Objective: The study aimed to calculate direct medical costs (DMC) during the first year of diagnosis and to evaluate the impact of guideline changes on treatment costs in clinical stage (CS) I testicular germ cell tumor (TGCT) patients in a German healthcare system. Materials and Methods: Healthcare expenditures as DMC during the first year of diagnosis for 307 TGCT patients in CS I treated at our institution from 1987 to 2013 were calculated from the statutory health insurance perspective using patient level data. Three periods were defined referring to the first European Association of Urology (EAU) guideline in 2001 as well as to subsequent major guideline changes in 2005 and 2010. Data source for cost calculations were the German Diagnosis Related Groups system for inpatient stays (version 2014) and the German system for reimbursement of outpatient care (EBM – Einheitlicher Bewertungsmaßstab, edition 2014). Results: During our 25 years of study period, mean DMC in the first year after diagnosis for the entire cohort of TGCT patients in CS I almost halved from EUR 13.000 to EUR 6.900 (p < 0.001). From 1987 to 2001, DMC for CS I seminomatous germ cell tumor (SGCT) patients were EUR 13.790 ± 4.700. From 2002 to 2010, mean costs were EUR 10.900 ± 5.990, and from 2011 to 2013, mean costs were EUR 5.190 ± 3.700. For CS I non-seminomatous germ cell tumor (NSGCT) patients, from 1987 to 2001, mean DMC were EUR 11.650 ± 5.690. From 2002 to 2010, mean costs were EUR 11.230 ± 5.990, and from 2011 to 2013, mean costs were EUR 11.170 ± 7.390. Follow-up examinations became less frequent over time, which caused a significant cost reduction for NSGCT (p = 0.042) while costs remained stable for SGCT. When adding costs of relapse treatment, active surveillance (AS) was the most cost-effective adjuvant treatment option in CS I NSGCT whereas one course carboplatin or AS caused similar expenditures in SGCT patients. Conclusion: The introduction of the EAU guidelines in 2001 caused a decrease in DMC in CS I seminoma patients. This cost reduction mainly took place due to the declining importance of radiation therapy. No substantial changes were seen in patients with CS I NSGCT. Costs for follow-up care also diminished, but to a lesser degree. Even when considering expenditures for relapse treatment, AS remained cost-effective in CS I TCGT patients. Our data show that evidence-based medicine in TGCT can reduce DMC in the first year after diagnosis.

Keywords:
Testicular cancer stage I, Cost of illness, Health economics , Practice guidelines, Evidence based medicine
1.
Trama A, Mallone S, Nicolai N, Necchi A, Schaapveld M, Gietema J, Znaor A, Ardanaz E, Berrino F; RARECARE Working Group: Burden of testicular, paratesticular and extragonadal germ cell tumours in Europe. Eur J Cancer 2012; 48: 159–169.
2.
Pectasides D, Pectasides E, Constantinidou A, Aravantinos G: Current management of stage I testicular non-seminomatous germ cell tumours. Crit Rev Oncol Hematol 2009; 70: 114–123.
3.
Kourie HR, Klastersky JA: Physical long-term side-effects in young adult cancer survivors: germ cell tumors model. Curr Opin Oncol 2017; 29: 229–234.
4.
Fung C, Fossa SD, Williams A, Travis LB: Long-term morbidity of testicular cancer treatment. Urol Clin 2015; 42: 393–408.
5.
Heinzelbecker J, Katzmarzik M, Weiss C, Trojan L, Michel MS, Haecker A: Changes of stage, predictive factors and adjuvant treatment modalities in seminomatous testicular cancer from 1987 to 2007 and their impact on the status of metastasis, recurrence-free and overall survival: a single-center analysis. Urol Int 2011; 87: 282–287.
6.
Tandstad T, Stahl O, Hakansson U, Dahl O, Haugnes HS, Klepp OH, Langberg CW, Laurell A, Oldenburg J, Solberg A, et al: One course of adjuvant BEP in clinical stage I nonseminoma mature and expanded results from the SWENOTECA group. Ann Oncol 2014; 25: 2167–2172.
7.
Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna MP, Nicolai N, Oldenburg J: Guidelines on testicular cancer: 2015 update. Eur Urol 2015; 68: 1054–1068.
8.
Shibley L, Brown M, Schuttinga J, Rothenberg M, Whalen J: Cisplatin-based combination chemotherapy in the treatment of advanced-stage testicular cancer: cost-benefit analysis. J Natl Can Inst 1990; 82: 186–192.
9.
Jönsson B, Hofmarcher T, Lindgren P, Wilking N: The cost and burden of cancer in the European Union 1995–2014. Eur J Cancer 2016; 66: 162–170.
10.
Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna MP; European Association of Urology: EAU guidelines on testicular cancer: 2011 update. Eur Urol 2011; 60: 304–319.
11.
IQWiG M: Allgemeine Methoden Version 4.0 vom 23.09. 2011. https://www. iqwig. de/download. IQWiG_Methoden_Version_4_0 pdf.
12.
Zaiß A: DRG: Verschlüsseln leicht Gemacht. Deutsche Kodierrichtlinien mit Tipps, Hinweisen und Kommentierungen Stand 2014, p 12.
13.
Bundesvereinigung K: Einheitlicher Bewertungsmaßstab, Berlin: Kassenärztliche Bundesvereinigung, 2014.
14.
Hartmann M, Krege S, Souchon R, De Santis M, Gillessen S, Cathomas R, Hodentumore IA: Nachsorge von Patienten mit Hodentumoren. Der Urologe 2011; 50: 830–835.
15.
Fourcade RO, Benedict Á, Black LK, Stokes ME, Alcaraz A, Castro R: Treatment costs of prostate cancer in the first year after diagnosis: a short-term cost of illness study for France, Germany, Italy, Spain and the UK. BJU Int 2010; 105: 49–56.
16.
Link RE, Allaf ME, Pili R, Kavoussi LR: Modeling the cost of management options for stage I nonseminomatous germ cell tumors: a decision tree analysis. J Clin Oncol 2005; 23: 5762–5773.
17.
Sharda NN, Kinsella TJ, Ritter MA: Adjuvant radiation versus observation: a cost analysis of alternate management schemes in early-stage testicular seminoma. J Clin Oncol 1996; 14: 2933–2939.
18.
Kakehi Y, Kamoto T, Kawakita M, Ogawa O: Follow-up of clinical stage I testicular cancer patients: cost and risk benefit considerations. Int J Urol 2002; 9: 154–160.
19.
Francis R, Bower M, Brunstrom G, Holden L, Newlands ES, Rustin GJ, Seckl MJ: Surveillance for stage I testicular germ cell tumours: results and cost benefit analysis of management options. Eur J Cancer 2000; 36: 1925–1932.
20.
Sokoloff MH, Joyce GF, Wise M; Urologic Diseases in America Project: Testis cancer. J Urol 2007; 177: 2030–2041.
21.
Nord C, Olofsson S-E, Glimelius I, Cedermark GC, Ekberg S, Cavallin-Ståhl E, Neovius M, Jerkeman M, Smedby KE: Sick leave and disability pension among Swedish testicular cancer survivors according to clinical stage and treatment. Acta Oncologica 2015; 54: 1770–1780.
22.
Li C, Ekwueme DU, Rim SH, Tangka FK: Years of potential life lost and productivity losses from male urogenital cancer deaths – United States, 2004. Urology 2010; 76: 528–535.
23.
Cox JA, Gajjar SR, Lanni TB Jr, Swanson TA: Cost analysis of adjuvant management strategies in early stage (stage I) testicular seminoma. Res Rep Urol 2015; 7: 1.
24.
Dieckmann KP, Dralle-Filiz I, Heinzelbecker J, Matthies C, Bedke J, Ellinger J, Sommer J, Haben B, Souchon R, Anheuser P, Pichlmeier U: Seminoma clinical stage 1-patterns of care in Germany. Urol Int 2016; 96: 390–398.
25.
Kamran SC, Seisen T, Markt SC, Preston MA, Trinh QD, Frazier LA, Choueiri TK, Martin NE, Nguyen PL, Beard CJ: Contemporary treatment patterns and outcomes for clinical stage IS testicular cancer. Eur Urol 2018; 73: 262–270.
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2018
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