Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
BACKGROUND: For people with localised prostate cancer, active treatments are effective but have significant side effects. Minimally invasive treatments that destroy (or ablate) either the entire gland or the part of the prostate with cancer may be as effective and cause less side effects at an acceptable cost. Such therapies include cryotherapy, high-intensity focused ultrasound (HIFU) and brachytherapy, among others. OBJECTIVES: This study aimed to determine the relative clinical effectiveness and cost-effectiveness of ablative therapies compared with radical prostatectomy (RP), external beam radiotherapy (EBRT) and active surveillance (AS) for primary treatment of localised prostate cancer, and compared with RP for salvage treatment of localised prostate cancer which has recurred after initial treatment with EBRT. DATA SOURCES: MEDLINE (1946 to March week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (29 March 2013), EMBASE (1974 to week 13, 2013), Bioscience Information Service (BIOSIS) (1956 to 1 April 2013), Science Citation Index (1970 to 1 April 2013), Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2013), Cochrane Database of Systematic Reviews (CDSR) (issue 3, 2013), Database of Abstracts of Reviews of Effects (DARE) (inception to March 2013) and Health Technology Assessment (HTA) (inception to March 2013) databases were searched. Costs were obtained from NHS sources. REVIEW METHODS: Evidence was drawn from randomised controlled trials (RCTs) and non-RCTs, and from case series for the ablative procedures only, in people with localised prostate cancer. For primary therapy, the ablative therapies were cryotherapy, HIFU, brachytherapy and other ablative therapies. The comparators were AS, RP and EBRT. For salvage therapy, the ablative therapies were cryotherapy and HIFU. The comparator was RP. Outcomes were cancer related, adverse effects (functional and procedural) and quality of life. Two reviewers extracted data and carried out quality assessment. Meta-analysis used a Bayesian indirect mixed-treatment comparison. Data were incorporated into an individual simulation Markov model to estimate cost-effectiveness. RESULTS: The searches identified 121 studies for inclusion in the review of patients undergoing primary treatment and nine studies for the review of salvage treatment. Cryotherapy [3995 patients; 14 case series, 1 RCT and 4 non-randomised comparative studies (NRCSs)], HIFU (4000 patients; 20 case series, 1 NRCS) and brachytherapy (26,129 patients; 2 RCTs, 38 NRCSs) studies provided limited data for meta-analyses. All studies were considered at high risk of bias. There was no robust evidence that mortality (4-year survival 93% for cryotherapy, 99% for HIFU, 91% for EBRT) or other cancer-specific outcomes differed between treatments. For functional and quality-of-life outcomes, the paucity of data prevented any definitive conclusions from being made, although data on incontinence rates and erectile dysfunction for all ablative procedures were generally numerically lower than for non-ablative procedures. The safety profiles were comparable with existing treatments. Studies reporting the use of focal cryotherapy suggested that incontinence rates may be better than for whole-gland treatment. Data on AS, salvage treatment and other ablative therapies were too limited. The cost-effectiveness analysis confirmed the uncertainty from the clinical review and that there is no technology which appears superior, on the basis of current evidence, in terms of average cost-effectiveness. The probabilistic sensitivity analyses suggest that a number of ablative techniques are worthy of further research. LIMITATIONS: The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction. CONCLUSIONS: The findings indicate that there is insufficient evidence to form any clear recommendations on the use of ablative therapies in order to influence current clinical practice. Research efforts in the use of ablative therapies in the management of prostate cancer should now be concentrated on the performance of RCTs and the generation of standardised outcomes. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012002461. FUNDING: The National Institute for Health Research Health Technology Assessment programme.
Date Issued
2015-07-01
Date Acceptance
2015-04-01
Citation
Health Technology Assessment, 2015, 19 (49), pp.1-490
ISSN
1366-5278
Publisher
NIHR Health Technology Assessment Programme
Start Page
1
End Page
490
Journal / Book Title
Health Technology Assessment
Volume
19
Issue
49
Copyright Statement
© Queen’s Printer and Controller of HMSO 2015. This work was produced by Ramsay
et al., under the terms of a commissioning
contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and
study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement
is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be
addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre,
Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
et al., under the terms of a commissioning
contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and
study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement
is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be
addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre,
Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Identifier
http://www.ncbi.nlm.nih.gov/pubmed/26140518
Subjects
Ablation Techniques
Aged
Aged, 80 and over
Cost-Benefit Analysis
Databases, Bibliographic
Erectile Dysfunction
Great Britain
Humans
Incidence
Long Term Adverse Effects
Male
Middle Aged
Neoplasm Recurrence, Local
Outcome and Process Assessment (Health Care)
Prevalence
Prostate-Specific Antigen
Prostatic Neoplasms
Quality-Adjusted Life Years
State Medicine
Survival Analysis
Urinary Incontinence
Health Policy & Services
Public Health And Health Services
Library And Information Studies
Information Systems
Publication Status
Published
Coverage Spatial
England