Chemotherapy Versus Surgery for Stage IIA Nonseminomatous Germ Cell Tumor: A Comparative Cost Utility Analysis

INTRODUCTION: Patients with marker negative Stage IIA nonseminomatous germ cell tumor (NSGCT) may be treated with chemotherapy or retroperitoneal lymph node dissection (RPLND). While both strategies have high cure rates, chemotherapy has higher longterm toxicities. In the absence of randomized trials, we conducted a cost-effectiveness analysis of chemotherapy vs RPLND for stage IIA NSGCT using a microsimulation approach. METHODS: A health transition state model compared open, nerve-sparing RPLND to 3 cycles of BEP chemotherapy for marker negative stage IIA NSGCT. Transition probabilities, utility values, and private payor costs for each health state were estimated from the literature. Primary outcomes were costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime horizon. Sensitivity analyses identified clinically relevant parameters altering model conclusions. RESULTS: Using a simulated cohort of 300,000 patients with Stage IIA NSGCT, total lifetime treatment costs were $50,735 for RPLND and $91,830 for chemotherapy. RPLND had 1.57 additional QALYs compared to chemotherapy. Thus, RPLND was the dominant strategy (lower cost and higher effectiveness), and chemotherapy was not cost-effective. On sensitivity analysis, chemotherapy only became cost-effective at edge cases when: the 3-year risk of progression after RPLND exceeded 27.8% (base case: 10%) or when chemotherapy toxicities were eliminated. CONCLUSIONS: RPLND results in improved QALYs at lower costs for patients with stage IIA NSGCT due to significant chronic toxicities from chemotherapy. As such, RPLND should be preferred for most stage IIA NSGCT patients, while chemotherapy should be preferred for patients with a particularly higher risk of progression after RPLND.