Cost-efficacy analysis of hormonal treatments for advanced prostate cancer

Sergio Iannazzo, Lorenzo Pradelli



Introduction: prostatic cancer is the second more frequent cancer in Italy (after lung cancer) and is the third cancer-related death cause. Age is the principal risk factor and, given the ageing process undergoing in the Italian population, it seems clear that the public sanitary expenditure to treat the disease is bound to increase, arising the need to perform pharmacoeconomic evaluations of the therapeutic strategies available. Methods: we performed a cost/utility analysis, through a Markov model, of several hormonal therapies in patients with advanced prostate cancer who underwent radical prostatectomy, from the biochemical recurrence to death. Nine androgen suppression therapies were considered: orchiectomy, two nonsteroidal antiandrogens (NSAA), four luteinizing hormone-releasing hormone (LHRH) agonists, cyproterone acetate and the association of a NSAA and a LHRH (BAT). In the simulation the androgen suppression therapies were started at the PSA recurrence and never stopped until death. The model used the Italian NHS prospective and a time horizon corresponding to patient’s lifetime. Drug costs were calculated for each therapy, considering the less costly brand. Results: all the considered therapies produced a life expectancy (LE) of about 12 life years (LYs) with a small variability ranging from 12.3 LYs for BAT (the most effective) to 11.37 LYs for NSAA-flutamide (the least effective). Quality adjusted life expectancy ranged from 9.98 QALYs for BAT to 9.28 QALYs for NSAA-flutamide. The average cost per patient presented a more enhanced variability, from 12,538 Euro for orchiectomy to 59,496 Euro for NSAA-bicalutamide. Among all the alternatives orchiectomy resulted the most cost/effective alternative with a cost/utility ratio of about 1,300 Euro/QALY. In the LHRH-agonists class leuprorelin was the most cost/effective with about 2,200 Euro/QALY. A one-way sensitivity analysis showed a substantial stability of the results. Conclusions: BAT resulted the most effective therapy, but also the one associated with the highest expected cost. Orchiectomy was marginally less effective but at the same time generated the lowest cost and, thus, represented the most cost/effective strategy. Nonetheless, its application in actual clinical practice is difficult and quite always refused by patients. Among the class of LHRH-agonists leuprorelin (considering the less costly brand, Eligard®) dominated the alternatives and, thus, could provide an excellent therapeutic strategy.


Prostatic cancer; Cost/utility analysis; Markov model; Hormonal therapies

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