Focal therapy versus radical prostatectomy and external beam radiotherapy as primary treatment options for non-metastatic prostate cancer: results of a cost-effectiveness analysis

Figures & data

Figure 1. Health state transition diagram.

Figure 2. Model schematic – example for radical prostatectomy. Note that all patients start in “stable disease” state.

Table 1. Summary of clinical parameters used in the model.

Description	Value	Source
Time to first post-index treatment change	Variable monthly rates based on analysis of time-to-event data, as described in text	Imperial College dataset
Time to subsequent recurrence, metastases or death (salvage EBRT)		Stephenson 2004, Stephenson 2007, Bartowiak 2018^12–14
Time to subsequent recurrence, metastases or death (salvage surgery)		Chade 2012^15
Time to castrate resistance post-recurrence (ADT - post-recurrence)		Tamada 2018^16
Time to castrate resistance post-recurrence (ADT + CTx - metastatic disease)		Kiriakopoulos 2018^17
Time to death (ADT - post recurrence)		Bauman 2020^18
Time to death (ADT + CTx - metastatic disease)		Kiriakopoulos 2018^17
Time to death (all others)		Imperial College dataset
Proportion of first treatment changes due to local recurrence	0.9	Imperial College dataset
Proportion of first treatment changes due to metastatic disease	0.1	Imperial College dataset
Proportion having repeat focal therapy following first focal therapy recurrence	0.785	Imperial College dataset
Proportion having radiotherapy following first focal therapy recurrence	0.054	Imperial College dataset
Proportion having prostatectomy following first focal therapy recurrence	0.107	Imperial College dataset
Proportion having repeat focal therapy following second focal therapy recurrence	0.351	Imperial College dataset
Proportion having radiotherapy following second focal therapy recurrence	0.378	Imperial College dataset
Proportion having prostatectomy following second focal therapy recurrence	0.189	Imperial College dataset
Proportion having radiotherapy following subsequent focal therapy recurrence	0.33	Clinical opinion
Proportion having prostatectomy following subsequent focal therapy recurrence	0.33	Clinical opinion
Proportion having radiotherapy following post-prostatectomy recurrence	0.89	Imperial College dataset
Proportion having focal therapy following radiotherapy treatment recurrence	0.05	Imperial College dataset
Proportion having prostatectomy following radiotherapy treatment recurrence	0.05	Imperial College dataset

Table 2. Estimation of complication costs.

Complication	Subcategory	Basis of costing	Source	Expected incidence			Cost Month 1	Cost Month 2+
				Prostatectomy	Radiotherapy	Focal therapy
Urinary leak	Mild	1 pad/day	NHS Drug Tariff NHS Reference Costs	23%	5%	1%	£17	£17
	Moderate	2+ pads per day		13%	0%	0%	£35	£35
	Severe	Surgery (50% LB50Z: Implantation of artificial urinary sphincter; 50% LB21B: Major open, prostate or bladder neck Procedures)		0.5%	0%	0%	£6,187	£0
Cystoscopic interventions		LB70C/D: Complex endoscopic, prostate or bladder neck procedures (weighted mean of daycase and elective)	NHS Reference Costs	20%	20%	8.3%	£2,871	£0
Erectile dysfunction	Oral Px	Sildenafil 2x week + 2 GP visits/year	NHS Drug Tariff NHS Reference Costs PSSRU	40%	40%	2%	£10	£10
	Vacuum pump	1 pump + 2 GP visits/year		6%	6%	0.1%	£19	£19
	IC injections	Alprostadil 20 μg once weekly + 2 GP visits/year		5%	5%	0.1%	£47	£47
	Penile implant	LB74Z: Implantation of penile prosthesis		0.3%	0.3%	0%	£5,150	£0
Bowel problems	Recto-anal procedures	FE31Z: Diagnostic colonoscopy with biopsy (Weighted mean of daycase and elective	NHS Drug Tariff NHS Reference Costs	10%	18.4%	0.1%	£696	£0
	Fecal incontinence	1-2 pads per day		0.1%	5.%	0%	£35	£35
Readmission within 30 days		50:50 1 and 2 nights @ £286 per day	NHS Reference Costs	0.3%	0%	0%	£429	£0
Mean complication cost: month 1				£707.47	£727.88	£239.46
Mean complication cost: month 2+				£15.91	£10.02	£0.43

Table 3. Monte Carlo cost-effectiveness ranking using WTP = £30,000/QALY.

Strategy	Cost	Incremental cost	QALYs	Incremental QALYs	ICER (Cost/QALY)	NMB	Incremental NMB
Base case
Focal therapy	£7,527		7.01			£202,590
EBRT	£10,959	£3,432	6.79	−0.22	–£15,652 (Dominated)	£192,881	£9,709
Prostatectomy	£13,247	£5,721	6.91	−0.10	–£59,952 (Dominated)	£194,307	£8,283
Scenario analysis (undiscounted)
Focal therapy	£8,058		8.26			£239,857
EBRT	£11,427	£3,369	7.97	−0.29	-£11,639 (Dominated)	£227,804	£12,053
Prostatectomy	£13,997	£5,940	8.13	−0.13	-£45,171 (Dominated)	£229,972	£9,885

Figure 3. Monte Carlo cost-effectiveness ranking using WTP = £30,000/QALY, (a) for comparison of focal therapy vs EBRT and b) for comparison of focal therapy vs prostatectomy.

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