Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery versus Medical Therapy in the Management of Microprolactinoma in the United States.

Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery versus Medical Therapy in the Management of Microprolactinoma in the United States.

World Neurosurg. 2015 Nov 5;

Authors: Jethwa PR, Patel TD, Hajart AF, Eloy JA, Couldwell WT, Liu JK

Abstract
BACKGROUND: Although prolactinomas are effectively treated with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) using decision analysis modeling.
METHODS: A two-armed decision tree was created using TreeAge Pro Suite 2012 comparing upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the healthcare third-party payer. Based on a literature review, plausible distributions for costs and utilities were assigned to each potential outcome, taking into account medical and surgical costs and complications. Base case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons.
RESULTS: In the base case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis. However, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e. medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery vs. microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio (ICER) of $80,235/QALY at 5-year and $40,737/QALY at 10-years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy.
CONCLUSIONS: Based on the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.

PMID: 26548828 [PubMed - as supplied by publisher]

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