Presentation Authors: Uwe Bieri, Kerstin Huebel, Harald Seeger, Zurich, Switzerland, Girish S. Kulkarni, Toronto, Canada, Tullio Sulser, Thomas Hermanns, Marian S. Wettstein*, Zurich, Switzerland
Introduction: The general rule that every active malignancy is an absolute contraindication for renal transplantation (RT) is challenged by low-risk prostate cancer (PC), a malignancy nowadays mostly managed by active surveillance (AS) instead of definitive treatment (DT) due to its low risk of metastatic progression. Therefore, treatment teams often face the difficult task to balance the benefits of an early RT against the remaining risk of tumor progression. The aim of the current study was to compare the quality-adjusted life expectancy of different management strategies in patients diagnosed with AS-eligible PC during the pre-transplantation work-up.
Methods: We developed a 7-state Markov microsimulation model and simulated the following 4 management strategies in a sampled cohort of 100&[prime]000 males: (A) DT & listing after waiting period of 2 years (y), (B) DT & immediate listing, (C) AS & listing after waiting period of 2y and (D) AS & immediate listing. Transition probabilities and utilities were obtained through literature review.
Results: Mean quality-adjusted life years (QALYs) per strategy and the corresponding Monte-Carlo standard errors are presented in Figure 1. Strategies B and D clearly yield on average a higher amount of QALYs compared to strategies A and C (4.34 & 4.28 vs. 4.01 & 3.97). Furthermore, strategies B & D were in comparison to strategies A & C not only associated with a higher proportion of successfully performed RTs (% RT: 53.6% & 51.9% vs. 40.8% & 40.2%) but also with on average less time on hemodialysis (y HD; 3.7y vs. 4.2y). When it comes to the percentage of patients that progress to metastatic PC, the strategies involving DT (A & B; 2.5% & 2.7%) trump the AS approaches (C & D; 4.8% & 5.3%).
Conclusions: Regardless of the ultimate decision between AS and DT, immediate listing of patients diagnosed with AS-eligible PC during pre-transplantation work-up is crucial from a quality-adjusted life expectancy perspective. The cumulative time on HD can be considered a more important driver of the differences in QALYs between the 4 strategies than the higher rate of metastatic progression associated with AS. Future decision-analytic research should mainly focus on the investigation of the 2 favored strategies B & D and also incorporate a cost perspective.