Modeling the cost of management options for stage I nonseminomatous germ cell tumors: a decision tree analysis.

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 post-chemotherapy 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.

Cost-effective strategies for the follow-up of patients with germ cell tumors.

Cost-effective strategies for the follow-up of patients with germ cell tumors must be based on the known natural history of the disease, the accuracy and cost of diagnostic modalities, and the efficacy and effectiveness of therapy when recurrences are detected. The natural history of stage I and stage II germ cell tumors are reviewed, including the unique circumstances of late recurrences. The accuracy and cost of imaging modalities are also reviewed and general recommendations to cost-effective follow-up are proposed.

A rational approach to managing stage I nonseminomatous germ cell cancer.

Regardless of the treatment option selected for management of low-stage germ cell cancer, ultimate survival is nearly identical. Treatment-related morbidity is very low regardless of management modality and the individual patient can expect similar physical limitations owing to therapy. The overall difference in loss of productivity between treatment programs varies by little more than 1 week. The cost of treatment is similar for all methods, although there is a definite financial advantage to surveillance, less so for selective surveillance, when compared with other forms of management. Socioeconomic factors are of importance when managing limited resources for a large population, but are of less concern to an individual, especially when the mean differences in per patient costs vary by only $5000. Because of these close similarities in efficacy, morbidity, and costs treatment decisions should be individualized. A responsible and reliable patient can be managed safely by selective surveillance. Those individuals considered to be less self-motivated to pursue intensive care should be managed by primary therapy. Without more information regarding the long-term outcomes associated with primary adjuvant chemotherapy, primary adjuvant RPLND, where experienced surgical support is available, is the preferred management for low-stage germ cell cancer in patients selected for, or electing, active treatment rather than surveillance. Active investigations examining the role of medical management in this population should be continued. Our preferred choice of initial management is to offer selective surveillance to appropriate patients and modified RPLND to the remainder.

Combined 201Tl and 67Ga brain SPECT in patients with suspected central nervous system lymphoma or germinoma: clinical and economic value.

BACKGROUND: Surgical resection is costly and an unfavorable prognostic factor for primary central nervous system (CNS) lymphoma and germinoma patients. OBJECTIVE: To assess the diagnostic and economic impact of combined 201Tl and 67Ga brain SPECT on the management of patients suspected of having CNS lymphoma or germinoma. METHODS: Sequential 201Tl and 67Ga brain SPECT was performed in 40 patients with cranial tumors to assess the diagnostic and economic impact of combined 201Tl and 67Ga SPECT on the management of patients suspected of having CNS lymphoma or germinoma. All intracranial masses were pathologically confirmed. The final diagnoses of a total of 47 foci were: 11 non-Hodgkin's lymphomas in 10 patients, 3 germinomas in 2 patients, 10 glioblastomas in 9 patients, 10 cerebral metastases in 8 patients, 13 meningiomas in 11 patients. Decision-tree sensitivity analysis for pretest probability regarding expected cost saving was performed for introduction of the combined study. RESULTS: All but one focus of CNS lymphomas or germinomas (92.9%, 13/14) exhibited more intense uptake of 67Ga than of 201Tl (p < 0.001). All foci of glioblastomas (10/10) and meningiomas (13/13), and 60% of metastatic foci (6/10) exhibited higher uptake of 201Tl than of 67Ga (p < 0.035). Expected cost saving in the 1% to 50% range of pretest probability of CNS lymphoma or germinoma would be from minus dollars 842US to plus dollars 2,047US per patient for introduction of the combined study, because of substitution of stereotactic biopsy for craniotomy. The pretest probability was the key factor for cost saving of the combined study. CONCLUSIONS: A 67Ga-positive and 201Tl-positive pattern with more intense uptake of 67Ga than 201Tl probably suggests CNS lymphoma or germinoma. This combination study appears to be cost-effective only in patients highly suspected of having CNS lymphoma or germinoma.

Follow-up of clinical stage I testicular cancer patients: cost and risk benefit considerations.

BACKGROUND: Regardless of the way it is managed, a high cure rate has been achieved for recurrent low-stage testicular cancer. Achieving a balance between survival and the patient's inconvenience and expense during follow-up, has therefore become an important issue. METHODS: Prognoses and recurrence patterns were investigated in 39 patients with stage I non-seminomatous germ cell tumor of the testis (NSGCT), and 82 patients with stage I seminomatous germ cell tumor of the testis (SGCT), who underwent high orchiectomy between 1970 and 1997 at our institution. We considered the cost benefits and the risks by reviewing our results together with other reported results. RESULTS: Patients with clinical stage I NSGCT under surveillance showed no progression later than 4 years after orchiectomy. The ability to detect progression using chest X-ray alone appeared very low. There was no infradiaphragmatic recurrence after adjuvant radiotherapy for patients with stage I SGCT. Only two of 204 patients showed progression, which included eight of our patients who underwent two cycles of adjuvant carboplatin therapy. CONCLUSIONS: Four years of intensive follow-up is probably sufficient for patients with stage I NSGCT under surveillance, and routine chest X-rays may be required only during the first year of surveillance. The benefit of using adjuvant radiotherapy for patients with stage I SGCT is that we could remove abdominal and pelvic CT scans from the routine follow-up protocol. Randomized trials will clarify whether the adjuvant carboplatin therapy is less toxic, provides better prognosis and is more cost-effective than adjuvant radiotherapy.

Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with Stage 1 nonseminoma treated with adjuvant chemotherapy.

OBJECTIVES: To study survival and late events after adjuvant chemotherapy in Stage 1 nonseminoma. METHODS: From 1978 to 1986, all patients had surveillance. From 1986, adjuvant chemotherapy (initially a 3-day regimen of etoposide, bleomycin, and cisplatin, but, more recently, bleomycin, Oncovin, and cisplatin) was offered to patients at a high risk of relapse (greater than 30%). RESULTS: A total of 382 patients with Stage 1 nonseminoma treated between 1978 and 2000 were reviewed. Of the 234 patients treated by surveillance, 71 (30%) had relapses (5 after 2 years), 6 died (2.6%) of germ cell cancer, and 3 developed second primary testicular cancer. Of the 148 men treated with adjuvant chemotherapy, 6 (4%) had relapses and 2 (1.4%) died of chemoresistant cancer. After one course of etoposide, bleomycin, and cisplatin, 3 (6.5%) of 46 developed a relapse; after two courses, 1 (3.6%) of 28 did so; and after bleomycin, Oncovin, and cisplatin every 10 days x2, 2 (2.7%) of 74 patients did so. Of the high-risk patients who were offered adjuvant treatment, 24% declined. As a consequence, the relapse rate of the surveillance patients only fell from 36% to 27% after the introduction of adjuvant therapy, although for the total cohort treated in the adjuvant era, the relapse rate was 16%. CONCLUSIONS: Adjuvant chemotherapy is more effective than retroperitoneal lymph node dissection for reducing the relapse risk in high-risk Stage 1 nonseminoma. However, given the uncertainty about the incidence of postchemotherapy late events, surveillance and retroperitoneal lymph node dissection remain justified alternatives. With positron emission tomography and laparoscopy showing increasing promise in these cases, quality-of-life studies and greater patient involvement in treatment selection are needed.