Comparative effectiveness review of treatment options for pituitary microadenomas in acromegaly.
OBJECTIVE
Acromegaly, a syndrome of excess growth hormone (GH) secretion typically caused by a GH-secreting pituitary adenoma, reduces life expectancy by approximately 10 years when left untreated. Treatment of acromegaly involves combinations of one or more discrete therapeutic modalities to achieve biochemical control. Unfortunately, data capable of informing decisions among alternate management strategies are presently lacking.


METHODS
The authors performed a comparative effectiveness research (CER) review integrating efficacy, cost, and quality of life (QOL) analysis for treatment strategies comprising various combinations of surgery, radiotherapy, stereotactic radiosurgery, and pharmacotherapy in patients with acromegaly caused by a pituitary microadenoma. A management decision tree was used to identify 5 treatment strategies, each with up to 4 potential treatment steps. Efficacy was assessed using recent literature reports of biochemical control rates for each modality. Cost estimations were derived from wholesale drug prices and from the Healthcare Cost and Utility Project. Quality of life data were obtained from studies utilizing the Acromegaly Quality of Life Questionnaire.


RESULTS
Individual treatment modalities were analyzed and ranked in each of 3 domains: highest rate of success, lowest cost, and highest QOL, and these scores were combined to facilitate comparison of overall effectiveness of each of the management strategies. These aggregate effectiveness scores were used to compare the 5 strategies from the decision tree, and a novel strategy was also proposed.


CONCLUSIONS
The choice of management strategy must be individualized for each patient with acromegaly. This CER analysis provides a comprehensive framework to inform clinical decisions among alternate management strategies in patients with GH-secreting pituitary microadenomas.
Department of Neurosurgery, Cleveland Clinic, OH, USA. nmarko@gmail.com
Nicholas F
NF
Marko
Emily
E
LaSota
Amir H
AH
Hamrahian
Robert J
RJ
Weil
D000236:Adenoma / Q000628:therapy*; D003131:Combined Modality Therapy; D057186:Comparative Effectiveness Research; D003362:Cost-Benefit Analysis; D019468:Disease Management; D004358:Drug Therapy / Q000191:economics; D049912:Growth Hormone-Secreting Pituitary Adenoma / Q000628:therapy*; D006801:Humans; D019635:Neurosurgical Procedures / Q000191:economics; D010911:Pituitary Neoplasms / Q000628:therapy*; D011788:Quality of Life; D016634:Radiosurgery / Q000191:economics; D011878:Radiotherapy / Q000191:economics; D016896:Treatment Outcome