Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Amy Justice

Second Advisor

George Goshua

Abstract

Background: Current standards of care guide patients with high-risk prostate cancer (T3a or Gleason score 8–10 or PSA >20 ng/ml) toward treatment options such as radical prostatectomy (RP), or radiotherapy (RT) regardless of their life expectancy. These interventions are often invasive, costly, and may offer limited benefit compared to active surveillance (AS). While previous cost-effectiveness analyses have established that active surveillance in low-risk prostate cancer patients (T1–T2a, Gleason score ≤6, and PSA <10 ng/ml) is a cost-effective initial strategy, its role in the management of high-risk patients, especially those with limited life expectancy, remains unclear. This study aims to extend previous cost-effectiveness modeling to the high-risk population to inform decision makers on the most appropriate strategy of care considering a 10-year time horizon.

Methods: This retrospective cost-effectiveness cohort study using the Veterans Affairs Cohort Study (VACS) dataset, which contain electronic health records of men with high-risk prostate cancer. Patients included in this cohort were at least 50 years old from 2009-2019, designated as high-risk according to the NCCN guidelines, and non-metastatic at baseline. The Veteran Affairs HERC (Health Economics Resource Center) Average Cost Dataset was used to calculate total yearly healthcare costs per patient. TreeAgePro software was used with a 3% discount rate and a 1-year model cycle to estimate the cost-effectiveness for 10 years after start of treatment. A combination of literature search and VACS dataset analyses was conducted to inform transition probabilities. QALYs were determined through literature search of those being treated with AS, RP, or RT at any risk level. Univariate and multivariate sensitivity analyses were conducted on all input parameters.

Results: 20.4% of patients initially managed with active surveillance converted to radical prostatectomy or radiotherapy. Over the 10-year simulation horizon, the average cost per patient was $425,000 for AS, $473,000 for RP, and $787,000 for RT. The incremental cost-effectiveness ratio (ICER) of radiotherapy relative to active surveillance is $545,000/QALY. Radiotherapy provides an additional 0.66 QALYs compared to active surveillance. The model was sensitive to the cost of active surveillance, follow-up cost of radical prostatectomy, and follow-up cost of radiotherapy. Active surveillance was the most cost-effective strategy in 88% of 10,000 Monte Carlo iterations.

Conclusion: Active surveillance is a cost-effective strategy for newly diagnosed patients with high-risk non-metastatic prostate cancer at a willingness-to-pay threshold of $100,000/QALY. This is due to lower long-term costs of active surveillance, however, variation in costs of follow-up could change optimal strategy. These findings support the consideration of active surveillance as an initial management strategy in high-risk prostate cancer patients.

Comments

This is an Open Access Thesis.

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