Purpose: Targeted strategies for chemoprevention of prostate cancer with finasteride toward higher risk groups could be more cost-effective than untargeted chemoprevention. Recently published risk prediction models by Xu et al. can predict a man's risk of prostate cancer as a function of family history and 14 genetic markers. In this study, we estimated the cost-effectiveness of chemoprevention strategies across risk groups defined by family history and number of inherited risk alleles.
Method: We developed a probabilistic Markov model with 8 health states using data from SEER databases, US life tables, the published medical literature and other on-line sources to estimate costs and quality-adjusted survival to model the impact of chemoprevention with finasteride on the prevention of prostate cancer. We incorporated a decision tree to integrate the prevalence of different risk groups based on family history and genetic risk factors to evaluate the cost-effectiveness of various prevention strategies.
Result: In men 50 years of age, chemoprevention with finasteride for 25 years is estimated to increase (discounted) quality-adjusted life expectancy by 0.101 QALYs (95% CI: 0.006-0.151) at an incremental (discounted) cost of $9,043 (95% CI: 8,549-9,498) relative to no chemoprevention; an incremental cost-effectiveness ratio of $89,300 per QALY (95% CI, 58,800-149,800). Among men with a negative family history, the cost-effectiveness of chemoprevention ranged from $128,600 per QALY (95% CI; 78,000-248,700) in men with 7 or fewer risk alleles to $65,200/QALY (95% CI: 43,900-114,800) in men with 14 or more risk alleles. Across all men with a positive family history (and no genetic testing), the cost-effectiveness of chemoprevention was estimated at $64,200 per QALY. At an estimated cost of $400 per individual with a negative family history, the cost-effectiveness of targeting chemoprevention based on genetic information ranged from $98,100 per QALY when restricting chemoprevention to men with 14 or more risk alleles to $103,200 per QALY when expanding chemoprevention to men with 8 or more risk alleles.
Conclusion: In men with a negative family history of prostate cancer, there was little gain in cost-effectiveness when targeting chemoprevention to men on the basis of this set of genetic risk factors.