Faculty of Medicine
Cost-effectiveness analysis of post-orchiectomy management for clinical stage I non-seminoma germ cell testicular cancer
David-Dan Nguyen1,2,3, Madhur Nayan3, Jinyi Zhu4, Jane Kim4, Christopher J. Sweeney5, Steven L. Chang2,3.
1Faculty of Medicine, McGill University, Montreal, QC, Canada; 2Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States; 3Division of Urology, Brigham and Women's Hospital, Boston, MA, United States; 4Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA, United States; 5Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
Introduction: The optimal management following initial orchiectomy of testicular cancer patients with a clinical stage (CS) I non-seminomatous germ cell tumor (NSGCT) is controversial. There is a survival equipoise between retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and surveillance following initial orchiectomy. Considering that differences in survival outcomes are marginal, we performed a cost-effectiveness analysis to elucidate the tradeoffs and expected values for each management option.
Methods: We developed a Markov cohort simulation model that projected overall survival (OS), cancer-specific survival (CSS), quality-adjusted life-years (QALYs), and healthcare cost from the payer’s perspective with a lifetime time horizon for a cohort of 33-year-old CS1 NSGCT patients. Disease history, characteristics of relapses, relapse treatment algorithms, and utility values were derived from a comprehensive review of the literature and expert opinion. Costs were determined based on the Premier Hospital Database, a national hospital discharge database representing 20% of hospitals in the United States. The model was calibrated and validated against existing literature. A willingness-to-pay (WTP) threshold of $50,000 per QALY was employed.
Results: In the base case, surveillance was associated with the highest OS, CSS, and QALYs. It was associated with a 94.7% 15-year OS, a 98.6% 15-year CSS, and 22.06 QALYs. RPLND was more costly and less effective than both surveillance and primary chemotherapy. The incremental cost-effectiveness ratio associated with surveillance, as compared to primary chemotherapy, was $1410 per QALY gained, which is well below the WTP threshold. Results of the cost-effectiveness analysis are summarized in Figure 1.
Conclusion: We found that surveillance for CS1 NSGCT patients is the optimal strategy compared to RPLND and primary chemotherapy. These findings can inform clinical decision-making as well as resource allocation.
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