Cost-effectiveness of Photodynamic Therapy and 5-Fluorouracil Cream versus Surgical Excision in Treatment of Bowen’s Disease: a trial based economic evaluation

Introduction Given the increasing incidence of Bowen’s disease, treatment leads to a substantial economic burden for healthcare services. There are several treatment options for Bowen's disease, of which surgical excision, 5-fluorouracil and methylaminolevulinate photodynamic therapy (MAL-PDT) are the most commonly used. Recently, results from a randomized controlled non-inferiority trial showed that 5-fluorouracil was non-inferior to excision and was associated with a better cosmetic outcome. MAL-PDT was not shown to be non-inferior to excision. Although 5-fluorouracil and MAL-PDT were expected to be cheaper than excision, it remains to be determined whether the potential cost savings compensate for the loss of effectiveness. Objectives To determine which treatment is cost-effective from a health care perspective when comparing surgical excision, MAL-PDT, and 5% 5-fluorouracil cream for Bowen’s disease. Methods Data were collected alongside a randomized controlled trial with 250 patients in the Netherlands. Valuation of treatment costs was based on documented resource use and Dutch cost prices. A cost-effectiveness was performed from a health care perspective. The primary outcome was the decremental cost-effectiveness ratio (DCER), expressed as the cost-savings per additional recurrence or residual Bowen’s disease. Bootstrap analysis and sensitivity analysis were performed to address uncertainty. This trial is registered with ClinicalTrials.gov number, NCT03909646. Results At 12 months after treatment, the costs for 5-fluorouracil cream were significantly lower (- €311(CI: -240 – -378)) and the costs for MAL-PDT were higher (€3 (CI: -74– 65)) compared to excision. 5-fluorouracil cream offers cost savings compared to excision, but is less effective although within the non-inferiority margin of 22%. Our results showed that 5-fluorouracil has the highest probability of being cost-effective at willingness to accept threshold values of €2500 and lower compared to MAL-PDT and surgical excision. Discussion 5-fluorouracil cream is a cost-effective treatment at a threshold value of €2500 and lower when compared to surgical excision and MAL-PDT. Therefore, from a cost-effectiveness point of view, 5-fluorouracil is considered the first-choice treatment option for Bowen’s disease.