Lifetime Health and Economic Outcomes of Active Surveillance, Radical Prostatectomy, and Radiotherapy for Favorable-Risk Localized Prostate Cancer

Implementation of Physical Therapist Services for Men Undergoing Radical Prostatectomy: An Administrative Case Report

OBJECTIVE

Prostate cancer is the most commonly diagnosed cancer among men in the USA, and radical prostatectomy (RP) is the primary surgical treatment option. With an increasing number of men undergoing RP and surviving prostate cancer, clinical management strategies have broadened to improve the preoperative and postoperative patient experience and minimize treatment-related functional consequences. Urinary incontinence is a predictable functional consequence of RP. Recent reviews recommend preoperative and postoperative physical therapist services as the standard of care for men undergoing RP to decrease the severity of urinary incontinence and improve patients' quality of life. Despite compelling evidence, the routine provision of physical therapist services preoperatively and postoperatively for men undergoing RP is limited. The purpose of this case report is to describe the implementation of preoperative and postoperative physical therapist services for men undergoing RP in a US health care system using the knowledge-to-action process and the Consolidated Framework for Implementation Research frameworks.

CASE DESCRIPTION

The implementation process included 4 steps: (1) development of a preoperative and postoperative physical therapist services program; (2) identification of barriers and enablers for implementation; (3) implementation of the program; and (4) evaluation of the effectiveness of the implemented program.

RESULTS

Outcomes from the implementation of a physical therapist services program for men undergoing RP included lower urinary incontinence rates, improved patient satisfaction, and increased physical therapist utilization.

CONCLUSION

This case report documents the implementation of physical therapist services for men undergoing RP. The use of implementation frameworks enabled the identification of unique enablers, barriers, and strategies for the implementation of physical therapist services for men undergoing RP.

IMPACT

Implementing preoperative and postoperative physical therapist services for men undergoing RP improves patient outcomes. The implementation process and outcomes can be considered by other health care systems when developing preoperative and postoperative physical therapist services for men undergoing RP.

The impact of management option on out-of-pocket costs and perceived financial burden among men with localised prostate cancer in Australia within 6 months of diagnosis

Objective This study aimed to quantify the out-of-pocket (OOP) costs and perceived financial burden among Australian men with localised prostate cancer in the first 6 months after diagnosis, by primary management option. Methods This cost-analysis quantified OOP costs using administrative claims data and self-reported survey data. Financial burden was assessed using the COmprehensive Score for financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) tool. Participants were recruited into a randomised control trial from public or private treatment centres in Victoria and Queensland. Generalised linear models were used to predict OOP costs and COST-FACIT scores. Results Median total OOP costs within 6 months of diagnosis for 256 Australian patients with localised prostate cancer was A$1172 (A$343-2548). Up to 50% of the sample reported A$0 costs for most medical services. Compared with those managed with active surveillance, men having active treatment had 6.4 (95% CI: 3.2-12.7) times greater total OOP costs. Management option, higher Gleason score at diagnosis and having multiple comorbidities were significant predictors of higher OOP costs. Overall high scores on the COST-FACIT indicated low levels of financial burden for the entire sample. Conclusion Largely attributable to being managed with active surveillance, Australian men diagnosed with localised prostate cancer reported relatively low OOP costs and financial burden in the first 6 months post-diagnosis. Together with clinical outcomes, clinicians can use this up to date evidence on costs and perceived financial burdens to assist localised prostate cancer patients and their families make informed decisions about their preferred management option.

Advantageous Detection of Significant Prostate Cancer Using a Low-Field, Office-Based MRI System

Background Methods to diagnose prostate cancer (PCa), a highly prevalent disease, remain inadequate in terms of accuracy, cost, and logistical constraints for both patients and providers. Early and accurate detection of PCa is crucial to patient management, most notably in increasing quality of life and lowering cost burdens when considering the associated treatment and follow-up pathways. This article aims to discuss the impact to care pathways for nine patients whose PCa was detected by a novel Food and Drug Administration-cleared low-field magnetic resonance imager (MRI) for transperineal PCa interventions but was missed by standard-of-care systematic transrectal ultrasound (TRUS). Methodology From December 2020 to March 2022, 41 men with elevated prostate-specific antigen (PSA) levels, positive digital rectal exam findings, and Prostate Imaging Reporting & Data System scores of three or higher were enrolled. Patients first underwent targeted transperineal biopsy guided by a low-field MRI (MRIgTBx) and co-registered with T2-weighted images from a pre-procedural 3-T MRI with suspicious lesions annotated by a board-certified radiologist. Following this procedure, patients underwent standard-of-care systematic transrectal ultrasound-guided biopsy (TRUSgSBx). The entire procedure was supervised by a board-certified urologist. Results Of the 41 enrolled patients, both MRIgTBx and TRUSgSBx biopsies detected PCa in 20 patients. MRIgTBx detected PCa in an additional nine patients that were missed by TRUSgSBx. Five of the nine patients elected to pursue immediate treatment. Patients with suspected PCa and a negative biopsy return to the clinic every three to six months for PSA tests, with additional biopsies performed every year for cases with increasing PSA levels. Conclusions Early detection of PCa in nine of the 41 patients using a novel MRIgTBx method has allowed for change management resulting in an improved quality of life and cost saving for those who opted for immediate treatment. Early intervention in cases where the standard-of-care TRUSgSBx treatment was falsely negative ultimately led to a decrease in additional screening procedures, biopsies, associated tests, and an improved pathway for patient management.

The Economic Burden of Localized Prostate Cancer and Insights Derived from Cost-Effectiveness Studies of the Different Treatments

Prostate cancer has huge health and societal impacts, and there is no clear consensus on the most effective and efficient treatment strategy for this disease, particularly for localized prostate cancer. We have reviewed the scientific literature describing the economic burden and cost-effectiveness of different treatment strategies for localized prostate cancer in OECD countries. We initially identified 315 articles, studying 13 of them in depth (those that met the inclusion criteria), comparing the social perspectives of cost, time period, geographical area, and severity. The economic burden arising from prostate cancer due to losses in productivity and increased caregiver load is noticeable, but clinical decision-making is carried out with more subjective variability than would be advisable. The direct cost of the intervention was the main driver for the treatment of less severe cases of prostate cancer, whereas for more severe cases, the most important determinant was the loss in productivity. Newer, more affordable radiotherapy strategies may play a crucial role in the future treatment of early prostate cancer. The interpretation of our results depends on conducting thorough sensitivity analyses. This approach may help better understand parameter uncertainty and the methodological choices discussed in health economics studies. Future results of ongoing clinical trials that are considering genetic characteristics in assessing treatment response of patients with localized prostate cancer may shed new light on important clinical and pharmacoeconomic decisions.