title: Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States.
abstract: BACKGROUND
  Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling.
  
  
  METHODS
  A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons.
  
  
  RESULTS
  In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy.
  
  
  CONCLUSIONS
  On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.
authors.affiliation: Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA.
authors.forename: Pinakin R
authors.initials: PR
authors.lastname: Jethwa
authors.affiliation: Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA.
authors.forename: Tapan D
authors.initials: TD
authors.lastname: Patel
authors.affiliation: Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA.
authors.forename: Aaron F
authors.initials: AF
authors.lastname: Hajart
authors.affiliation: Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA.
authors.forename: Jean Anderson
authors.initials: JA
authors.lastname: Eloy
authors.affiliation: Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA.
authors.forename: William T
authors.initials: WT
authors.lastname: Couldwell
authors.affiliation: Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA. Electronic address: james.liu.md@rutgers.edu.
authors.forename: James K
authors.initials: JK
authors.lastname: Liu
mesh_terms: D000328:Adult; D000368:Aged; D001971:Bromocriptine / Q000191:economics / Q000627:therapeutic use*; D000077465:Cabergoline; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D004873:Ergolines / Q000191:economics / Q000627:therapeutic use*; D005260:Female; D017048:Health Care Costs; D006727:Hormone Antagonists / Q000191:economics / Q000627:therapeutic use*; D006801:Humans; D006966:Hyperprolactinemia / Q000188:drug therapy* / Q000209:etiology; D008017:Life Expectancy; D008297:Male; D006278:Medicare; D008866:Microsurgery / Q000191:economics* / Q000379:methods; D008875:Middle Aged; D009010:Monte Carlo Method; D044583:Neuroendoscopy / Q000191:economics* / Q000379:methods; D010911:Pituitary Neoplasms / Q000150:complications / Q000188:drug therapy / Q000191:economics* / Q000601:surgery / Q000628:therapy*; D015175:Prolactinoma / Q000150:complications / Q000188:drug therapy / Q000191:economics* / Q000601:surgery / Q000628:therapy*; D019057:Quality-Adjusted Life Years; D013101:Sphenoid Sinus / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D004873:Ergolines; D006727:Hormone Antagonists; D001971:Bromocriptine; D000077465:Cabergoline
keywords: Bromocriptine; Cabergoline; Cost-effectiveness analysis; Endoscopic; Microprolactinoma; Microscopic; Pituitary tumors; Transsphenoidal surgery