April 10, 2008
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Treatment status may alter cost-effectiveness of finasteride

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Administration of finasteride may not be cost-effective when considering the effect of survival differences between treated and untreated patients with prostate cancer.

Researchers at The University of Texas Southwestern Medical Center and M.D. Anderson Cancer Center constructed an analysis model to establish the lifetime prostate health-related cost, starting at age 50, among patients assigned finasteride compared with patients assigned placebo.

The quality-adjusted cost-effectiveness ratio for finasteride in patients not administered chemoprevention was $122,747 per quality-adjusted life-years saved.

The quality-adjusted cost-effectiveness ratio was reported to be $112,062 per quality-adjusted life-years saved in cases where finasteride was not found to raise the incidence of high-grade tumors.

“Chemoprevention of prostate cancer with an agent that has no effect on the prevalence of benign prostatic hyperplasia can render a cost-effectiveness ratio of <$50,000 per quality-adjusted life-years saved when applied to a high-risk population associated with 25% risk reduction and a cost of $30 per month,” wrote the researchers. – by Paul Burress

Cancer. 2008;112:1058-1065.

PERSPECTIVE

In this report by Svatek and colleagues addressing the cost-effectiveness of prostate cancer chemoprevention, a serious attempt has been made to quantify the benefits associated with a reduction in prostate cancer risk commensurate with that demonstrated by finasteride in the Prostate Cancer Prevention Trial. The researchers conclude that finasteride is unlikely to be cost-effective when considering survival. However, it is also known that chemoprevention may be cost-effective in high-risk populations when considering adjustments for the effect on quality of life.

Unfortunately the researchers fail to quantify a number of issues relevant to the discussion. The emotional burden and distress of even low-risk prostate cancer is substantial and is not appropriately addressed in these studies.

Despite the well-documented distress, anxiety, and depression in spouses of patients with prostate cancer (eg, J Clin Oncol. 2008;26:599-605.), these changes are not assessed. Radiation, either as a primary or salvage therapy, is not addressed; yet, urinary, sexual and rectal function may be substantially impacted by radiation. Further, the potential savings associated with a lower rate of hormonal treatment is not discussed in terms outside of the cost of the treatments. Hormonal treatments are clearly associated with adverse cardiovascular, psychologic, bone and metabolic events, each of which has additional costs. Further, no estimation of work-related benefits of effective chemoprevention are factored into their analysis. Taken together, though the overall attempt to address the issue of chemoprevention cost-effectiveness in prostate cancer is laudable, the analysis presented by Svatek and colleagues should be viewed with caution. There are many opportunities for improvement and the actual benefits of prevention appear underestimated.

Oliver Sartor, MD

Piltz Professor of Cancer Research
Departments of Medicine and Urology, Tulane Medical School, New Orleans