Comparative effectiveness review of treatment options for pituitary microadenomas in acromegaly

Clinical article

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  • 1 Departments of Neurosurgery and
  • 2 Endocrinology, and
  • 3 The Brain Tumor and Neuro-Oncology Center, Cleveland Clinic; and
  • 4 Case Western Reserve School of Medicine, Cleveland, Ohio
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Object

Acromegaly, a syndrome of excess growth hormone (GH) secretion typically caused by a GH-secreting pituitary adenoma, reduces life expectancy by approximately 10 years when left untreated. Treatment of acromegaly involves combinations of one or more discrete therapeutic modalities to achieve biochemical control. Unfortunately, data capable of informing decisions among alternate management strategies are presently lacking.

Methods

The authors performed a comparative effectiveness research (CER) review integrating efficacy, cost, and quality of life (QOL) analysis for treatment strategies comprising various combinations of surgery, radiotherapy, stereotactic radiosurgery, and pharmacotherapy in patients with acromegaly caused by a pituitary microadenoma. A management decision tree was used to identify 5 treatment strategies, each with up to 4 potential treatment steps. Efficacy was assessed using recent literature reports of biochemical control rates for each modality. Cost estimations were derived from wholesale drug prices and from the Healthcare Cost and Utility Project. Quality of life data were obtained from studies utilizing the Acromegaly Quality of Life Questionnaire.

Results

Individual treatment modalities were analyzed and ranked in each of 3 domains: highest rate of success, lowest cost, and highest QOL, and these scores were combined to facilitate comparison of overall effectiveness of each of the management strategies. These aggregate effectiveness scores were used to compare the 5 strategies from the decision tree, and a novel strategy was also proposed.

Conclusions

The choice of management strategy must be individualized for each patient with acromegaly. This CER analysis provides a comprehensive framework to inform clinical decisions among alternate management strategies in patients with GH-secreting pituitary microadenomas.

Abbreviations used in this paper:AcroQoL = Acromegaly Quality of Life Questionnaire; AWP = average wholesale price; CER = comparative effectiveness research; GH = growth hormone; HCUP = Healthcare Cost and Utility Project; IGF-1 = insulin-like growth factor–1; LAR = long-acting repeatable; SRS = stereotactic radiosurgery.

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Contributor Notes

* Dr. Marko and Ms. LaSota contributed equally to this work

Address correspondence to: Nicholas F. Marko, M.D., Cancer Research UK Cambridge Research Institute, Cambridge, CB2 0RE United Kingdom. email: nmarko@gmail.com.

Please include this information when citing this paper: published online June 22, 2012; DOI: 10.3171/2012.4.JNS11739.

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