Endoscopic Transsphenoidal Surgery versus Medical Therapy for the Treatment of Microprolactinoma: A Cost-Effectiveness Analysis

Introduction: Although prolactinomas are effectively treated with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid lifelong medical therapy. We performed a cost-effectiveness analysis comparing endoscopic transsphenoidal surgery and medical therapy using decision analysis modeling.

Methods: A decision tree was created using TreeAge Pro Suite 2012 comparing surgery in one arm versus medical therapy in the other. Based on a literature review, costs and utilities were assigned to each potential outcome, taking into account medical and surgical costs and complications. Base case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at various time points.

Results: Using a willingness-to-pay threshold of $50,000/QALY, the cost-effectiveness of surgery and cabergoline therapy was near equivalent at the 10-year time point. However, by the 15-year mark, surgery was clearly more cost-effective than cabergoline (net monetary benefit [NMB] of $715,977 vs. $712,851, respectively). The cost-effectiveness of surgery and bromocriptine therapy was nearly equivalent at the 15-year time point, but at the 20-year mark, surgery was more cost-effective (NMB of $966,947 vs. $964,931, respectively). Using two-way sensitivity analysis, if the surgical cure rate was greater than 90% with less than 1% complication rate, surgery was more cost-effective than cabergoline at 11 years and bromocriptine at 18 years. Monte Carlo simulations validated the approximate time points when surgery was more cost-effective.

Conclusions: Surgical resection of microprolactinomas in young patients appears to be more cost-effective than lifelong medical therapy, if high surgical cure rates with minimal complications are expected.