androgen-deprivation (LTAD) or no further treatment (short-term androgen-deprivation [STAD]). The specific objective of the current study was to determine whether LTAD was a cost-effective treatment for patients with locally advanced prostate carcinoma. METHODS: The cost-effectiveness of LTAD was tested using a Markov model that was designed using proprietary software. The analysis took a payor's perspective. Unit costs were obtained by estimation using a global Medicare fee schedule. Costs and outcomes were discounted by 3%. Distributions were sampled at random from the treatment utilities, transition probabilities, and costs using a second-order Monte Carlo simulation technique. RESULTS: The expected mean cost was 32,564 dollars for LTAD compared with 33,039 dollars for STAD after accounting for the additional cost of salvage treatment for men who were treated with STAD. The mean number of quality-adjusted life years (QALYs) for men who received LTAD was 4.13 QALYs compared with a mean of 3.68 QALYs for men who received STAD. The cost-effectiveness acceptability curve analysis showed a 91% probability that LTAD was cost-effective compared with STAD. Although overall survival was similar in the LTAD and STAD groups, the patients who received LTAD experienced gains in QALYs and had lower costs, because LTAD prevented biochemical failure and the necessitating salvage hormone therapy. CONCLUSIONS: The current analysis showed that LTAD was cost-effective for the entire population studied in RTOG trial 92-02.
Asunto(s)
Adenocarcinoma/economía , Neoplasias de la Próstata/economía , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/radioterapia , Antagonistas de Andrógenos/economía , Antagonistas de Andrógenos/uso terapéutico , Antineoplásicos Hormonales/economía , Antineoplásicos Hormonales/uso terapéutico , Terapia Combinada , Análisis Costo-Beneficio , Flutamida/economía , Flutamida/uso terapéutico , Goserelina/economía , Goserelina/uso terapéutico , Humanos , Masculino , Cadenas de Markov , Método de Montecarlo , Terapia Neoadyuvante/economía , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/radioterapia , Años de Vida Ajustados por Calidad de Vida , Radioterapia Conformacional/economía , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVES: To determine the cost-effectiveness of combined androgen blockade (CAB) with bicalutamide versus CAB with flutamide in men with Stage D2 prostate cancer. Both bicalutamide and flutamide are commonly used in CAB for prostate cancer. Although the cost of bicalutamide is more than that of flutamide, it is important that the efficacy, quality of life, and side effects are also considered when determining whether CAB with bicalutamide is a cost-effective option. METHODS: A decision model was created to compare treatment strategies. Survival and side-effect information was based on a randomized trial that directly compared bicalutamide and flutamide. The costs and quality-of-life effects related to therapy were determined from published sources. RESULTS: The incremental cost per quality-adjusted life year gained for bicalutamide versus flutamide was 22,000 dollars and 16,000 dollars at 5 and 10 years, respectively. If a quality adjustment was not included, the incremental cost-effectiveness ratio for CAB with bicalutamide compared with CAB with flutamide was even more favorable (20,000 dollars/life year gained at 5 years). One-way sensitivity analysis demonstrated that the cost-effectiveness estimates were most sensitive to drug costs and survival (baseline survival was not significantly different between therapies). Multi-way uncertainty analysis revealed that the median value of the incremental cost-effectiveness ratio at 5 years was 13,637 dollars/quality-adjusted life year when all the parameters were varied over a clinically reasonable range. CONCLUSIONS: Bicalutamide is cost-effective compared with flutamide when used for androgen blockade as part of CAB for men with advanced prostate cancer.
Asunto(s)
Antagonistas de Andrógenos/economía , Antagonistas de Andrógenos/uso terapéutico , Anilidas/economía , Anilidas/uso terapéutico , Antineoplásicos/economía , Antineoplásicos/uso terapéutico , Flutamida/economía , Flutamida/uso terapéutico , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/economía , Análisis Costo-Beneficio , Quimioterapia Combinada , Humanos , Masculino , Nitrilos , Compuestos de TosiloRESUMEN
BACKGROUND: More than 50,000 male patients received hormonal therapy for metastatic prostate carcinoma in 1995. Nonsteroidal antiandrogens, such as flutamide, when used in conjunction with castration, are effective in prolonging the time to progression of disease and survival. Only one-third of newly diagnosed patients with metastatic prostate carcinoma receive flutamide. Physicians may be reluctant to prescribe flutamide because of quality of life, toxicity, and cost considerations. METHODS: Physician focus groups evaluated quality of life factors for metastatic prostate cancer. RESULTS: Using quality of life estimates with the National Cancer Institute's (NCI) 0036 clinical trial results, our revised model of flutamide use predicted that, for minimal disease, survival increased by 4.33 quality adjusted months (QAMs) at an incremental cost of $25,000 per quality adjusted life year (QALY) saved and for severe disease, survival increased by 4.11 QAM at a cost of $18,000 per QALY saved. However, if quality of life estimates are used in conjunction with the Prostate Cancer Trialists' Collaborative Group (PCTCG) meta-analysis estimates, survival increased by 2.1 QAM at an incremental cost of $41,000 per QALY saved for persons with severe disease and increased by 2.6 QAM at an incremental cost of $53,700 per QALY saved for persons with minimal disease. CONCLUSIONS: Using NCI 0036 trial data, flutamide has an incremental cost-effectiveness more favorable than most therapies, while estimates based on the PCTCG found a less favorable outcome for the drug. Concerns about out-of-pocket expenditures and efficacy limit flutamide utilization; quality of life considerations are less cogent.
Asunto(s)
Antagonistas de Andrógenos/economía , Antagonistas de Andrógenos/uso terapéutico , Antineoplásicos Hormonales/economía , Antineoplásicos Hormonales/uso terapéutico , Carcinoma/tratamiento farmacológico , Flutamida/economía , Flutamida/uso terapéutico , Modelos Económicos , Neoplasias de la Próstata/tratamiento farmacológico , Antagonistas de Andrógenos/efectos adversos , Antineoplásicos Hormonales/efectos adversos , Carcinoma/secundario , Análisis Costo-Beneficio , Progresión de la Enfermedad , Flutamida/efectos adversos , Grupos Focales , Costos de la Atención en Salud , Humanos , Masculino , Metaanálisis como Asunto , Estudios Multicéntricos como Asunto , National Institutes of Health (U.S.) , Orquiectomía , Formulación de Políticas , Calidad de Vida , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos , Valor de la VidaRESUMEN
OBJECTIVES: Although combined androgen blockade with flutamide plus medical or surgical castration is effective in metastatic prostate cancer, debate exists over whether it is cost effective. METHODS: Decision analysis model of hypothetical cohorts of 70-year-old men presenting with metastatic prostate cancer, using a societal perspective, calculated anticipated survival and incremental cost per life-year gained. Time to progression and survival rate were from the Intergroup 0036 trial. Costs were based on Medicare data and wholesale drug pricing. Flutamide was estimated to reduce the relative risk of progressive disease by 25% (range, 0 to 50%). Costs and survival benefits were discounted at a 5% annual rate. RESULTS: In our model for minimal disease, median survival increased from 42.3 to 49.4 months with flutamide and average survival by 5.2 months at an incremental cost of $25,300 per life-year gained. If the efficacy were as high as 50%, the benefit would be 12 months at a cost of $13,700 per life-year gained. At a 10% efficacy, the benefit would be 1.9 months at a cost of $60,900 per life-year gained. For severe disease, the model estimated the median survival increased from 29.5 to 34.3 months with flutamide and average survival by 4.0 months at an incremental cost of $20,000 per life-year gained. At worst-case 10% efficacy, the benefit decreased to 1.5 months at an incremental cost of $47,500 per life-year gained. Total costs for patients treated with an orchiectomy and flutamide compared to leuprolide alone were similar if severe disease was present and actually lowered costs if there was minimal disease. CONCLUSIONS: Flutamide has an incremental cost effectiveness more favorable than most accepted therapies. If drug costs are covered under health care reform, flutamide should be initiated and covered for all good performance status patients.
Asunto(s)
Flutamida/economía , Modelos Teóricos , Neoplasias de la Próstata/tratamiento farmacológico , Anciano , Análisis Costo-Beneficio , Flutamida/uso terapéutico , Humanos , Masculino , Metástasis de la Neoplasia , Neoplasias de la Próstata/patologíaRESUMEN
OBJECTIVE: To compare the costs of the various options presently available in Australia for treatment of advanced prostatic carcinoma by androgen deprivation. DESIGN: Forty patients underwent a bilateral orchidectomy for prostatic carcinoma during the 1990/91 financial year at the Princess Alexandra Hospital, Brisbane. The Yale Cost Model, as adapted for use in Australian case-mix projects, was used to derive a diagnosis related group (DRG) cost for this procedure. This was compared with the projected cost that would be incurred in treating patients with the various medical alternatives. To enable comparison, expenses were calculated assuming a mean duration of survival of two years. RESULTS: The average cost of a bilateral orchidectomy was $2869. This compared to $11,253 for goserelin and $12,329 for cyproterone acetate when used alone in treating a single patient. Flutamide is presently only approved for combination therapy with a luteinising hormone-releasing hormone agonist, and when used with goserelin an average cost of $16,148 per patient was projected. CONCLUSIONS: Bilateral orchidectomy is clearly the cheapest means of hormone manipulation for prostatic carcinoma. Unless the costs of alternative therapies are drastically reduced in Australia, their use is difficult to justify in other than exceptional circumstances. We believe their use should be restricted presently to patients who would otherwise require a bilateral orchidectomy and have an anticipated survival of less than six months.