BPH treatments’ cost-effectiveness put to test

Findings from a cost-effectiveness analysis provide useful information for physicians, patients, and payers about available treatments for lower urinary tract symptoms (LUTS) due to BPH, according to the authors who conducted it.

Published in ClinicoEconomics and Outcomes Research (2017; 10:29-43) and conducted using a Markov model, the analysis compared the cost-effectiveness of six BPH treatment options over a period of 2 years. The treatments included combination drug therapy with an alpha-selective adrenergic receptor blocker plus a 5-alpha-reductase inhibitor (using either generic or branded medications); minimally invasive therapy with convective radiofrequency (RF) water vapor thermal therapy (Rezum), conductive RF thermal therapy (Prostiva), or prostatic urethral lift (UroLift); and invasive surgery with transurethral resection of the prostate (TURP) or photovaporization of the prostate (GreenLight PVP).

Based on the results, the authors concluded that convective RF water vapor thermal therapy warrants consideration as a first-line treatment alternative to medical therapy for men seeking treatment for bothersome moderate to severe symptoms of BPH, including those with an enlarged central zone or median lobe hyperplasia.

“BPH ranks in the top 10 prominent and costly diseases in men over 50 years of age in the U.S., and with population aging, we can expect that the health care costs for BPH will continue to increase,” said lead author James Ulchaker, MD, vice chairman of urology at Cleveland Clinic. “As our health care system moves toward value-based medicine, it’s important to understand and appreciate the costs and effects of the various treatment options for BPH. In particular, with the recent introductions of several minimally invasive therapy options, it’s important to determine how and where these options fit into the patient care pathway relative to medical therapy and surgery.

“Ours is the first cost-effectiveness analysis to evaluate the most common BPH treatment options across all categories rather than within individual categories. Considering its relative cost-effectiveness, convective RF water vapor thermal therapy might be a preferred choice in a health care system seeking to contain costs,” Dr. Ulchaker added.

The analysis was conducted using data obtained from 40 published articles. Effectiveness of the various treatments was assessed using International Prostate Symptom Score (IPSS) data and using a common baseline score of 22 to compare treatment modalities, taking into account that the baseline IPSS scores tended to be lower in medication studies than for the other options. The model included costs for initial treatment, management of common early- and late-occurring adverse events associated with significant costs or chronic conditions (ie, urinary incontinence, de novo erectile dysfunction, urethral strictures, bladder neck contractures or stenosis, urinary tract infections, acute urinary retention, and retreatment due to return of symptoms). Rates for adverse events and retreatment were determined from reports in the medical literature.

Costs for the BPH therapies, diagnostics and procedures, and treatments for adverse events were derived from the 2016 Medicare national average fee schedules. Drug payments were estimated from 2014 Medicare Part D prescriber data for combination drug therapy.

Combo drug therapy not cost-effective

The results showed that combination drug therapy with generic medications was the least expensive option but not cost-effective because medications were the least effective option. The three minimally invasive therapies had similar effectiveness and cost less than combination treatment with branded medications, but the cost of the prostatic urethral lift was over twofold higher than that of Rezum or Prostiva procedure, Dr. Ulchaker said. The invasive surgical options were slightly more effective than the minimally invasive procedures, but carried a twofold higher cost than the RF procedures.

Commenting on the roles of the minimally invasive therapies, Dr. Ulchaker told Urology Times, “Prostiva has been around for many years and utilizes the traditional method of RF thermal therapy, which uses conductive heat transfer. Historically, Prostiva has not been well adopted due to procedure time, side effects, and lack of long-term durability.”

“Rezum utilizes another method of heat transfer-convective RF water vapor thermal therapy, which reduces procedure time, minimizes side effects, and so far, offers longer-term durable outcomes.”

Dr. Ulchaker was a clinical investigator in the pivotal trial of the convective RF water vapor thermal therapy. The cost-effectiveness modeling and analysis was supported by NxThera, and the analysis was performed by an independent health care economist.