Cost Comparison Between Watchful Waiting With Active Surveillance and Active Treatment of Clinically Localized Prostate Cancer

Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms

IMPORTANCE

Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer.

OBJECTIVE

To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021.

EXPOSURES

State Medicaid expansion status.

MAIN OUTCOMES AND MEASURES

Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses.

RESULTS

Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas.

CONCLUSIONS AND RELEVANCE

These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.

Radical prostatectomy versus deferred treatment for localised prostate cancer

BACKGROUND

Prostate cancer is a common cancer but is oftentimes slow growing. When confined to the prostate, radical prostatectomy (RP), which involves removal of the prostate, offers potential cure that may come at the price of adverse events. Deferred treatment, involving observation and palliative treatment only (watchful waiting (WW)) or close monitoring and delayed local treatment with curative intent as needed in the setting of disease progression (active monitoring (AM)/surveillance (AS)) might be an alternative. This is an update of a Cochrane Review previously published in 2010.

OBJECTIVES

To assess effects of RP compared with deferred treatment for clinically localised prostate cancer.

SEARCH METHODS

We searched the Cochrane Library (including CDSR, CENTRAL, DARE, and HTA), MEDLINE, Embase, AMED, Web of Science, LILACS, Scopus, and OpenGrey. Additionally, we searched two trial registries and conference abstracts of three conferences (EAU, AUA, and ASCO) until 3 March 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared RP versus deferred treatment in patients with localised prostate cancer, defined as T1-2, N0, M0 prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of references and extracted data from included studies. The primary outcome was time to death from any cause; secondary outcomes were: time to death from prostate cancer; time to disease progression; time to metastatic disease; quality of life, including urinary and sexual function; and adverse events. We assessed the certainty of evidence per outcome using the GRADE approach.  MAIN RESULTS: We included four studies with 2635 participants (average age between 60 to 70 years). Three multicentre RCTs, from Europe and USA, compared RP with WW (n = 1537), and one compared RP with AM (n = 1098). Radical prostatectomy versus watchful waiting RP probably reduces the risk of death from any cause (hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.70-0.90; 3 studies with 1537 participants; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1000 men in the RP group compared to 839 deaths per 1000 men in the WW group. RP probably also lowers the risk of death from prostate cancer (HR 0.57, 95% CI 0.44-0.73; 2 studies with 1426 participants; moderate-certainty evidence). Based on prostate cancer-specific mortality at 29 years, this corresponds to 195 deaths from prostate cancer per 1000 men in the RP group compared with 316 deaths from prostate cancer per 1000 men in the WW group. RP may reduce the risk of progression (HR 0.43, 95% CI 0.35-0.54; 2 studies with 1426 participants; I² = 54%; low-certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1000 men for the RP group compared with 684 progressions per 1000 men for the WW group) and probably reduces the risk of developing metastatic disease (HR 0.56, 95% CI 0.46-0.70; 2 studies with 1426 participants; I² = 0%; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1000 men for RP compared with 431 metastatic diseases per 1000 men for WW. General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio (RR) 1.0, 95% CI 0.85-1.16; low-certainty evidence), corresponding to 344  patients with high quality of life per 1000 men for the RP group compared with 344 patients with high quality of life per 1000 men for the WW group. Rates of urinary incontinence may be considerably higher (RR 3.97, 95% CI 2.34-6.74; low-certainty evidence), corresponding to 173 incontinent men per 1000 in the RP group compared with 44 incontinent men per 1000 in the WW group, as are rates of erectile dysfunction (RR 2.67, 95% CI 1.63-4.38; low-certainty evidence), corresponding to 389 erectile dysfunction events per 1000 for the RP group compared with 146 erectile dysfunction events per 1000 for the WW group, both at 10 years' follow-up. Radical prostatectomy versus active monitoring Based on one study including 1098 participants with 10 years' follow-up, there are probably no differences between RP and AM in time to death from any cause (HR 0.93, 95% CI 0.65-1.33; moderate-certainty evidence). Based on overall mortality at 10 years, this corresponds to 101 deaths per 1000 men in the RP group compared with 108 deaths per 1000 men in the AM group. Similarly, risk of death from prostate cancer probably is not different between the two groups (HR 0.63, 95% CI 0.21-1.89; moderate-certainty evidence). Based on prostate cancer-specific mortality at 10 years, this corresponds to nine prostate cancer deaths per 1000 men in the RP group compared with 15 prostate cancer deaths per 1000 men in the AM group. RP probably reduces the risk of progression (HR 0.39, 95% CI 0.27-0.56; moderate-certainty evidence; at 10 years, this corresponds to 86 progressions per 1000 men for RP compared with 206 progressions per 1000 men for AM) and the risk of developing metastatic disease (RR 0.39, 95% CI 0.21-0.73; moderate-certainty evidence; at 10 years, this corresponds to 24 metastatic diseases per 1000 men for the RP group compared with 61 metastatic diseases per 1000 men for the AM group).The general quality of life during follow-up was not different between the treatment groups. However, urinary function (mean difference (MD) 8.60 points lower, 95% CI 11.2-6.0 lower) and sexual function (MD 14.9 points lower, 95% CI 18.5-11.3 lower) on the Expanded Prostate Cancer Index Composite-26 (EPIC-26) instrument, were worse in the RP group.

AUTHORS' CONCLUSIONS

Based on long-term follow-up, RP compared with WW probably results in substantially improved oncological outcomes in men with localised prostate cancer but also markedly increases rates of urinary incontinence and erectile dysfunction. These findings are largely based on men diagnosed before widespread PSA screening, thereby limiting generalisability. Compared to AM, based on follow-up to 10 years, RP probably has similar outcomes with regard to overall and disease-specific survival yet probably reduces the risks of disease progression and metastatic disease. Urinary function and sexual function are probably decreased for the patients treated with RP.

A Cost-Effectiveness and Quality of Life Analysis of Different Approaches to the Management and Treatment of Localized Prostate Cancer

The aim of this study was to compare the cost-effectiveness and quality-adjusted life years (QALYs) of active monitoring (AM), radical prostatectomy (PR), and external-beam radiotherapy with neoadjuvant hormone therapy (RT) for localized prostate cancer. Microsimulations of radical prostatectomy, 3D-conformal radiotherapy, or active monitoring were performed using Medicare reimbursement schedules and clinical trial results for a target population of men aged 50–69 years with newly diagnosed localized prostate cancer (T1-T2, NX, M0) over a time horizon of 10 years. Quality-adjusted life years (QALYs) and costs were assessed and sensitivity analyses performed. Monte Carlo simulations revealed that the mean cost for AM, PR, and RT were $15,654, $18,791, and $30,378, respectively, and QALYs were 6.96, 7.44, and 7.9 years, respectively. The incremental cost-effectiveness ratio (ICER) was $6,548 for PR over AM and $68,339 for RT over PR. Results were sensitive to the number of years of follow-up and procedure cost. With relaxed assumptions for AM, the ICER of PR and RT met the societal willingness to pay (WTP) threshold of $50,000 per QALY. Compared with AM, PR was highly cost-effective. RT and PR for localized prostate cancer can be cost-effective, but RT must offer increased QALYs or decreased procedural costs to be cost-effective compared to PR. Newer and cheaper radiotherapy strategies like stereotactic body radiotherapy may play a crucial role in future early prostate cancer management.

Quality of care and economic considerations of active surveillance of men with prostate cancer

The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.g., quality) for acceptable costs. This review discusses quality of care considerations for men contemplating active surveillance, and highlights cost implications at the patient, health-system, and societal level related to pursuit of non-interventional management of men diagnosed with localized prostate cancer. In general, most quality measures are focused on prostate cancer care in general, rather that active surveillance patients specifically. However, most prostate cancer quality measures are pertinent to men seeking close observation of their prostate tumors with active surveillance. These include accurate documentation of clinical stage, informed discussion of all treatment options, and appropriate use of imaging for less-aggressive prostate cancer. Furthermore, interventions that may help improve the quality of care for active surveillance patients are reviewed (e.g., quality collaboratives, judicious antibiotic use, etc.). Finally, the potential economic impact and benefits of broad acceptance of active surveillance strategies are highlighted.

Comparative effectiveness of prostate cancer screening between the ages of 55 and 69 years followed by active surveillance

BACKGROUND

Because of the recent grade C draft recommendation by the US Preventive Services Task Force (USPSTF) for prostate cancer screening between the ages of 55 and 69 years, there is a need to determine whether this could be cost-effective in a US population setting.

METHODS

This study used a microsimulation model of screening and active surveillance (AS), based on data from the European Randomized Study of Screening for Prostate Cancer and the Surveillance, Epidemiology, and End Results Program, for the natural history of prostate cancer and Johns Hopkins AS cohort data to inform the probabilities of referral to treatment during AS. A cohort of 10 million men, based on US life tables, was simulated. The lifetime costs and effects of screening between the ages of 55 and 69 years with different screening frequencies and AS protocols were projected, and their cost-effectiveness was determined.

RESULTS

Quadrennial screening between the ages of 55 and 69 years (55, 59, 63, and 67 years) with AS for men with low-risk cancers (ie, those with a Gleason score of 6 or lower) and yearly biopsies or triennial biopsies resulted in an incremental cost per quality-adjusted life-year (QALY) of $51,918 or $69,380, respectively. Most policies in which screening was followed by immediate treatment were dominated. In most sensitivity analyses, this study found a policy with which the cost per QALY remained below $100,000.

CONCLUSIONS

Prostate-specific antigen-based prostate cancer screening in the United States between the ages of 55 and 69 years, as recommended by the USPSTF, may be cost-effective at a $100,000 threshold but only with a quadrennial screening frequency and with AS offered to all low-risk men. Cancer 2018;124:507-13. © 2017 American Cancer Society.

The cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer

Background

Radical prostatectomy is the most common treatment for localised prostate cancer in New Zealand. Active surveillance was introduced to prevent overtreatment and reduce costs while preserving the option of radical prostatectomy. This study aims to evaluate the cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy.

Methods

Markov models were constructed to estimate the life-time cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer patients aged 45–70 years, using national datasets in New Zealand and published studies including the SPCG-4 study. This study was from the perspective of the Ministry of Health in New Zealand.

Results

Radical prostatectomy is less costly than active surveillance in men aged 45–55 years with low risk localised prostate cancer, but more costly for men aged 60–70 years. Scenario analyses demonstrated significant uncertainty as to the most cost-effective option in all age groups because of the unavailability of good quality of life data for men under active surveillance. Uncertainties around the likelihood of having radical prostatectomy when managed with active surveillance also affect the cost-effectiveness of active surveillance against radical prostatectomy.

Conclusions

Active surveillance is less likely to be cost-effective compared to radical prostatectomy for younger men diagnosed with low risk localised prostate cancer. The cost-effectiveness of active surveillance compared to radical prostatectomy is critically dependent on the ‘trigger’ for radical prostatectomy and the quality of life in men on active surveillance. Research on the latter would be beneficial.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3522-z) contains supplementary material, which is available to authorized users.

Healthcare costs among men with favorable risk prostate cancer managed with observation strategies versus immediate treatment in an integrated healthcare system

OBJECTIVE

This study explored short-term healthcare costs of men managed with observation strategies (OBS) vs immediate treatment (IMT) for favorable risk prostate cancer (PCa) from the Geisinger Health System, a single integrated health system in Pennsylvania, as evidence from the community setting is limited.

METHODS

A retrospective cohort study was conducted using electronic health records from men aged ≥40 years diagnosed with favorable risk PCa (T1 or 2, PSA ≤15 ng/mL, Gleason ≤7 [3 + 4]) between January 2005 and October 2013. Prostate-specific healthcare costs were compared between the OBS and IMT cohorts in men with ≥3 years of follow-up and available linked claims data. Sub-group analyses focused on those men with low-risk PCa (T1-2a, PSA ≤10 ng/mL, Gleason ≤6). Sensitivity analysis stratified the study sample in three cohorts: OBS, switched from OBS to definitive treatment (OBS switch), and IMT.

RESULTS

A total of 352 patients were included (OBS = 70 and IMT = 282). Compared with IMT, OBS resulted in significantly lower cumulative PCa-related healthcare costs for the first 3 years ($15,785 vs $23,177; p-value <.001). The main cost drivers were outpatient procedures. The OBS cohort had the lowest incremental PCa-related healthcare costs in the first 3 years (OBS: $5,011 vs OBS switch: $26,040, net cost savings = $21,029, p < .001; OBS: $5,011 vs IMT: $24,064, net cost savings = $19,053, p < .001).

CONCLUSIONS

In favorable risk PCa, half of the patients who initially chose OBS eventually underwent treatment after their PCa diagnosis. As expected, OBS was associated with reduced disease management costs compared with IMT.

[Prevalence and diversity of management of prostate cancer patients classified as low risk using D'Amico group or Cancer of the Prostate Risk Assessment (CAPRA) score: A French multicenter study]

OBJECTIVES

Currently, the French High Authority for Health does not recommend mass screening for prostate cancer (PCa), due to the risk of over-treatment, notably of low risk patients. Our study is intended to reflect the therapeutic attitudes for the management of patients classified as low risk of progression in French clinical centers.

METHODS

For all positive prostate biopsies performed during 2012 and 2013 in five French departments of urology, clinicopathological characteristics required to calculate the d'Amico risk group and the Cancer of the Prostate Risk Assessment (CAPRA) score were filled. Information on the first treatment of "low risk" patients was collected.

RESULTS

A total of 1035 patients were included, with a median age at diagnosis of 66 years old. According to d'Amico and CAPRA classifications, 30.4% and 35.0% of patients were at low, 34.5% and 33.2% at intermediate, 35.1% and 31.8% at high risk. The diagnosis severity increased with age (P<0.0001). The main treatment for low risk patients was radical prostatectomy (41.6% and 42.0% for d'Amico and CAPRA, respectively), but active surveillance was the most frequent treatment if diagnosed after 75 years old. The management of low risk patients varied significantly between centers (P<0.0001), according to the therapeutic platforms available within the hospital.

CONCLUSIONS

In absence of strong progression predictor, the management of low risk PCa remains based on center habits and local therapeutic platforms. New predictive markers, such as multiparametric MRI or molecular tests, are needed to guide rational management of low risk PCa.

LEVEL OF EVIDENCE

4.

Relationships as Medicine: Quality of the Physician-Patient Relationship Determines Physician Influence on Treatment Recommendation Adherence

OBJECTIVE

To determine whether quality of physician-patient relationships influences uptake of physician treatment recommendations in men with clinically localized prostate cancer (PCa).

STUDY SETTING

Data were collected July 2010 to August 2014 at two cancer centers and three community facilities.

STUDY DESIGN

Analyses were prospective and cross-sectional. We modeled associations between quality of the patient-physician relationship and influence of physician recommendations on treatment choice using generalized estimating equations (GEE).

DATA COLLECTION

Data were collected via survey and medical record abstraction.

PRINCIPAL FINDINGS

Participants (N = 1166) were 14.7 percent minority; 37.1 percent had low-, 47.5 percent had intermediate-, and 15.4 percent had high-risk PCa. Those reporting a better physician-patient relationship perceived that their physician's treatment recommendation was more influential (RR = 1.05, 95 percent CI = 1.04-1.05, p < .001) and were more likely to choose the recommended treatment (OR = 2.92, 95 percent CI = 2.39, 3.58, p < .001). A pattern of interactions emerged indicating that quality of the physician-patient relationship was more strongly associated with influence of recommendations for more, versus less aggressive treatment in those with low-risk, but not intermediate-risk disease.

CONCLUSIONS

Prioritizing quality of the physician-patient relationship through training, practice change, and patient feedback may increase adherence. However, strategies need to align with efforts to reduce physician recommendations for inefficacious treatments to prevent overtreatment.

Costs of conservative management of early-stage prostate cancer compared to radical prostatectomy-a claims data analysis

Background

Due to widespread PSA testing incidence rates of localized prostate cancer increase but curative treatment is often not required. Overtreatment imposes a substantial economic burden on health care systems. We compared the direct medical costs of conservative management and radical therapy for the management of early-stage prostate cancer in routine care.

Methods

An observational study design is chosen based on claims data of a German statutory health insurance fund for the years 2008–2011. Three hundred fifty-three age-matched men diagnosed with prostate cancer and treated with conservative management and radical prostatectomy, are included. Individuals with diagnoses of metastases or treatment of advanced prostate cancer are excluded.

In an excess cost approach direct medical costs are considered from an insured community perspective for in- and outpatient care, pharmaceuticals, physiotherapy, and assistive technologies. Generalized linear models adjust for comorbidity by Charlson comorbidity score and recycled predictions method calculates per capita costs per treatment strategy.

Results

After follow-up of 2.5 years per capita costs of conservative management are €6611 lower than costs of prostatectomy ([−9734;−3547], p < 0.0001). Complications increase costs of assistive technologies by 30% (p = 0.0182), but do not influence any other costs. Results are robust to cost outliers and incidence of prostate cancer diagnosis. The short time horizon does not allow assessing long-term consequences of conservative management.

Conclusions

At a time horizon of 2.5 years, conservative management is preferable to radical prostatectomy in terms of costs. Claims data analysis is limited in the selection of comparable treatment groups, as clinical information is scarce and bias due to non-randomization can only be partly mitigated by matching and confounder adjustment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1886-4) contains supplementary material, which is available to authorized users.

A hospital-based study of initial observation for low-risk prostate cancer and its predictors in the United States

INTRODUCTION

Initial observation (IO) is a strategy to minimize prostate cancer overtreatment. We sought to evaluate contemporary trends in IO utilization for low-risk prostate cancer in the United States and to identify factors associated with its uptake.

METHODS

Using the National Cancer Database, we identified men with low-risk prostate cancer diagnosed between 2004 and 2011. IO utilization was plotted over time. Multivariate logistic regression was performed to determine the influence of diagnosis year and other factors on IO selection.

RESULTS

Of the 219 971 men with low-risk prostate cancer, 21 231 (9.7%) underwent IO. Beginning in 2008, IO use increased significantly with time (range: 7.5%-14.3%). Compared to 2004, patients diagnosed in 2011 had 2.5 times the odds of choosing IO (odds ratio [OR] 2.5, confidence interval [CI] 2.3-2.6, p < 0.01). Aside from diagnosis year, age, race, Charlson score, clinical T stage, and PSA level predicted IO use (p < 0.01). Other predictors of IO included hospital type, insurance provider, and household income. Specifically, comprehensive cancer centres, private insurance, and higher income predicted decreased IO usage (OR 0.5, CI 0.5-0.5, p < 0.01; OR 0.4, CI 0.4-0.4, p < 0.01; and OR 0.8, CI 0.8-0.9, p < 0.01, respectively). Less educated men were also less likely to undergo observation (OR 0.8, CI 0.8-0.9, p < 0.01). Treatment within the western United States was significantly, but weakly, associated with increased use of IO (p < 0.01).

CONCLUSIONS

In recent years, low-risk prostate cancer has been increasingly managed with IO, appropriately driven by patient and disease factors. Unexpectedly, observation usage also varies by race, hospital, insurance, income, and geography, suggesting that non-clinical factors may affect treatment selection.

Surgical versus Medical Treatment of Ocular Surface Squamous Neoplasia: A Cost Comparison

PURPOSE

The objective of this study was to compare the cost associated with surgical versus interferon-alpha 2b (IFNα2b) treatment for ocular surface squamous neoplasia (OSSN).

DESIGN

A matched, case-control study.

PARTICIPANTS

A total of 98 patients with OSSN, 49 of whom were treated surgically and 49 of whom were treated medically.

METHODS

Patients with OSSN treated with IFNα2b were matched to patients treated with surgery on the basis of age and date of treatment initiation. Financial cost to the patient was calculated using 2 different methods (hospital billing and Medicare allowable charges) and compared between the 2 groups. These fees included physician fees (clinic, pathology, anesthesia, and surgery), facility fees (clinic, pathology, and operating room), and medication costs. Time invested by patients was calculated in terms of number of visits to the hospital and compared between the 2 groups. Parking costs, transportation, caregiver wages, and lost wages were not considered in our analysis.

MAIN OUTCOME MEASURES

Number of clinic visits and cost of therapy as represented by both hospital charges and Medicare allowable charges.

RESULTS

When considering cost in terms of time, the medical group had an average of 2 more visits over 1 year compared with the surgical group. Cost as represented by hospital charges was higher in the surgical group (mean, $17 598; standard deviation [SD], $7624) when compared with the IFNα2b group (mean, $4986; SD, $2040). However, cost between the 2 groups was comparable when calculated on the basis of Medicare allowable charges (surgical group: mean, $3528; SD, $1610; medical group: mean, $2831; SD, $1082; P = 1.00). The highest cost in the surgical group was the excisional biopsy (hospital billing $17 598; Medicare allowable $3528), and the highest cost in the medical group was interferon ($1172 for drops, average 8.0 bottles; $370 for injections, average 5.4 injections).

CONCLUSIONS

Our data in this group of patients previously demonstrated equal efficacy of surgical versus medical treatment. In this article, we consider costs of therapy and found that medical treatment involved two more office visits, whereas surgical treatment could be more or equally costly depending on insurance coverage.

[Economic evaluation of the treatments of non-metastatic prostate cancer]

OBJECTIVES

Prostate cancer is the most frequent cancer and the third leading cause of cancer death in men in France. The development of treatment for prostate cancer is fast and sometimes relies on costly innovations. Medico-economic studies are however rare in this area. This literature review aims to summarize available medico-economic data on the initial management of localized prostate cancer and discuss the quality and usability of existing economic studies on the subject.

MATERIALS AND METHOD

Literature review was done using PubMed and Cochrane databases. Studies and articles were selected based on several criteria: population with initial treatment for localized prostate cancer (without metastasis), comparative studies with surgery as control treatment, studies in countries members of the OECD, articles in English or French published between 2004 and 2014.

RESULTS

The surgical robot, one of the newest innovations, is more expensive than conventional open surgery or no robotic laparoscopy, even if it is associated with a reduction of the original period of stay. Radiation therapy seems more expensive than surgery as initial therapy of localized prostate cancer.

CONCLUSION

Conclusions remain limited because of the rarity of reliable health economic studies on the subject.

Active surveillance for low-risk prostate cancer compared with immediate treatment: a Canadian cost comparison

BACKGROUND

Clinical consequences of active surveillance compared with immediate treatment have been evaluated in patients with low-risk prostate cancer; yet, its financial benefits have not been adequately studied in Canada or elsewhere. Our study objective was to evaluate the direct costs associated with active surveillance and immediate treatment in the Canadian context.

METHODS

We developed a Markov model with Monte Carlo microsimulations to estimate the Canadian cost of prostate cancer associated with immediate treatment and active surveillance strategies. The patients receiving active surveillance were assumed to receive delayed treatment at a rate of 8.35%, 4.17% and 2.1% per year for the first 2 years, years 3 to 5, and years 6 to 10 of follow-up, respectively. All costs were assigned in Canadian dollars and reflect Quebec's health system.

RESULTS

With active surveillance, the mean cost of prostate cancer management over the first year and 5 years of follow-up was estimated at $6200 (95% confidence interval [CI] $6083-$6317) per patient. The mean cost corresponding to immediate treatment was estimated at $13 735 (95% CI $13 615-$13 855) per patient. We estimated that patients receiving active surveillance who received delayed treatment incurred higher costs of $16 257 per patient.

INTERPRETATION

Active surveillance could offer important economic benefits to the Canadian health system, estimated at $96.1 million for each annual cohort of incident prostate cancer. These results add to the economic rationale advocating active surveillance for eligible men with low-risk prostate cancer.

Multidisciplinary care and management selection in prostate cancer

The management of prostate cancer is complicated by the multitude of treatment options, the lack of proven superiority of one modality of management, and the presence of physician bias. Care at a multidisciplinary prostate cancer clinic offers patients the relative convenience of consultation with physicians of multiple specialties within the confines of a single visit and appears to serve as a venue in which patients can be counseled regarding the risks and benefits of available therapies in an open and interactive environment. Physician bias may be minimized in such an environment, and patient satisfaction rates are high. Available data suggest that low-risk patients who are seen at a multidisciplinary prostate cancer clinic appear to select active surveillance in greater proportion. However, relatively few studies have investigated the other added value that multidisciplinary clinics provide to the patient or health care system, and therefore, additional studies assessing the impact of multidisciplinary care in the management of patients with prostate cancer are needed.

Overdiagnosis and overtreatment of prostate cancer

CONTEXT

Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment.

OBJECTIVE

To review primary data on PCa overdiagnosis and overtreatment.

EVIDENCE ACQUISITION

Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches.

EVIDENCE SYNTHESIS

The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management.

CONCLUSIONS

Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy.

PATIENT SUMMARY

Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

Medical oncology consultation and minimization of overtreatment in men with low-risk prostate cancer

PURPOSE

Specialist bias, in which specialists recommend the therapy that they are capable of delivering, is thought to influence the treatment of patients with localized prostate cancer and to contribute to overtreatment of men with limited life expectancy. Consequently, rates of active surveillance, the preferred management modality per the National Comprehensive Cancer Network (NCCN) for patients with low- and very low-risk disease and a life expectancy of less than 10 and less than 20 years, respectively, are low. We sought to determine whether consultation with a medical oncologist is associated with increased rates of active surveillance in men with low-risk prostate cancer.

METHODS

We identified 188 patients with low-risk prostate cancer undergoing active surveillance at one of three referral centers in Boston, MA in 2009. Multivariable logistic regression was used to determine whether consultation with a medical oncologist was associated with selection of active surveillance. The data were reanalyzed for patients with low- and very low-risk disease and a life expectancy of less than 10 and less than 20 years, respectively.

RESULTS

Consultation with a medical oncologist was associated with increased rates of active surveillance (37% v 21%, P = .01), an association that remained significant on multivariable logistic regression (odds ratio [OR] = 2.70; 95% CI, 1.27 to 5.75; P = .01). When applied to patients with limited life expectancy, this finding remained significant (OR = 4.74; 95% CI, 1.17 to 19.25; P = .03).

CONCLUSION

Consultation with a medical oncologist is associated with increased rates of active surveillance, adherence to NCCN guidelines, and minimization of overtreatment in men with early prostate cancer and limited life expectancy.

Quality of physician-patient relationships is associated with the influence of physician treatment recommendations among patients with prostate cancer who chose active surveillance

OBJECTIVE

With growing evidence that some men with prostate cancer (PCa) may be overtreated, clinicians need greater knowledge of the factors that influence uptake of treatment recommendations in general, and specifically, uptake of active surveillance in patients for whom this is an appropriate treatment option. The objective of this study was to test the role of the quality of the physician-patient relationship in the choice to be followed by active surveillance, rather than receive definitive therapy (e.g., surgery and radiation). We hypothesized that patients would have been more influenced by their physicians' treatment recommendations to the degree that they held more positive perceptions of their relationship with their physicians, independent of treatment recommended.

METHODS AND MATERIALS

Patients with PCa (n = 120) being followed with active surveillance at a comprehensive cancer center completed self-report assessments of their treatment decision-making process. Generalized estimating equations were used to model the association between participants' perceptions of their relationships with their physicians and influence of these physicians' recommendations on their treatment decision.

RESULTS

After controlling for the type of treatment recommended, Gleason score, and education, 3 predictors, trust in the physician, perceived closeness with the physician, and the degree to which the physician shared control over treatment decision making, were associated with greater influence of physician's treatment recommendation. Receiving a recommendation for active surveillance, compared with definitive therapy, was also associated with higher perceived trust, closeness, shared control over treatment decision making, lower likelihood of having been treated poorly by a physician, and greater influence of physician's treatment recommendation.

CONCLUSIONS

There is increasing concern that patients with relatively less aggressive PCa, older age, or serious comorbidities are being unnecessarily treated with surgery or radiation, putting them at risk for side effects, and contributing to high health care costs. When active surveillance is an appropriate course of treatment, the quality of patients' relationships with their physicians may be a determinant of following a recommendation for active surveillance. Results may have implications for treatment uptake in general, indicating that the quality of the physician-patient relationship, including trust, closeness, shared decision making--all elements of patient-centered care--may be important motivators of treatment adoption and adherence.

Observation versus initial treatment for men with localized, low-risk prostate cancer: a cost-effectiveness analysis

BACKGROUND

Observation is underutilized among men with localized, low-risk prostate cancer.

OBJECTIVE

To assess the costs and benefits of observation versus initial treatment.

DESIGN

Decision analysis simulating treatment or observation.

DATA SOURCES

Medicare schedules, published literature.

TARGET POPULATION

Men aged 65 and 75 years who had newly diagnosed low-risk prostate cancer (prostate-specific antigen level <10 µg/L, stage ≤T2a, Gleason score ≤3 + 3).

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Treatment (brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy) or observation (active surveillance [AS] or watchful waiting [WW]).

OUTCOME MEASURES

Quality-adjusted life expectancy and costs.

RESULTS OF BASE-CASE ANALYSIS

Observation was more effective and less costly than initial treatment. Compared with AS, WW provided 2 additional months of quality-adjusted life expectancy (9.02 vs. 8.85 years) at a savings of $15,374 ($24,520 vs. $39,894) in men aged 65 years and 2 additional months (6.14 vs. 5.98 years) at a savings of $11,746 ($18,302 vs. $30,048) in men aged 75 years. Brachytherapy was the most effective and least expensive initial treatment.

RESULTS OF SENSITIVITY ANALYSIS

Treatment became more effective than observation when it led to more dramatic reductions in prostate cancer death (hazard ratio, 0.47 vs. WW and 0.64 vs. AS). Active surveillance became as effective as WW in men aged 65 years when the probability of progressing to treatment on AS decreased below 63% or when the quality of life with AS versus WW was 4% higher in men aged 65 years or 1% higher in men aged 75 years. Watchful waiting remained least expensive in all analyses.

LIMITATION

Results depend on outcomes reported in the published literature, which is limited.

CONCLUSION

Among these men, observation is more effective and costs less than initial treatment, and WW is most effective and least expensive under a wide range of clinical scenarios.

PRIMARY FUNDING SOURCE

National Cancer Institute, U.S. Department of Defense, Prostate Cancer Foundation, and Institute for Clinical and Economic Review.

Incidence of upgrading and upstaging in patients with low-volume Gleason score 3+4 prostate cancers at biopsy: finding a new group eligible for active surveillance

INTRODUCTION

The aim of this study was to identify patients with low-volume Gleason score 3+4 (GS3+4) prostate cancer (PCa) who may be candidates for active surveillance (AS) by analyzing the incidence of upgrading and upstaging following radical prostatectomy (RP).

PATIENTS AND METHODS

Of 907 patients who underwent RP at our institute over the last 5 years, 66 men diagnosed with low-volume GS3+4 PCa at needle biopsy were identified. The incidence of upstaging and upgrading was assessed.

RESULTS

The overall rate of upgrading and upstaging was 31.8 and 25.6%, respectively. Preoperative PSA levels were significantly higher in patients who were upgraded (p = 0.015). The optimal preoperative PSA cutoff level for the prediction of upgrading was 4.73 ng/ml (sensitivity 85.7%, specificity 57.8%). Patients with <15% of maximum cores positive had significantly lower upstaging rate than those with >15% of maximum cores positive (p = 0.035). Clinical stage and number of positive cores had marginal association with upgrading and upstaging statistically (p = 0.061 and 0.081, respectively).

CONCLUSIONS

In patients with low-volume GS3+4 PCa at biopsy, underestimation may be effectively avoided when we select patients with PSA <4.73 and % maximum cancer involvement on positive cores <15%.

Many young men with prostate-specific antigen (PSA) screen-detected prostate cancers may be candidates for active surveillance

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Little is known as to the potential for over-treatment of young men diagnosed with prostate cancer. We show that for men aged ≤55 years with PSA screen-detected disease, 45% of the tumours are classified as very low risk and 85% of these have favourable pathology, yet most are actively treated. These findings raise the spectre of over-treatment for a group of men likely to be affected by treatment side-effects.

OBJECTIVE

To identify a population of young men (aged <55 years at diagnosis) with very-low-risk prostate cancer (stage cT1c, with prostate-specific antigen [PSA] density of <0.15 ng/mL/g, Gleason score ≤6, and ≤2 positive biopsy cores with <50% tumour involvement) that may be candidates for active surveillance (AS).

PATIENTS AND METHODS

We queried a Department of Defense tumour registry and hard-copy records for servicemen diagnosed with prostate cancer from 1987 to 2010. Statistical analyses were undertaken using Fisher's exact and chi-square testing.

RESULTS

From 1987-1991 and 2007-2010, PSA screen-detected tumours diagnosed in men aged ≤55 years rose >30-fold. Data for a subset of men (174) with PSA screen-detected cancer were evaluable for disease risk assessment. Of the 174 men with screen-detected disease, 81 (47%) had very-low-risk disease. Of that group, 96% (78/81) selected treatment and, of 57 men undergoing radical prostatectomy (RP), the tumours of 49 (86%) carried favourable pathology (organ confined, <10% gland involvement, Gleason ≤6).

CONCLUSIONS

Nearly half of young men with PSA screen-detected prostate cancer are AS candidates but the overwhelming majority seek treatment. Considering that many tumours show favourable pathology at RP, there is a possibility that these patients may benefit from AS management.

Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Multiple treatment alternatives exist for localised prostate cancer, with few high-quality studies directly comparing their comparative effectiveness and costs. The present study is the most comprehensive cost-effectiveness analysis to date for localised prostate cancer, conducted with a lifetime horizon and accounting for survival, health-related quality-of-life, and cost impact of secondary treatments and other downstream events, as well as primary treatment choices. The analysis found minor differences, generally slightly favouring surgical methods, in quality-adjusted life years across treatment options. However, radiation therapy (RT) was consistently more expensive than surgery, and some alternatives, e.g. intensity-modulated RT for low-risk disease, were dominated - that is, both more expensive and less effective than competing alternatives.

OBJECTIVE

To characterise the costs and outcomes associated with radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (RT: dose-escalated three-dimensional conformal RT, intensity-modulated RT, brachytherapy, or combination), using a comprehensive, lifetime decision analytical model.

PATIENTS AND METHODS

A Markov model was constructed to follow hypothetical men with low-, intermediate-, and high-risk prostate cancer over their lifetimes after primary treatment; probabilities of outcomes were based on an exhaustive literature search yielding 232 unique publications. In each Markov cycle, patients could have remission, recurrence, salvage treatment, metastasis, death from prostate cancer, and death from other causes. Utilities for each health state were determined, and disutilities were applied for complications and toxicities of treatment. Costs were determined from the USA payer perspective, with incorporation of patient costs in a sensitivity analysis.

RESULTS

Differences across treatments in quality-adjusted life years across methods were modest, ranging from 10.3 to 11.3 for low-risk patients, 9.6-10.5 for intermediate-risk patients and 7.8-9.3 for high-risk patients. There were no statistically significant differences among surgical methods, which tended to be more effective than RT methods, with the exception of combined external beam + brachytherapy for high-risk disease. RT methods were consistently more expensive than surgical methods; costs ranged from $19 901 (robot-assisted prostatectomy for low-risk disease) to $50 276 (combined RT for high-risk disease). These findings were robust to an extensive set of sensitivity analyses.

CONCLUSIONS

Our analysis found small differences in outcomes and substantial differences in payer and patient costs across treatment alternatives. These findings may inform future policy discussions about strategies to improve efficiency of treatment selection for localised prostate cancer.

Economic analysis of active surveillance for localized prostate cancer

PURPOSE OF REVIEW

Active surveillance is gaining wider acceptance in the urologic community as an effective treatment option for patients with low-risk prostate cancer. The purpose of this review is to analyze the economics of active surveillance in comparison with other therapies.

RECENT FINDINGS

Evaluating the economics of active surveillance in patients with low-risk prostate cancer is constrained by a prolonged natural history of disease. Recent cost model studies using hypothetical patients with low-risk prostate cancer showed that the estimated direct cost of active surveillance over long term was the lowest compared with direct costs of immediate treatment with radical prostatectomy, external beam radiation therapy, primary androgen deprivation therapy or brachytherapy. Active surveillance is associated with more quality-adjusted life years than immediate therapies with similar or lower lifetime costs. Physician reimbursement for active surveillance exceeded that from upfront radical prostatectomy after 3-5 years of follow-up and may be an important driving factor for physicians to practice active surveillance.

SUMMARY

Active surveillance appears to reduce prostate cancer healthcare expenditure by reducing the number of costly therapies. Results from clinical trials will allow the measurement of the true economic value of active surveillance in the future.

Multidisciplinary care and pursuit of active surveillance in low-risk prostate cancer

PURPOSE

Multidisciplinary clinics offer a unique approach to the management of patients with cancer. Yet, limited data exist to show that such clinics affect management. The purpose of this study was to determine whether consultation at a multidisciplinary clinic is associated with selection of active surveillance in patients with low-risk prostate cancer.

PATIENTS AND METHODS

The study comprised 701 men with low-risk prostate cancer managed at three tertiary care centers in Boston, MA in 2009. Patients either obtained consultation at a multidisciplinary prostate cancer clinic, at which they were seen by a combination of urologic, radiation, and medical oncologists in a concurrent setting, or they were seen by individual practitioners in sequential settings. The primary outcome was selection of active surveillance.

RESULTS

Crude rates of selection of active surveillance in patients seen at a multidisciplinary clinic were double that of patients seen by individual practitioners (43% v 22%), whereas the proportion of men treated with prostatectomy or radiation decreased by approximately 30% (P < .001). On multivariate logistic regression, older age (odds ratio [OR], 1.09; 95% CI, 1.05 to 1.12; P < .001), unmarried status (OR, 1.66; 95% CI, 1.01 to 2.72; P = .04), increased Charlson comorbidity index (OR, 1.37; 95% CI, 1.06 to 1.77; P = .02), fewer positive cores (OR, 0.92; 95% CI, 0.90 to 0.94; P < .001), and consultation at a multidisciplinary clinic (OR, 2.15; 95% CI, 1.13 to 4.10; P = .02) were significantly associated with pursuit of active surveillance.

CONCLUSION

Multidisciplinary care is associated with increased selection of active surveillance in men with low-risk prostate cancer. This finding may have an important clinical, social, and economic impact.

Active surveillance for prostate cancer compared with immediate treatment: an economic analysis

BACKGROUND

The costs associated with a contemporary active surveillance strategy compared with immediate treatment for prostate cancer are not well characterized. The purpose of this study is to elucidate the health care costs of an active surveillance paradigm for prostate cancer.

METHODS

A theoretical cohort of 120,000 men selecting active surveillance for prostate cancer was created. The number of men remaining on active surveillance and those exiting to each of 5 treatments over 5 years were simulated in a Markov model. Estimated total costs after 5 years of active surveillance with subsequent delayed treatment were compared with immediate treatment. Sensitivity analyses were performed to test the effect of various surveillance strategies and attrition rates. Additional analyses to include 10 years of follow-up were performed.

RESULTS

The average simulated cost of treatment for 120,000 men initiating active surveillance with 5 years of follow-up and subsequent delayed treatment resulted in per patient cost savings of $16,042 (95% confidence interval [CI], $16,039-$16,046) relative to initial curative treatment. This represents a $1.9 billion dollar savings to the cohort. The strict costs of active surveillance exceeded those of brachytherapy in the ninth year of follow-up. A yearly biopsy within the active surveillance cohort increased costs by 22%, compared with every other year biopsy. At 10 years of follow-up, active surveillance still resulted in a cost benefit; however, the savings were reduced by 38% to $9944 (95% CI, $9941-$9948) per patient relative to initial treatment.

CONCLUSIONS

These data demonstrate that active surveillance represents a considerable cost savings over immediate treatment for prostate cancer in a theoretical cohort after 5 and 10 years of follow-up.

The economic burden of prostate cancer

In the present review we discuss expenditure on prostate cancer diagnosis, treatment and follow-up and evaluate the cost of prostate cancer and its management in different countries. Prostate cancer costs were identified from published data and internet sources. To provide up-to-date comparisons, costs were inflated to 2010 levels and the most recent exchange rates were applied. A high proportion of the costs are incurred in the first year after diagnosis; in 2006, this amounted to 106.7-179.0 million euros (€) in the European countries where these data were available (UK, Germany, France, Italy, Spain and the Netherlands). In the USA, the total estimated expenditure on prostate cancer was 9.862 billion US dollars ($) in 2006. The mean annual costs per patient in the USA were $10,612 in the initial phase after diagnosis, $2134 for continuing care and $33,691 in the last year of life. In Canada, hospital and drug expenditure on prostate cancer totalled C$103.1 million in 1998. In Australia, annual costs for prostate cancer care in 1993-1994 were 101.1 million Australian dollars. Variations in costs between countries were attributed to differences in incidence and management practices. Per patient costs depend on cancer stage at diagnosis, survival and choice of treatment. Despite declining mortality rates, costs are expected to rise owing to increased diagnosis, diagnosis at an earlier stage and increased survival. Unless new strategies are devised to increase the efficiency of healthcare provision, the economic burden of prostate cancer will continue to rise.

Active surveillance for prostate cancer: progress and promise

Widespread prostate-specific antigen (PSA) -based screening and aggressive treatment of prostate cancer have reduced mortality rates substantially, but both remain controversial in large part because of high rates of overdiagnosis and overtreatment of otherwise indolent tumors. Active surveillance--or close monitoring of PSA levels combined with periodic imaging and repeat biopsies--is gaining acceptance as an alternative initial management strategy for men with low-risk prostate cancer. In reported series, rates of progression to active treatment with intermediate-term follow-up have ranged from 14% to 41%, and likelihood of subsequent cure with surgery or radiation does not seem to be compromised by an initial trial of surveillance. Two related challenges to broader acceptance of surveillance are better characterization at time of diagnosis of the risk of progression (including likelihood that given tumor may have been undersampled by diagnostic biopsy) and validation of optimal end points once surveillance begins. Both are subjects of intense ongoing investigation, with emerging biomarkers and novel imaging tests expected to facilitate decision making substantially. Recent reports have suggested active surveillance can be a cost-effective approach and preserve quality of life, but these questions must be assessed more definitively in prospective cohorts. Ultimately, by minimizing the harms of overtreating low-risk prostate cancer, active surveillance may help settle the controversy surrounding prostate cancer screening and management.