Comparative Cost-effectiveness of Contemporary Treatment Strategies for Stage IIA Seminoma

Abstract Background The Surgery in Early Metastatic Seminoma (SEMS) trial examined retroperitoneal lymph node dissection (RPLND) as first-line treatment for patients with isolated 1-3cm retroperitoneal lymphadenopathy. To date, the standard of care for these patients has been either chemotherapy or radiotherapy (XRT). Herein, we evaluated the relative cost-effectiveness of these management strategies. Methods A microsimulation model assessed the cost-effectiveness of RPLND, chemotherapy, and XRT for stage IIA seminoma. Sensitivity analyses were performed to evaluate model robustness. RPLND recurrence probabilities were obtained from the SEMS trial. All other probability and utility values were obtained from published literature. Primary outcomes included costs from a commercial insurer’s perspective, effectiveness (quality adjusted life years, QALYs), and incremental cost-effectiveness ratios (ICER) using a willingness-to-pay threshold of $100,000/QALY. Results At a lifetime horizon, the mean costs per patient for RPLND, XRT, and chemotherapy were $58,469, $98,783, and $104,096 and the mean QALYs were 40.61, 40.70, and 39.15, respectively. RPLND was found to be the most cost-effective approach due to high costs and accrued disutility of chronic toxicities associated with both XRT (ICER: $433,845/QALY) and chemotherapy (dominated). On one-way sensitivity analyses, RPLND was no longer cost-effective if the probabilities of infertility and cardiovascular toxicity after XRT were less than 13% and 16%, respectively, or if the 2-year probability of progression after RPLND was over 26%. Conclusions RPLND was the most cost-effective treatment approach for stage IIA seminoma. These findings support clinical guideline consideration of including RPLND as a treatment option for well selected patients with stage IIA seminoma.