EURURO Vol. 72 No. 5

713 860

1. Introduction
Since the turn of the century, new technologies have
revolutionized the treatment of prostate cancer. Starting in
the early 2000s, intensity-modulated radiotherapy (IMRT)
was rapidly adopted by radiation oncologists, such that by
2007 the vast majority of radiation for prostate cancer was
delivered using this method Around the same time,
surgical treatment of prostate cancer was transformed by the
rapid dissemination and adoption of robot-assisted radical
prostatectomy (RARP). While in 2004 <10% of radical
prostatectomy procedures were performed using a robotic
approach, this proportion increased to 73% by 2012 . More
recently, proton beam therapy has emerged as a new
radiation treatment modality. This new technology diffused
more slowly than IMRT and RARP, representing only 5% of
radiation treatments for prostate cancer in the USA in 2012
. Yet, some centers are strong proponents of its use ,
and others will build proton beam facilities in the upcoming
years
Treatment with any of these new technologies—IMRT,
RARP, or proton beam therapy—is associated with significant
upfront costs: $2 million for a robotic platform and $150
million for a proton beam therapy cyclotron facility
Moreover, maintenance of the equipment and disposables
come with additional expenditures However, some of
these costs may be offset by better outcomes or less resource
use during the treatment episode. For example, decreased
adverse events and shorter hospital stays associated
with robotic surgery may offset some of the additional cost.
To date, we lack a comprehensive review of the scientific
literature on the costs and health care economics associated
with these new treatments for prostate cancer. For this
reason, we set out to systematically review the literature to
identify the key economic trade-offs implicit in a particular
treatment choice for prostate cancer. Specifically, we sought
to identify cost-analysis, cost-effectiveness, cost-benefit, and
cost-utility studies in the English literature, comparing the
cost of each of the new technologies with its more traditional
counterpart. These data can inform patients and clinicians
when making treatment choices for prostate cancer.
2. Evidence acquisition
We performed a systematic review of the literature
according to the Preferred Reporting Items for Systematic
reviews and Meta-analyses (PRISMA) statement and the
PRISMA protocol (see Appendix A for the protocol)
. We performed three separate searches, one each
for RARP, IMRT, and proton beam therapy. We systematically
searched Medline, Embase, and Web of Science for manu-
scripts that compared treatment with one of the new
technologies[3_TD$DIFF] to [8_TD$DIFF]treatment with the predecessor standard
treatment and that reported data on cost, with cost defined
as cost analysis, cost effectiveness, cost benefit, or cost utility
. We limited our search to manuscripts in the English
language that were published between January 2001 and
July 2016, and excluded editorials. Restriction to the English
language was felt to be unlikely to bias our results based on a
recent systematic review of empirical studies on this topic
. The searches were performed on July 15, 2016 (IMRT
and proton beam therapy) and on July 25, 2016 (RARP). After
removing duplicates, the searches yielded 362 citations for
IMRT, 207 citations for proton beam therapy, and 926 cita-
tions for RARP ). Details about the search strategies and
their results are available in Appendix B.
We excluded manuscripts that did not assess treatment
of locoregional prostate cancer, did not examine the
technology of interest (ie, not about RARP, IMRT, or proton
beam therapy), did not include cost outcomes as defined
above, were not a primary research article (eg, meeting
abstract, editorial, and comment), or did not compare the
technology of interest with its predecessor standard
treatment (only RARP vs radical retropubic prostatectomy
[RRP], IMRT vs three-dimensional conformal radiotherapy
[3D-CRT], and proton beam therapy vs IMRT were includ-
ed). We first excluded manuscripts based on a review of the
title and abstract. Among the remaining manuscripts, we
then reviewed the full text, again applying the exclusion
criteria. A flow diagram of the search and selection process
is shown in
We then systematically abstracted the evidence from the
full-text manuscripts according to the protocol. We
summarized the number of subjects included, type of
study, comparison groups, cost definitions, perspectives
(payer vs hospital vs society), and main findings. Risk of bias
was assessed with a focus on selection bias, comparability
of groups, and follow-up. Data were synthesized in
narrative form because of the controversies surrounding
methodologies to convert different types of economic
outcomes published over a range of years . Given the
topic of this review, formal assessment of metabiases such
as publication bias or selective reporting within studies was
difference in costs remains unclear. Attempts to estimate whether this increased cost is
worth the expense are hampered by the uncertainty surrounding improvements in out-
comes, such as cancer control and side effects of treatment. If the new technologies can
consistently achieve better outcomes, then they may be cost effective.
Patient summary: We review the cost and cost effectiveness of robot-assisted radical
prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate
cancer treatment. These technologies are costlier than their traditional counterparts. It
remains unclear whether their use is associated with improved cure and reducedmorbidity,
and whether the increased cost is worth the expense.
Published by Elsevier B.V. on behalf of European Association of Urology.
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