A decision analysis comparing 3 active surveillance protocols for the treatment of patients with low‐risk prostate cancer

Abstract

Background

Active surveillance (AS) is a viable management option for approximately 50% of men who are newly diagnosed with prostate cancer. To the authors' knowledge, no direct comparisons between the different variants of AS protocols have been conducted to date. The authors developed a microsimulation decision model to evaluate which of 3 alternative AS protocols is optimal for men with low‐risk prostate cancer, and compared each of these with immediate treatment.

Methods

Men who were diagnosed with low‐risk prostate cancer at age 65 years were modeled as having been treated with either immediate therapy or via each of 3 AS protocols. Modeled AS protocols represent those in the literature; a modified AS protocol was included in a sensitivity analysis. Immediate therapy included radical prostatectomy, external‐beam radiotherapy, or brachytherapy. Outcome measures were quality‐adjusted life‐years (QALYs) and costs. Cost‐effectiveness analysis and deterministic and probabilistic sensitivity analyses were performed.

Results

Immediate therapy produced fewer QALYs than all variants of AS. Of the AS protocols evaluated, biennial biopsy was found to be the only efficient option, with an incremental cost‐effectiveness ratio of $3490 per QALY compared with immediate therapy. It delayed the need for curative therapy by a mean of 56 months, and was found to be preferred in >86.9% of cases in probabilistic sensitivity analysis. A modified version of low‐intensity AS dominated all other options.

Conclusions

For a 65‐year‐old man with low‐risk prostate cancer, AS with biennial biopsy appears to be highly cost‐effective compared with common alternatives. An AS protocol using triennial biopsy was found to dominate all other strategies and should be considered for men who are comfortable with a longer period between biopsies. The optimal strategy depends on a patient's tolerance for periodic biopsies and comfort with delaying radical treatment. Physicians should incorporate these patient preferences into decision making.

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