A Decision Analysis of Alternative Treatment Strategies for Clinically Localized Prostate Cancer

Fleming, Craig; Jh, Wasson; Pc, Albertsen; Mj, Barry; Je, Wennberg

doi:10.1001/jama.1993.03500200064035

Cited by 408 publications

(136 citation statements)

References 36 publications

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“…With this approach, outcome data from prostate cancer treatment along with assumptions on the natural history of untreated prostate cancer are entered into the computer program to obtain results which have been expressed in terms of quality adjusted life years gained or lost and the cost per quality adjusted life year saved. 1,2 The output of such computer models is vulnerable to erroneous assumptions in the input data regarding the natural history of the disease, the efficacy of treatment, and the attempt to quantify differences in quality of life.…”

Section: Discussionmentioning

confidence: 99%

“…A study by Fleming et al suggested minimal net clinical benefit to treating early prostate cancer. 1 However, their model of untreated prostate cancer used a Swedish study which had patients with primarily well differentiated prostate cancer (65.8%) and relatively little moderately or poorly differentiated prostate cancer (34.2%). 33 This distribution does not accurately reflect the spectrum of disease seen in the United States.…”

Section: Discussionmentioning

confidence: 99%

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A quantitative analysis of the costs and benefits of prostate cancer screening

Benoit

Grönberg

Naslund

2001

Prostate Cancer Prostatic Dis

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The present study attempts to quantitate in an economically and clinically meaningful manner the cost and cost-effectiveness of prostate cancer screening and subsequent treatment, including complications from that treatment. Outcome data from large prostate cancer screening trials using prostate specific antigen (PSA) and digital rectal examination (DRE) and PSA alone were used to construct the screening model. The benefit of screening is expressed in years of life saved by screening, which is calculated by comparing the survival rate of men with prostate cancer to the survival rate of men in the general population. The cost of screening, treatment, and complications were estimated using the Medicare data base and published reports on the cost, morbidity and mortality for radical prostatectomy. The cost per year of life saved by prostate cancer screening with PSA and DRE was $2339 -3005 for men aged 50 -59, $3905 -5070 for men aged 60 -69, and $3574 -4627 overall for men aged 50 -69. The cost per year of life saved by prostate cancer screening with PSA alone for men aged 50 -70 was $3822 -4956. A sensitivity analysis demonstrates that the cost per year of life saved by prostate cancer screening will not change substantially even if the assumptions in this model have been underestimated or overestimated by 100%. This study quantifies only those parameters which can be reliably compared in concrete terms such as dollars, treatment impact on survival, published complication rates and published treatment costs. Using this type of analysis, prostate cancer screening appears to be a cost-effective intervention. However, the issue of whether prostate cancer screening is cost-effective will be decided definitively only when randomized, controlled trials are available to quantify the costs and benefits of prostate cancer screening. Prostate Cancer and Prostatic Diseases (2001) 4, 138-145.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A quantitative analysis of the costs and benefits of prostate cancer screening

Benoit

Grönberg

Naslund

2001

Prostate Cancer Prostatic Dis

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“…11 We analyzed this model previously, 12 and we found it reasonably approximated the natural history of prostate cancers. In our Markov model (depicted in Fig.…”

Section: Decision Analysis Modelmentioning

confidence: 97%

“…Previous decision analyses have modeled the impact of treatment based on capsular penetration. 11,12,14 Capsular penetration, however, cannot be determined in the WW patient. Rather, we have chosen to model treatment efficacy using actual treatment data, pooled and analyzed in the same manner as the WW data.…”

Section: Decision Analysis Modelmentioning

confidence: 99%

A Decision Analysis for Treatment of Clinically Localized Prostate Cancer

1997

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OBJECTIVE:To determine the preferred treatment of clinically localized prostate cancer. DESIGN:Cancer grade, patient age, and comorbidities are considered in a Markov model with Monte Carlo sensitivity analyses. Large and recent pooled analyses and patient-derived utilities are included. RESULTS:Principal findings suggest benefit for radical prostatectomy relative to watchful waiting for men under 70 years of age with low to moderate comorbidity. Men older than 70 with high comorbidity and disease of low to moderate grade do better with watchful waiting. CONCLUSIONS:Cohort-level sensitivity analyses suggest a quality-adjusted treatment benefit for radical prostatectomy for younger men and treatment harm for older men. Tailored patient and clinician decisions remain necessary, especially for men older than 70 in good health but with aggressive cancers. radical prostatectomy (RP) would help resolve the debate. The results of such a trial, however, are at least a decade away. In the meantime, we must rely on rational comparisons of the risks and benefits with either choice.The purpose of this study is to compare WW and RP in a decision analysis in which the risks of adverse events and patients' feelings about those events are quantified. Our perspective is that of society; we analyzed the data to determine the preferred treatment for a hypothetical cohort of men with localized prostate cancer. Although costeffectiveness is important, it is not included in this report. Our outcomes of interest are life expectancy, with and without adjustments for quality of life, for WW and RP patients who are between the ages of 60 and 75.Two large pooled analyses of metastasis-free survival have recently been conducted: one on WW patients, 4 and one on RP patients. 5,6 In addition, a recent analysis by Albertsen et al. has illustrated the increased risk of death due to noncancerous chronic illnesses in the prostate cancer population. 7 Recent studies have also examined treatment and complication impacts on quality of life 8,9 and patient utilities. 10 Our analysis incorporates all of these recent developments in an attempt to provide a comprehensive and current evaluation of the choice between RP and WW for localized prostate cancer. METHODS Decision Analysis ModelWe build on a model of prostate cancer previously published by the Prostate Patient Outcomes Research Team (PORT). 11 We analyzed this model previously, 12 and we found it reasonably approximated the natural history of prostate cancers. In our Markov model (depicted in Fig. 1), all patients begin with localized prostate cancer with no evidence of metastases and are treated by WW or RP. Each 6 months, a fraction of the patients progress to hormonally controlled metastatic disease. In subsequent 6-month periods, a fraction of these patients progress to hormone-refractory metastatic disease and eventual death from prostate cancer. At every 6-month period, a fraction of the patients die from causes other than prostate cancer. The arrows in Figure 1 illustrate the permissibl...

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“…Clinicians are unable to predict disease progression and to inform the patient whether his tumour is likely to progress, or whether any form of treatment will alter the outcome. New criteria to define the aggressive and metastatic potential of early prostate cancer are needed, particularly in view of the recent controversies and evidence from North American studies questioning the benefits of radical surgery over observation in early stage prostatic adenocarcinoma (Fleming et al, 1993;Lu-Yao et al, 1993;Chodak et al, 1994). Furthermore, even in cases where the disease appears to be confined to the prostate, cancers are understaged in over 50% of cases, with resulting positive surgical margins, extracapsular extension and potential treatment failure (Epstein et al, 1993).…”

mentioning

confidence: 99%