Prostate cancer is a leading cause of cancer deaths among men, second only after lung cancer (Reference Barry3;Reference Burkhardt, Litwin and Rose6), and the cost burden of prostate cancer is high (Reference Barry3;Reference Burkhardt, Litwin and Rose6). The current therapeutic options for clinically localized (T1–T2 stage) prostate cancer include, among radical prostatectomy techniques, radical retropubic prostatectomy (RRP)—the surgical treatment modality of proven efficacy granted with level 1 evidence (Reference Bill-Axelson, Holmberg and Ruutu4;8), three-dimensional conformal radiotherapy (3DCRT) and brachytherapy (BT)—based on the transrectal ultrasound-guided transperineal implantation of permanent radioactive sources (commonly called “seeds”) evaluated through a computed tomography-based system for postimplantation quality. Surgical treatments and 3DCRT are associated with injuries on adjacent tissue, whereas BT seems to be affected by less side effects when compared with other treatments: this suggests that many patients may find BT more attractive because it also is as equally effective (Reference Norderhaug, Dahl and Høisaeter19). High-intensity focused ultrasound data are not yet available in terms of long-term follow-up (Reference Hummel, Paisley, Morgan, Currie and Brewer16); the same holds true for the therapeutic option commonly known as “watchful waiting” (grade B recommendation) (Reference Heidenreich, Aus and Bolla14). At present, there are no published trials that directly compare long-term survivals after the various treatments of clinically localized disease, leaving the question of survival benefit unanswered (Reference Buron, Le Vu and Cosset7).
Systematic reviews of the best available evidence (10;15) claim that efficacy and complications affect the choice of treatment. Our review compares RRP with BT, a choice often preferred by patients for reasons illustrated by Norderhaug et al. (Reference Norderhaug, Dahl and Høisaeter19).
This study is a part research series in Health Technology Assessment field developed by the Department of Public Health and San Giovanni Battista University Hospital (Turin, Italy), which recently focused on economic evaluations of available treatments for early prostate cancer. An analysis of surgical techniques has just been concluded (Reference Gianino, Galzerano, Tizzani and Gontero13); hence, the aim of our study is carrying out a comparative costs analysis of BT and RRP therapies for clinically localized prostate cancer to shed light on the difficulties that analysts face in comparing these treatments and their relative economic effectiveness.
MATERIALS AND METHODS
A literature search was performed on studies available in the Medline (Reference Alton, Eckerlund and Norlund2), Embase, DARE, and INAHTA databases, using the terms (MeSH or text search according to the database) “prostatectomy” and “costs”, “costs effective”, “cost benefit analysis”, “economic evaluation”. The detailed search procedure is available with the lead author. English, French, and Italian language references were included. Articles that met the following criteria were included in the analysis: published studies that focus on comparative cost analyses of RRP and BT. Excluded were transurethral resection of prostate and benign prostatic hyperplasia. Of ninety-one articles, only eight met the criteria for the analysis, and these studies were reviewed. Our analysis is based on the following data: (i) current average cost adjusted to U.S. currency and for inflation (base year 2002, that is, the last year used in the published articles to estimate costs) and for exchange rates (12;21); (ii) ratio of average cost of BT and RRP; (iii) difference between BT and RRP average costs; and (iv) relative average cost calculated as the difference between BT and RRP average costs over RRP average costs.
To verify the comparability among estimated BT and RRP average costs, we considered the following information as well: (i) reference period (preoperative, operative, and postoperative period); (ii) whether the cost estimation is based on direct costs or charges; and (iii)breakdown of direct costs or charges into different cost items.
RESULTS
We reviewed eight relevant published studies that focus on a comparative costs analysis between RRP and BT technique: seven of them compare BT with RRP technique, one of which compare RRP versus BT including adjuvant external beam radiotherapy. In summary (Table 1): (i) Kohan, Penson, and Buron papers suggest the same cost for RRP and BT, (ii) Wagner found BT to be the more expensive option, and (iii) Makhlouf found BT to be more costly than RRP with a direct cost of 63 percent over RRP average cost, and 16 percent over RRP average cost when average direct cost is based on charges. The difference between RRP and BT average costs is more than $3,600. Ciezki reaches the same conclusion; however, the author has used two different samples: Group 1 (BT with ultrasound performed in the office setting before implantation) and Group 2 (BT with ultrasound performed in the operating room at the time of the implantation of the seeds). For the first sample (Group 1) the relative average cost is around 85 percent over RRP average cost and for the second (Group 2) around 105 percent over RRP average cost.
Table 1. Average Cost, Relative Average Cost, Difference, Ratio (Current Average Cost Adjusted for U.S. Currency)
aBT with planning ultrasound performed in the office setting before implantation.
bBT with planning ultrasound performed in the operating room at the time implantation.
cDirect costs.
dCharge.
eEuros value 2001.
fThe values in dollar are obtained adjusting for an exchange rate of $0.8813 per €.
RRP, radical retropubic prostatectomy; BT, brachytherapy.
Brandeis and Alexianu found BT to be less costly than RRP with a relative average cost around 20 percent over RRP average cost and around 40 percent over RRP average cost, respectively.
Table 2 shows that the average cost of RRP fluctuates between $7,437.12 and $28,304.54, and the average cost for BT varies from $ 7,548.88 to $ 26,321.00. The studies have all been performed during different periods of time and some refer to preoperative and operative costs only, while others include costs during postoperative follow-up periods.
Table 2. Average Cost Adjusted for Inflation (Base Year 2002)
aDirect costs.
bCharge.
Three studies measure BT ad RRP direct costs (Reference Alexianu and Weiss1;Reference Buron, Le Vu and Cosset7;Reference Ciezki, Klein and Angermeier9), whereas two studies, instead of measuring direct costs, use charges (Reference Brandeis, Pashos, Henning and Litwin5;Reference Wagner, Young and Bahnson22). Two studies use charges based on fee schedule (Reference Kohan, Armenakas and Fracchia17;Reference Penson, Schonfeld and Flanders20); finally, one author estimates average costs using at the same time charges and direct costs (Reference Makhlouf, Boyd, Chapman and Theodorescu18).
Two studies only, among the eight analyzed, provided a breakdown into different cost items of average costs or charges (see Table 3).
Table 3. Reference Period (Preoperative, Operative, and Postoperative Period), Whether the Cost Estimation Is Based on Direct Costs or Charges, and Breakdown of Direct Costs or Charges
DISCUSSION
Although the use of brachytherapy is growing in popularity, radical prostatectomy remains one of the most common treatments for localized prostate cancer. Because the impact of treatment on survival is still a matter of much debate and there is no clinical consensus in favor of one treatment to the others, cost factors become more important in treatment decision. In our study, we have reviewed the methods and data used in costing studies of the BT and RRP techniques. Our findings show there is a lack of homogeneity among published studies in the field. Differences in the estimated costs are related to different environments in which the two techniques (BT and RRP) are applied (i.e., provider/hospital characteristics such as hospital size or organizational structure, surgeon experience in treatment of prostate cancer, clinical characteristics, geographic region, and so on, may affect treatment costs).
The lack of homogeneity is due in particular to the use of different methodology in evaluating costs, different data, different cost items included, and different time frames.
No conclusion may be made about the relative cost of the two treatments used for early-stage prostate cancer based on this review. The factors mentioned above about different methodology contribute to this.
Another problem concerns the lack of detailed costs information (i.e., breakdown, for instance, anesthesia, laboratory medicine, medicine, pharmacy, nursing, radiology, operating room, surgical supplies, recovery room, and so on). Table 3 shows that Wagner et al. (Reference Wagner, Young and Bahnson22) and Makhlouf et al. (Reference Makhlouf, Boyd, Chapman and Theodorescu18) only, have provided a breakdown into different cost items. Some studies do not include detailed costs information, for instance Brandeis et al. and Ciezki et al. (Reference Brandeis, Pashos, Henning and Litwin5;Reference Ciezki, Klein and Angermeier9); others provide aggregate cost information only (Reference Alexianu and Weiss1;Reference Buron, Le Vu and Cosset7;Reference Kohan, Armenakas and Fracchia17;Reference Penson, Schonfeld and Flanders20).
More homogenous costing studies are needed to contribute to the question of which treatment is less costly as a basis for a true cost-effectiveness analysis of BT versus RRP (Reference Drummond, Stoddart and Torrance11).
CONTACT INFORMATION
Maria Michela Gianino, PhD (mariola.gianino@unito.it), Professor; Mario Galzerano, MD (mario.galzerano@unito.it), Major Student, Department of Public Health, Turin University, Via Santena 5 bis, Turin 10126, Italy
Davide Minniti, MD (dminniti@molinette.piemonte.it), Hospital Medical Manager, San Giovanni Battista University Hospital, Corso Bramante 88/90, Turin 10126, Italy
Cinzia Di Novi, (cinzia.dinovi@sp.unipm.it), Research Fellow, Department of Public Policy and Choice, Eastern Piedmont University, Via Cavour 84, Alessandria 15100, Italy
Barbara Martin, (barbara.martin@unito.it), Head Librarian, Department of Public Health, Turin University, Via Santena 5 bis, Turin 10126, Italy
Ottavio Davini, MD (odavini@molinette.piemonte.it), Hospital Medical Manager, Silvana Barbaro, MD (sbarbaro@molinette.piemonte.it), Hospital Medical Manager, San Giovanni Battista University Hospital, Corso Bramante 88/90, Turin 10126, Italy
