title: Observation versus initial treatment for men with localized, low-risk prostate cancer: a cost-effectiveness analysis.
abstract: BACKGROUND
  Observation is underutilized among men with localized, low-risk prostate cancer.
  
  
  OBJECTIVE
  To assess the costs and benefits of observation versus initial treatment.
  
  
  METHODS
  Decision analysis simulating treatment or observation.
  
  
  METHODS
  Medicare schedules, published literature.
  
  
  METHODS
  Men aged 65 and 75 years who had newly diagnosed low-risk prostate cancer (prostate-specific antigen level <10 µg/L, stage ≤T2a, Gleason score ≤3 + 3).
  
  
  METHODS
  Lifetime.
  
  
  CONCLUSIONS
  Societal.
  
  
  METHODS
  Treatment (brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy) or observation (active surveillance [AS] or watchful waiting [WW]).
  
  
  METHODS
  Quality-adjusted life expectancy and costs.
  
  
  RESULTS
  Observation was more effective and less costly than initial treatment. Compared with AS, WW provided 2 additional months of quality-adjusted life expectancy (9.02 vs. 8.85 years) at a savings of $15,374 ($24,520 vs. $39,894) in men aged 65 years and 2 additional months (6.14 vs. 5.98 years) at a savings of $11,746 ($18,302 vs. $30,048) in men aged 75 years. Brachytherapy was the most effective and least expensive initial treatment.
  
  
  RESULTS
  Treatment became more effective than observation when it led to more dramatic reductions in prostate cancer death (hazard ratio, 0.47 vs. WW and 0.64 vs. AS). Active surveillance became as effective as WW in men aged 65 years when the probability of progressing to treatment on AS decreased below 63% or when the quality of life with AS versus WW was 4% higher in men aged 65 years or 1% higher in men aged 75 years. Watchful waiting remained least expensive in all analyses.
  
  
  CONCLUSIONS
  Results depend on outcomes reported in the published literature, which is limited.
  
  
  CONCLUSIONS
  Among these men, observation is more effective and costs less than initial treatment, and WW is most effective and least expensive under a wide range of clinical scenarios.
  
  
  BACKGROUND
  National Cancer Institute, U.S. Department of Defense, Prostate Cancer Foundation, and Institute for Clinical and Economic Review.
authors.affiliation: Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Institute for Clinical and Economic Review, Institute for Technology Assessment, Boston, MA 02115, USA. Julia_Hayes@dfci.harvard.edu
authors.forename: Julia H
authors.initials: JH
authors.lastname: Hayes
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Ollendorf
authors.forename: Steven D
authors.initials: SD
authors.lastname: Pearson
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Barry
authors.forename: Philip W
authors.initials: PW
authors.lastname: Kantoff
authors.forename: Pablo A
authors.initials: PA
authors.lastname: Lee
authors.forename: Pamela M
authors.initials: PM
authors.lastname: McMahon
mesh_terms: D000368:Aged; D001706:Biopsy / Q000191:economics; D001918:Brachytherapy / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D051517:Digital Rectal Examination / Q000191:economics; D018450:Disease Progression; D017048:Health Care Costs; D006801:Humans; D008297:Male; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy / Q000191:economics; D011471:Prostatic Neoplasms / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D012680:Sensitivity and Specificity; D057832:Watchful Waiting / Q000191:economics*
chemical_list: D017430:Prostate-Specific Antigen