title: Modeling the cost of management options for stage I nonseminomatous germ cell tumors: a decision tree analysis.
abstract: OBJECTIVE
  Patients with clinical stage I nonseminomatous germ cell tumors (NSGCTs) have been managed with surveillance, chemotherapy, or retroperitoneal lymphadenectomy (RPLND) with similar survival outcomes. Cost factors influencing the choice of therapy were evaluated using computer-based decision analysis.
  
  
  METHODS
  A detailed model was developed that integrates projected costs for more than 60 possible treatment outcomes. It incorporates primary, adjuvant, and salvage chemotherapy, primary and post-chemotherapy RPLND, and both laparoscopic and open surgical approaches. Starting values and probabilities were derived from a comprehensive meta-analysis of the last 25 years of testes cancer literature. Hypothesis testing was performed using sensitivity analysis.
  
  
  RESULTS
  The model predicts a cost premium for both primary chemotherapy (18.7%) and RPLND (51.7%) compared with surveillance. If laparoscopic RPLND was practiced, the cost premium for primary surgery (29.1%) approached that of chemotherapy (26.4%). Open RPLND was 1.25x as costly as laparoscopic RPLND, primarily because of longer hospitalization. The choice of open RPLND yielded a 6.9% cost premium for a surveillance program in this model. For such a program, primary chemotherapy became cost advantageous when the probability of recurrence during surveillance was more than 46%.
  
  
  CONCLUSIONS
  This model allows a variety of treatment cost hypotheses to be tested. Primary RPLND is never cost advantageous over surveillance or primary chemotherapy. Surgical costs can significantly increase the overall cost of a surveillance program. In stage I patients with high-risk tumor characteristics, primary chemotherapy may have a cost advantage over surveillance.
authors.affiliation: James Buchanan Brady Urological Institute, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins Medical Institute, Johns Hopkins Hospital, Baltimore, MD 21287, USA. rlink5@jhmi.edu
authors.forename: Richard E
authors.initials: RE
authors.lastname: Link
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
authors.forename: Roberto
authors.initials: R
authors.lastname: Pili
authors.forename: Louis R
authors.initials: LR
authors.lastname: Kavoussi
mesh_terms: D000970:Antineoplastic Agents / Q000627:therapeutic use; D003663:Decision Trees; D018237:Germinoma / Q000191:economics* / Q000473:pathology / Q000628:therapy*; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D009367:Neoplasm Staging; D013736:Testicular Neoplasms / Q000191:economics* / Q000473:pathology / Q000628:therapy*
chemical_list: D000970:Antineoplastic Agents