The radiotherapy group had fewer inpatient stays but more outpatient visits, colonoscopy, and sigmoidoscopy procedures. The active monitoring group involved more primary care resources, biopsies, MRI scans, bone scans and transurethral resections of the prostate (TURP). The surgery group had more infection- and urinary sphincter-related inpatient stays.

In a subgroup analysis, though cost-effectiveness remained mostly similar across treatments, active monitoring was less costly with higher QALYs in younger men and those with lower risk of disease. Meanwhile, among older men and those in higher-risk groups, radiotherapy appeared most cost-effective.

The differences found between patient subgroups are “consistent with clinical decisions that we make with our patients,” said Dr Beer, who was not surprised at the small differences seen between the subgroups.

“Taken together, this study does not definitively establish radiation therapy as the most cost-effective treatment in localized prostate cancer, but does support greater value in older patients with high-risk disease, Andrew Laccetti, MD, an oncologist at Memorial Sloan Kettering Bergen in Montvale, New Jersey, who was not involved with the trial, told Cancer Therapy Advisor. “The data further [endorse] active surveillance as an excellent, high-value management strategy for men with low-risk prostate cancer, particularly for those diagnosed at a younger age.”

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Dr Laccetti said it’s difficult to generalize and apply these results to the United States, as the US health care system has its own complexities.

“Accurate cost estimates are challenging to determine in the US considering diverse payers and reimbursement rates,” he said, noting it would be unreliable to apply the UK’s NHS cost estimates to the US. However, Dr Laccetti continued, “QALY estimates are likely similar between the 2 countries, as is the expectation for similar survival between active surveillance, radiation, and surgery.”

He referenced a SEER-Medicare analysis2 that showed costs associated with active surveillance were lower compared with definitive therapy, suggesting that “the conclusion that active surveillance is high value in low-risk disease is a reasonable generalization for the US.”

A substantial limitation of the study, however, is that it reflects prostate cancer management practices between 1999 and 2009, Dr Laccetti said.

“Contemporary advances in radiation technique, such as intensity-modulated radiation therapy, and surgical approach, such as robotic assisted prostatectomy, are likely more expensive,” he said. “Similarly, modern active surveillance protocols, now incorporating newer imaging technologies, such as prostate MRI, and varying frequencies of prostate biopsy, are unlikely to be represented in this data set.”

Dr Beer also pointed out, as the authors also acknowledged, the need to consider how the costs might vary over a longer time period.

“We know that the prostate cancer-related mortality in this study at 10 years was about 1%, which may mean that the vast majority of participants were still alive at the end of a decade and continue to be alive,” Dr Beer said. “If you were to look at 20-year costs, they may look a little bit different, with the observation actually coming out a little more expensive than active therapies,” he speculated, but added that it’s not yet possible to know for sure. For now, though, “for patients in the US, I think this study gives us reassuring information that we probably shouldn’t have to worry about costs when we make these choices.”   

Disclosure: The trial was funded by the UK National Institute for Health Research. Coauthor Malcolm Mason reported personal fees from Janssen Endocyte and Clovis, and scientific advisory work for Ellipsis Pharma and Oncotherics. No other authors, nor Drs Laccetti or Beer, had any industry ties to report.


  1. Noble SN, Garfield K, Lane JA, et al. The ProtecT randomised trial cost-effectiveness analysis comparing active monitoring, surgery, or radiotherapy for prostate cancer. Br J Cancer. Published online July 16, 2020. doi:10.1038/s41416-020-0978-4
  2. Trogdon JG, Falchook AD, Basak R, Carpenter WR, Chen RC. Total Medicare costs associated with diagnosis and treatment of prostate cancer in elderly men. JAMA Oncol. 2019;5(1):60-66. doi:10.1001/jamaoncol.2018.3701