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Modeling the Cost of Management Options for Stage I Nonseminomatous Germ Cell Tumors: A Decision Tree Analysis

From the James Buchanan Brady Urological Institute and the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins Medical Institutions, Baltimore, MD

Address reprint requests to Richard E. Link, MD, PhD, Brady Urological Institute, Johns Hopkins Hospital, 600 N Wolfe St, Suite 161, Jefferson St Building, Baltimore, MD 21287; e-mail: rlink5{at}jhmi.edu

PURPOSE: Patients with clinical stage I nonseminomatous germ cell tumors (NSGCTs) have been managed with surveillance, chemotherapy, or retroperitoneal lymphadenectomy (RPLND) with similar survival outcomes. Cost factors influencing the choice of therapy were evaluated using computer-based decision analysis.

METHODS: A detailed model was developed that integrates projected costs for more than 60 possible treatment outcomes. It incorporates primary, adjuvant, and salvage chemotherapy, primary and postchemotherapy RPLND, and both laparoscopic and open surgical approaches. Starting values and probabilities were derived from a comprehensive meta-analysis of the last 25 years of testes cancer literature. Hypothesis testing was performed using sensitivity analysis.

RESULTS: The model predicts a cost premium for both primary chemotherapy (18.7%) and RPLND (51.7%) compared with surveillance. If laparoscopic RPLND was practiced, the cost premium for primary surgery (29.1%) approached that of chemotherapy (26.4%). Open RPLND was 1.25x as costly as laparoscopic RPLND, primarily because of longer hospitalization. The choice of open RPLND yielded a 6.9% cost premium for a surveillance program in this model. For such a program, primary chemotherapy became cost advantageous when the probability of recurrence during surveillance was more than 46%.

CONCLUSION: This model allows a variety of treatment cost hypotheses to be tested. Primary RPLND is never cost advantageous over surveillance or primary chemotherapy. Surgical costs can significantly increase the overall cost of a surveillance program. In stage I patients with high-risk tumor characteristics, primary chemotherapy may have a cost advantage over surveillance.

Presented in part at the 2004 Society for Urologic Oncology Meeting, Bethesda, MD, December 3-4, 2004.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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