Elsevier

European Urology

Volume 72, Issue 5, November 2017, Pages 712-735
European Urology

Platinum Priority – Review – Prostate Cancer
Editorial by Timothy J. Wilt and Philipp Dahm on pp. 736–737 of this issue
Cost of New Technologies in Prostate Cancer Treatment: Systematic Review of Costs and Cost Effectiveness of Robotic-assisted Laparoscopic Prostatectomy, Intensity-modulated Radiotherapy, and Proton Beam Therapy

https://doi.org/10.1016/j.eururo.2017.03.028Get rights and content

Abstract

Context

Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode.

Objective

To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer.

Evidence acquisition

We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively.

Evidence synthesis

RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy.

Conclusions

Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective.

Patient summary

We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense.

Introduction

Since the turn of the century, new technologies have revolutionized the treatment of prostate cancer. Starting in the early 2000s, intensity-modulated radiotherapy (IMRT) was rapidly adopted by radiation oncologists, such that by 2007 the vast majority of radiation for prostate cancer was delivered using this method [1]. Around the same time, surgical treatment of prostate cancer was transformed by the rapid dissemination and adoption of robot-assisted radical prostatectomy (RARP). While in 2004 <10% of radical prostatectomy procedures were performed using a robotic approach, this proportion increased to 73% by 2012 [2]. More recently, proton beam therapy has emerged as a new radiation treatment modality. This new technology diffused more slowly than IMRT and RARP, representing only 5% of radiation treatments for prostate cancer in the USA in 2012 [3]. Yet, some centers are strong proponents of its use [4], and others will build proton beam facilities in the upcoming years [5].

Treatment with any of these new technologies—IMRT, RARP, or proton beam therapy—is associated with significant upfront costs: ∼$2 million for a robotic platform and ∼$150 million for a proton beam therapy cyclotron facility [6], [7]. Moreover, maintenance of the equipment and disposables come with additional expenditures [8]. However, some of these costs may be offset by better outcomes or less resource use during the treatment episode. For example, decreased adverse events [9] and shorter hospital stays [10] associated with robotic surgery may offset some of the additional cost.

To date, we lack a comprehensive review of the scientific literature on the costs and health care economics associated with these new treatments for prostate cancer. For this reason, we set out to systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer. Specifically, we sought to identify cost-analysis, cost-effectiveness, cost-benefit, and cost-utility studies in the English literature, comparing the cost of each of the new technologies with its more traditional counterpart. These data can inform patients and clinicians when making treatment choices for prostate cancer.

Section snippets

Evidence acquisition

We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement and the PRISMA protocol (see Appendix A for the protocol) [11], [12]. We performed three separate searches, one each for RARP, IMRT, and proton beam therapy. We systematically searched Medline, Embase, and Web of Science for manuscripts that compared treatment with one of the new technologies to treatment with the predecessor standard

Evidence synthesis

Many of the studies referred to in the following sections evaluated cost effectiveness by estimating the incremental cost effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) gained. To do this, they compare the cost of the new technology (RARP, IMRT, or proton beam therapy) with that of the standard treatment. Next, they compare outcomes and express them as QALY gained—the arithmetic product of quantity and quality of life that allows for assessment of outcomes

Conclusions

In conclusion, treatment with new technologies is costlier than treatment with traditional technologies. However, given the overall low quality of evidence and the inconsistencies across studies, precise differences in costs remain unclear. Moreover, attempts to estimate whether this increased cost is worth it are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. However, understanding the value of treatment with new

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    Florian R. Schroeck and Bruce L. Jacobs contributed equally to this work.

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