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 (5-FU) and methyl aminolevulinate photodynamic therapy (MAL-PDT) are the most commonly used. Recently, results from a randomized controlled non-inferiority trial showed that 5-FU 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-FU 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. The aim of this study was to determine the most cost-effective treatment for Bowen's disease when comparing surgical excision, MAL-PDT, and 5% 5-FU cream from a healthcare perspective. 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 analysis was performed from a healthcare 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-FU cream were significantly lower (EUR 311 [CI: -240 to -378]) and the costs for MAL-PDT were higher (EUR 3 [CI: -74 to 65]) compared to excision. 5-FU cream offers cost savings compared to excision, but is less effective although within the non-inferiority margin of 22%. Our results showed that 5-FU has the highest probability of being cost-effective at willingness to accept threshold values of EUR 2,500 and lower compared to MAL-PDT and surgical excision. Conclusion: 5-FU cream is a cost-effective treatment at a threshold value of EUR 2,500 and lower when compared to surgical excision and MAL-PDT. Therefore, from a cost-effectiveness point of view, 5-FU is considered the first-choice treatment option for Bowen's disease.