Active Surveillance, Radiofrequency Ablation, or Cryoablation for the Nonsurgical Management of a Small Renal Mass: A Cost-Utility Analysis |
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Authors: | Sasha N. Bhan MD MBA Stephen E. Pautler MD FRCSC Bobby Shayegan MD FRCSC Maurice D. Voss MD MBChB FRACR FRCPC Ron A. Goeree MA John J. You MD MSc FRCPC |
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Affiliation: | 1. Department of Radiology, McMaster University, Hamilton, ON, Canada 2. Divisions of Urology and Surgical Oncology, Departments of Surgery and Oncology, Western University, London, ON, Canada 3. McMaster Institute of Urology, St. Joseph’s Healthcare, Hamilton, ON, Canada 4. Department of Radiology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada 5. Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph’s Healthcare, Hamilton, ON, Canada 6. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada 7. Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Abstract: | Background Patients with a cortical small (≤4 cm) renal mass often are not candidates for or choose not to undergo surgery. The optimal management strategy for such patients is unclear. Methods A decision-analytic Markov model was developed from the perspective of a third party payer to compare the quality-adjusted life expectancy and lifetime costs for 67-year-old patients with a small renal mass undergoing premanagement decision biopsy, immediate percutaneous radiofrequency ablation or percutaneous cryoablation (without premanagement biopsy), or active surveillance with serial imaging and subsequent ablation if needed. Results The dominant strategy (most effective and least costly) was active surveillance with subsequent cryoablation if needed. On a quality-adjusted and discounted basis, immediate cryoablation resulted in a similar life expectancy (3 days fewer) but cost $3,010 more. This result was sensitive to the relative rate of progression to metastatic disease. Strategies that employed radiofrequency ablation had decreased quality-adjusted life expectancies (82–87 days fewer than the dominant strategy) and higher costs ($3,231–$6,398 more). Conclusions Active surveillance with delayed percutaneous cryoablation, if needed, may be a safe and cost-effective alternative to immediate cryoablation. The uncertainty in the relative long-term rate of progression to metastatic disease in patients managed with active surveillance versus immediate cryoablation needs to be weighed against the higher cost of immediate cryoablation. A randomized trial is needed directly to evaluate the nonsurgical management of patients with a small renal mass, and could be limited to the most promising strategies identified in this analysis. |
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