Clinical investigation
Prostate
Brachytherapy versus prostatectomy in localized prostate cancer: Results of a French multicenter prospective medico-economic study

https://doi.org/10.1016/j.ijrobp.2006.10.011Get rights and content

Purpose: To prospectively compare health-related quality of life (HRQOL), patient-reported treatment-related symptoms, and costs of iodine-125 permanent implant interstitial brachytherapy (IB) with those of radical prostatectomy (RP) during the first 2 years after these treatments for localized prostate cancer.

Methods and Materials: A total of 435 men with localized low-risk prostate cancer, from 11 French hospitals, treated with IB (308) or RP (127), were offered to complete the European Organization for Research and Treatment of Cancer core Quality of Life Questionnaire QLQ-C30 version 3 (EORTC QLQ-C30) and the prostate cancer specific EORTC QLQ-PR25 module before and at the end of treatment, 2, 6, 12, 18, and 24 months after treatment. Repeated measures analysis of variance and analysis of covariance were conducted on HRQOL changes. Comparative cost analysis covered initial treatment, hospital follow-up, outpatient and production loss costs.

Results: Just after treatment, the decrease of global HRQOL was less pronounced in the IB than in the RP group, with a 13.5 points difference (p < 0.0001). A difference slightly in favor of RP was observed 6 months after treatment (−7.5 points, p = 0.0164) and was maintained at 24 months (−8.2 points, p = 0.0379). Impotence and urinary incontinence were more pronounced after RP, whereas urinary frequency, urgency, and urination pain were more frequent after IB. Mean societal costs did not differ between IB (€8,019 at T24) and RP (€8,715 at T24, p = 0.0843) regardless of the period.

Conclusions: This study suggests a similar cost profile in France for IB and RP but with different HRQOL and side effect profiles. Those findings may be used to tailor localized prostate cancer treatments to suit individual patients’ needs.

Introduction

Prostate cancer is the commonest male cancer in many industrialized countries and the second leading cause of cancer death in men. In France, more than 40,000 new cases of prostate cancer were diagnosed in 2000 (1) and the increase in the annual number of new cases can be explained by aging of the population and by changes in the mode of detection with the recent widespread use of prostate-specific antigen (PSA) screening, which has resulted in a dramatic increase in the number of men diagnosed at both a younger age and at an earlier stage of the disease.

Currently the most common curative options for men with clinically localized (T1–T2) prostate cancer are radical prostatectomy (RP), external beam radiation therapy (EBRT), and interstitial brachytherapy (IB), which consists of inserting permanent radioactive sources into prostatic tissue. Management of localized prostate cancer by high-intensity focused ultrasound and active monitoring is also being explored, but no long-term follow-up data are available so far.

At present, there are no published trials that directly compare long-term survivals after the various treatments of clinically localized disease, leaving the question of survival benefit unanswered. However, studies have reported biochemical relapse-free survival rates that are similar up to 10 years after RP, EBRT, or IB for localized “low-risk” patients (T1–T2a, PSA ≤10 ng/mL, and Gleason score <7) (2, 3, 4, 5). In the absence of any evidence of overall differences in survival between IB and conventional treatments, health-related quality of life (HRQOL), treatment-related symptoms, and economic cost impact may become key factors.

The objective of this article is to compare IB with RP in terms of HRQOL, patient-reported treatment-related symptoms, and cost impact during the first 2 years after these treatments for localized prostate cancer. In this study, IB is compared with RP, as RP is considered to be the reference treatment in routine French medical practice for men with localized prostate cancer and a life expectancy of more than 10 years (6). Although EBRT can also be used as a treatment option, most of the time it is proposed for patients with a larger extension or for patients who are unsuitable for RP (e.g., age, comorbidities). In addition, at present, neither active monitoring nor high-intensity focused ultrasound are considered to be a treatment option in France for these patients with a life expectancy of more than 10 years (6).

The present article is part of a larger “French prostate cancer medico-economic study” whose purpose was threefold: (1) to compare HRQOL and economic data of IB with RP; (2) to document an EBRT patient cohort with the same HRQOL and economic criteria; and (3) to compare the physician’s and patient’s points of view concerning treatment-related symptoms. A total of 546 patients (T1/T2N0M0 localized prostate cancer, PSA ≤20 ng/mL, biopsy Gleason score <8) were included in the whole study. The present paper deals with the first part and main objective; the two other points will be subsequently reported.

Section snippets

Patients and treatments

Between March 2001 and June 2002, 435 patients diagnosed with localized prostate carcinoma, from 11 French hospitals, were treated without randomization of treatment with permanent implant IB (n = 308) or with RP (n = 127). Interstitial brachytherapy was performed in five cancer centers and one teaching hospital, while RP was performed in six teaching hospitals. For each type of treatment, patients were followed prospectively for at least 2 years.

In the IB group, all patients were implanted

Demographic data of treatment groups

Data on the subjects’ baseline demographics and clinical condition before treatment are indicated in Table 1. A comparison of the IB and RP groups demonstrated significant differences at baseline. Men in the IB group were significantly older, had less frequent working status, lower clinical stage, lower PSA level, and lower pretreatment IPSS score than men treated by RP. The percentage of men receiving neoadjuvant hormonal therapy was higher in the IB group (43.5%) than in the RP group (6.3%).

Discussion

The purpose of this article was to compare IB with RP, performed for localized prostate cancer patients, in terms of HRQOL, treatment-related symptoms, and costs. The entire study was based on an assumed equivalent level of efficacy.

Conclusion

The present study strongly suggests a similar societal cost profile for IB and RP in France but with different HRQOL and treatment-related symptoms profiles. Whereas RP is characterized by a very marked impairment in HRQOL immediately after treatment with subsequent improvement, IB shows a moderate but persistent impairment in HRQOL over 2 years. Urinary incontinence was found to be more frequent after RP, whereas urinary irritative and obstructive symptoms were more frequently registered after

Acknowledgments

The authors are grateful to Marc Colombel (Department of Urology, Hôpital Edouard Herriot, Lyon, France), Marie-Odile Carrere (Department of Health Economics, Centre Leon Berard, Lyon, France), Michel Soulie (Department of Urology, CHU Rangueil, Toulouse, France), Christine Bonhomme (Management Accounting Department, Centre Claudius Regaud, Toulouse, France), Frank Bladou (Department of Urology, Hôpital Salvator, Marseille, France), Anne-Gaëlle Le Coroller (Department of Health Economics,

References (30)

Cited by (0)

Supported by a grant from the French Ministry of Health STIC 2000.

Conflict of interest: none.

View full text