Comparative cost-effectiveness of alternative imaging and surveillance schedules for testicular seminoma

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Published: 19 Feb 2023
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Prof Robert Huddart - Royal Marsden NHS Foundation Trust, London, UK

Prof Robert Huddart speaks to ecancer about the TRISST randomised trial which demonstrated that effective monitoring could be achieved with a reduced scan schedule or using MRI instead of computed tomography.

He outlines that the risk of radiation exposure from standard CT surveillance is a major concern in the management of stage I seminoma testis patients.

Health resources were costed using publicly available national unit costs. Small differences exist in total costs and total quality-adjusted life years between different strategies. A 7 scan MRI schedule yielded more health benefits than other strategies but at higher costs.

Prof Huddart concludes by summarising the 3 scan MRI schedule may be the best option to replace current CT-based longer surveillance practice.

The TRISST trial is a trial that we’ve published some data on which was a trial in stage one seminoma. We undertook the study to look at whether we could either reduce the amount of imaging we do or switch from CT to MRI to reduce the radiation exposure to young men who otherwise have a very high cure rate. In the original trial we showed that both switching to MRI and reducing the frequency was non-inferior to the standard 70 CT protocol.

What we wanted to do was look at the balance, because obviously there’s a difference in cost basis for the different groups. The 3 CT groups seemed to have slightly more advanced recurrences than the other groups and so we’ve done a health economic analysis of the trial data. When I say we I mean my colleagues at the Health Economic Institute in York who are our collaborators in this work whose work I’m presenting on their behalf. 

The bottom line is that the 3 CT group did seem to be more expensive and probably slightly worse in terms of quality of life and therefore on this analysis wouldn’t be the favoured approach. The 7 CT arm did pretty well in that analysis but if you want to use a protocol which reduces the amount of radiation, you could switch to 3 MRI which had a very similar health utility score to the 7 CT arm, and was only fractionally more expensive. So you could switch to the 3 MRI with very little impact on cost.

If you have a little bit more money in your pocket you could switch over to the 7 MRI arm which did have some quality of life health benefits but cost a little bit more, with an estimated cost per QALY of about £7,900, which of course is below the threshold that is used by our health regulatory board, NICE, which usually have a threshold of £20,000 per QALY as something which is cost effective. So switching to 7 MRI is more cost effective; it would be cost effective on that basis. So certainly within the cost structure of the NHS in the UK, I’d at least go to 3 MRI for no extra cost but equivalent quality of life, or maybe a slightly improved quality of life with 7 MRI can be recommended.