Adenocarcinoma of the prostate: an expensive way to die

Under Treatment of Prostate Cancer in Rural Locations

PURPOSE

Compared to urban populations, rural populations rank poorly on numerous health indicators, including cancer outcomes. We examined the relationship of rural residence with stage and treatment among patients with prostate cancer, the second most common malignancy in men.

MATERIALS AND METHODS

Using the Pennsylvania Cancer Registry we identified all men diagnosed with prostate cancer between 2009 and 2015. Patients were classified as residing in a rural area, a large town or an urban area using the Rural-Urban Commuting Area classification. Our primary outcomes included indicators of prostate cancer treatment and treatment types but we also examined disease stage and mortality. We used the chi-square tests to assess differences between groups and estimated multivariable logistic regression models to assess the association between rural residence and treatment.

RESULTS

We identified 51,024 men diagnosed with localized or metastatic prostate cancer between 2009 and 2015. The overall incidence of prostate cancer decreased during the study period from 416 to 304/100,000 men while the incidence of metastatic disease increased from 336 to 538/100,000. Rural residents were less likely to undergo treatment than urban residents even when stratified by low, intermediate and high risk disease (aOR 0.77, 95% CI 0.64-0.91; aOR 0.71, 95% CI 0.58-0.89; and aOR 0.68, 95% CI 0.53-0.89, respectively). Rural status did not affect the receipt of radiation therapy compared to other treatment types.

CONCLUSIONS

Prostate cancer treatment differs between urban and rural residents. Rural residents are less likely to receive treatment even when stratified by disease risk.

Macrophage roles in the clearance of apoptotic cells and control of inflammation in the prostate gland after castration

BACKGROUND

Androgen deprivation results in massive apoptosis in the prostate gland. Macrophages are actively engaged in phagocytosing epithelial cell corpses. However, it is unknown whether microtubule-associated protein 1 light chain 3 alpha (LC3)-associated phagocytosis (LAP) is involved and contribute to prevent inflammation.

METHODS

Flow cytometry, RT-PCR and immunohistochemistry were used to characterize the macrophage subpopulation residing in the epithelial layer of the rat ventral prostate (VP) after castration. Stereology was employed to determine variations in the number of ED1 and ED2. Mice were treated with either chloroquine or L-asparagine to block autophagy.

RESULTS

M1 (iNOS-positive) and M2 macrophages (MRC1+ and ARG1+) were not found in the epithelium at day 5 after castration. The percentage of CD68⁺ (ED1) and CD163⁺ (ED2) phenotypes increased after castration but only CD68⁺ cells were present in the epithelium. RT-PCR showed increased content of the autophagy markers Bcl1 and LC3 after castration. In addition, immunohistochemistry showed the presence of LC3⁺ and ATG5⁺ cells in the epithelium. Double immunohistochemistry showed these cells to be CD68⁺ /LC3⁺ , compatible with the LAP phenotype. LC3⁺ cells accumulate significantly after castration. Chloroquine and L-asparagine administration caused inflammation of the glands at day 5 after castration.

CONCLUSIONS

CD68⁺ macrophages phagocytose apoptotic cell corpses and activate the LAP pathway, thereby contributing to the preservation of a non-inflammed microenvironment. Marked inflammation was detected when autophagy blockers were administered to castrated animals.

Cost-effectiveness analysis of treatments for metastatic castration resistant prostate cancer

OBJECTIVE

Treatment options for metastatic castration resistant prostate cancer (mCRPC) have expanded rapidly in recent years. Given the significant economic burden, we sought perform a cost-effectiveness analysis (CEA) of the contemporary treatment paradigm for mCRPC.

METHODS

We devised a treatment protocol consisting of sipuleucel-T, enzalutamide, abiraterone, docetaxel, radium-223, and cabazitaxel. We estimated number and length of treatments for each therapy using dosing schedules or progression free survival data from published clinical trials. We estimated treatment cost using billing data and Medicare reimbursement values and performed a CEA. Our analysis assumed US$100,000 per life year saved (LYS) as the threshold societal willingness to pay.

RESULTS

Incremental cost-effectiveness ratios (ICER) for strategies incorporating sipuleucel-T that were not eliminated by extended dominance exceeded the societal threshold willingness-to-pay of US$100,000 per LYS, the lowest of which was sipuleucel-T + enzalutamide + abiraterone + docetaxel at US$207,714 per LYS. Enzalutamide + abiraterone + docetaxel exhibited the most favorable ICER among strategies without sipuleucel-T at US$165,460 per LYS.

CONCLUSION

Based on the available survival data and current costs of treatment, all treatment strategies greatly exceed a commonly assumed societal willingness-to-pay threshold of US$100,000 per LYS. Improvements in this regard can only come with a reduction in pricing, better tailoring of treatment or significant enhancements in survival with clinical use of treatment combinations or sequences.

Costs in different states of prostate cancer

OBJECTIVES

This cross-sectional study assesses resource use and costs in different states of prostate cancer (PCa) in a real-life setting. Costs were estimated as incremental costs due to cancer for a six-month period and they included direct medical costs, productivity costs and costs of informal care.

METHODS

Resource use and cost data, irrespective of who the payer was, were retrieved from the registries for 611 PCa patients in the Helsinki area in Finland. In addition, patients answered background questions concerning informal care, work capacity and educational status. Patients were divided into four mutually exclusive groups based on disease state and time from diagnosis: primary (local disease, first six months after diagnosis; n = 47), rehabilitation (local disease, 0.5-1.5 years after diagnosis or recurrence; n = 158), remission (local disease, more than 1.5 years after diagnosis; n = 317) and metastatic (after detection of metastases; n = 89).

RESULTS

Costs differed markedly between the states of disease. Mean direct health care costs for the six-month periods were: primary treatment state € 2750, rehabilitation state € 1143, remission state € 760 and metastatic state € 7423. Productivity costs were also highest (€ 4277) in the metastatic state. Overall, the average share of indirect costs was around one third of the total costs. However, when including informal care, their combined share of the total costs increased to around half or more.

CONCLUSIONS

The results provided state-specific estimates of the direct health care and indirect costs of PCa in Finland. The treatment of metastatic disease is significantly more costly than treatment of early stage PCa. Although direct medical costs were higher compared to productivity costs, they should be taken into consideration when evaluating the costs of PCa.

Reducing prostate cancer racial disparity: evidence for aggressive early prostate cancer PSA testing of African American men

BACKGROUND

There is continuing controversy about prostate cancer testing and the recent American Urological Association guidelines. We hypothesize that the reduction and elimination of racial survival disparity among African American men (AAM; high-risk group) compared with European American men (EAM; intermediate-risk group) during the PSA testing era compared with the pre-PSA era strongly supports the use of PSA testing in AAM.

METHODS

We used Surveillance, Epidemiology, and End Results (SEER) data to investigate relative survival disparities between AAM and EAM. To evaluate pre-PSA testing era, we selected malignant first primary prostate cancer in AAM and EAM, all stages, diagnosed during 1973-1994. To evaluate relative survival disparities in the current PSA testing era, we selected malignant first primary local, regional, and distant stage prostate cancers diagnosed during 1998-2005 to calculate 5-year relative survival rates.

RESULTS

Age-adjusted 5-year relative survival of prostate cancer diagnosed during 1973-1994 in the national SEER data revealed significantly shorter survival for AAM compared with EAM (P < 0.0001). The SEER-based survival analysis from 1995 to 2005 indicated no statistical difference in relative survival rates between AAM and EAM by year of diagnosis of local, regional, or distant stage prostate cancer.

CONCLUSION

We conclude that the elimination of prostate cancer racial disparity of local, regional, and metastatic prostate cancer relative survival in the current PSA testing era compared with pre-PSA era as an endpoint to test PSA efficacy as a marker for prostate cancer diagnosis is evidence for aggressive testing of AAM.

IMPACT

Evidence for screening AAM.

The economics of abiraterone acetate for castration-resistant prostate cancer

Abiraterone acetate is an oral medication that has recently been granted approval for the treatment of metastatic castration resistant prostate cancer (mCRPC) prior and/or after chemotherapy with docetaxel. In this article we assess the economics of abiraterone acetate in mCRPC. Relevant studies demonstrated that abiraterone acetate had a minimal budget impact on health plans. A relevant advantage was the cost savings due to the lack of chemotherapy-related side effects as well as the ease of administration. The results of cost/benefit comparative studies with other novel agents (i.e. cabazitaxel, enzalutamide, sipuleucel-T) are warranted as well as the close collaboration between urologists and medical oncologists.

Desquamation is a novel phenomenon for collective prostate epithelial cell deletion after castration

The mechanism underlying castration-induced prostate regression, which is a classical physiological concept translated into the therapeutic treatment of advanced prostate cancer, involves epithelial cell apoptosis. In searching for events and mechanisms contributing to prostate regression in response to androgen modulation, we have frequently observed the collective deletion of epithelial cells. This work was undertaken to characterize this phenomenon hereafter named desquamation and to verify its presence after 17β-estradiol (E2) administration. Electron microscopy revealed that the desquamating cells had preserved cell-cell junctions and collapsed nuclear contents. The TUNEL reaction was negative for these cells, which were also negative for cleaved caspases-8, -9, -3 and nuclear apoptosis-inducing factor. Detailed analyses revealed that the condensed chromatin was first affected detaching from the nuclear lamina, which was observable after lamin A immunohistochemistry, suggesting the lack of lamin A degradation. A search in animals treated with supraphysiological E2 employed as an alternative anti-androgen treatment revealed no desquamation. The combined treatment (Cas + E2 group) caused changes particular to each treatment, including desquamation. In conclusion, desquamation appeared as a novel phenomenon contributing to collective prostate epithelial cell deletion, distinct from the classical castration-induced apoptosis and particular to the androgen deprivation resulting from surgical castration, and should be considered as part of the mechanisms promoting organ regression.

Cost-effectiveness analysis of stereotactic body radiation therapy versus intensity-modulated radiation therapy: an emerging initial radiation treatment option for organ-confined prostate cancer

PURPOSE

The purpose of this study is to compare the cost-effectiveness of two external beam radiation therapy techniques for treatment of low- to intermediate-risk prostate cancer: stereotactic body radiation therapy (SBRT) and intensity-modulated radiation therapy (IMRT).

MATERIALS AND METHODS

A Markov decision analysis model with probabilistic sensitivity analysis was designed with the various disease states of a 70-year-old patient with organ-confined prostate cancer to evaluate the cost-effectiveness of two external beam radiation treatment options.

RESULTS

The Monte Carlo simulation revealed that the mean cost and quality-adjusted life-years (QALYs) for SBRT and IMRT were $22,152 and 7.9 years and $35,431 and 7.9 years, respectively. The sensitivity analysis revealed that if the SBRT cohort experienced a decrease in quality of life of 4% or a decrease in efficacy of 6%, then SBRT would no longer dominate IMRT in cost-effectiveness. In fact, with these relaxed assumptions for SBRT, the incremental cost-effectiveness ratio of IMRT met the societal willingness to pay threshold of $50,000 per QALY.

CONCLUSION

Compared with IMRT, SBRT for low- to intermediate-risk prostate cancer has great potential cost savings for our health care system payers and may improve access to radiation, increase patient convenience, and boost quality of life for patients. Our model suggests that the incremental cost-effectiveness ratio of IMRT compared with SBRT is highly sensitive to quality-of-life outcomes, which should be adequately and comparably measured in current and future prostate SBRT studies.

Authentication of Algorithm to Detect Metastases in Men with Prostate Cancer Using ICD-9 Codes

Background

Metastasis is a crucial endpoint for patients with prostate cancer (PCa), but currently lacks a validated claims-based algorithm for detection.

Objective

To develop an algorithm using ICD-9 codes to facilitate accurate reporting of PCa metastases.

Methods

Medical records from 300 men hospitalized at Robert Wood Johnson University Hospital for PCa were reviewed. Using the presence of metastatic PCa on chart review as the gold standard, two algorithms to detect metastases were compared. Algorithm A used ICD-9 codes 198.5 (bone metastases), 197.0 (lung metastases), 197.7 (liver metastases), or 198.3 (brain and spinal cord metastases) to detect metastases, while algorithm B used only 198.5. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the two algorithms were determined. Kappa statistics were used to measure agreement rates between claim data and chart review.

Results

Algorithm A demonstrated a sensitivity, specificity, PPV, and NPV of 95%, 100%, 100%, and 98.7%, respectively. Corresponding numbers for algorithm B were 90%, 100%, 100%, and 97.5%, respectively. The agreement rate is 96.8% for algorithm A and 93.5% for algorithm B.

Conclusions

Using ICD-9 codes 198.5, 197.0, 197.7, or 198.3 in detecting the presence of PCa metastases offers a high sensitivity, specificity, PPV, and NPV value.

Healthcare resource use in advanced prostate cancer patients treated with docetaxel

OBJECTIVE

Although the treatment of metastatic castrate-resistant prostate cancer (mCRPC) has improved with newer therapies, there is little understanding how these therapies have impacted resource use and associated expenditures; available estimates are dated. The current study examined contemporary healthcare utilization and associated costs for mCRPC patients and how these measures changed over time.

METHODS

This retrospective cohort analysis used medical and pharmaceutical insurance claims data from a large non-payer-owned integrated claims database of US commercial insurers. Amongst all patients with a prostate cancer diagnosis (n=256,464), those with ≥ 1 docetaxel claim (docetaxel cohort, n=3642) were identified as mCRPC patients. Within the docetaxel cohort, an additional 6-months follow-up cohort (n=2862) was identified, i.e., patients with at least 6 months of follow-up after the first docetaxel claim. Resource utilization and costs were identified for all-cause hospitalizations, emergency room (ER) visits, physician visits and ambulatory visits, and prostate cancer-related prescription treatments.

RESULTS

Significant increases in the mean per-patient-per-month (PPPM) count for the docetaxel cohort were observed for all medical resources measured (hospitalizations and ER, physician, and ambulatory visits) in the post-docetaxel period compared with the pre-docetaxel period (p<0.0001); similar significant increases were observed for the 6-months follow-up cohort in the last 6 months (prior to lost to follow-up date) compared with the period preceding the last 6 months (p<0.0408 ambulatory visits, p<0.0001 all other resources). Total docetaxel cohort costs (mean [standard deviation]) rose from an average PPPM cost of US$2593 (3208) in the pre-docetaxel period to US$5847 (6990) in the post-docetaxel period (p<0.0001); each of the individual resources measured (hospitalization, all healthcare visits, and prescription costs) demonstrated significant increases (p<0.0001).

LIMITATIONS

Retrospective study design.

CONCLUSIONS

This large database analysis showed a significant increase in use of healthcare resources and associated costs among mCRPC patients following first-line docetaxel treatment.

Individualized strategy for dosing luteinizing hormone-releasing hormone agonists for androgen-independent prostate cancer: identification of outcomes and costs

PURPOSE

Continuing androgen suppression is the current standard in men with androgen-independent prostate cancer (AIPC). An individualized strategy, wherein luteinizing hormone-releasing hormone agonists (LH-RHas) are redosed when serum testosterone approaches a non-castrate level, may decrease costs without worsening outcomes. To understand possible outcomes, we performed a cost-utility analysis comparing individualized and fixed LH-RHa dosing strategies in men with AIPC.

METHODS

The model used a societal perspective, a 5-year time horizon, and 3% annual cost discounting. The model accounted for direct costs of androgen suppression. Utilities were varied in accordance with published preference data.

RESULTS

Under base-case assumptions, individualized LH-RHa dosing yielded 1.089 expected quality-adjusted life years (QALYs), compared with 1.094 expected QALYs for fixed LH-RHa dosing. In cost analysis, lifetime per-patient costs for androgen suppression were estimated to be $5,694 for individualized LH-RHa dosing and $9,157 for fixed LH-RHa dosing. Applied to the total population, a strategy of individualized LH-RHa dosing would cost $170 million for androgen suppression, compared with $274 million for fixed LH-RHa dosing. Under these assumptions, adopting the individualized strategy resulted in $692,600 gained from a societal perspective for each QALY lost (the decremental cost utility).

CONCLUSION

The results suggest that an individualized LH-RHa dosing strategy would be associated with moderate savings on an individual basis but substantial savings on a population basis, and would not adversely affect quality of life or life expectancy. Further research is needed to establish the effects of this strategy on symptoms and survival, as well as patient satisfaction and true costs.

Cost-effectiveness of intensity-modulated radiation therapy

Technical advances have given medicine the opportunity to refine current treatment techniques to improve outcomes. Computed tomography, magnetic resonance imaging and high energy linear accelerators are but a few examples of technology translating into clinical practice. Intensity-modulated radiation therapy is a form of 3D conformal radiation that is being increasingly incorporated into the management of patients with prostate cancer. As with any new technology, the cost of intensity-modulated radiation therapy is considerably greater than standard therapy. Economic models can be useful to compare treatments when this comparison cannot be performed in a clinical trial. A Markov Model was used to compare the use of intensity-modulated radiation with 3D conformal radiation therapy in the treatment of a 70 year old man with a good- and intermediate-risk prostate cancer. Cost data for men with Medicare insurance and prostate cancer treated with intensity-modulated radiation therapy and 3D conformal radiation therapy was obtained from the billing department at the Fox Chase Cancer Center (PA, USA). Utilities were collected from men undergoing intensity-modulated radiation therapy and 3D conformal radiation therapy for prostate cancer. Intensity-modulated radiation therapy was found to be cost effective in the treatment of a 70 year old man with prostate cancer with a incremental cost-effectiveness ratio of USD 16,182/quality-adjusted life year for men with intermediate-risk prostate cancer and USD 17,448/ quality-adjusted life year for men with good-risk prostate cancer. Sensitivity analysis found that a longer time horizon of the analysis and younger age at treatment favorably impact the cost-effectiveness ratio.

Cost effectiveness of risk-prediction tools in selecting patients for immediate post-prostatectomy treatment

BACKGROUND AND OBJECTIVE

Ideally, tests that predict the risk of cancer recurrence should be capable of guiding treatment decisions that are both therapeutically effective and cost effective. This paper evaluates the cost effectiveness of two tools that identify patients at high risk for biochemical (prostate-specific antigen) recurrence of prostate cancer after prostatectomy, the hypothesis being that accurate classification of high-risk patients will allow more appropriate use of secondary (adjuvant/salvage) treatment and may improve on current clinical practice. These risk-prediction tools are the Kattan postoperative nomogram, which uses clinicopathologic features, and the Prostate Px test, which employs additional morphometric and immunofluorescence features of the prostate specimen to predict risk of biochemical recurrence. These tools were trained on patients treated at the Memorial Sloan-Kettering Cancer Center (996 patients for the nomogram, 342 patients for the Prostate Px test).

METHODS

The cost effectiveness of the Prostate Px test, the Kattan postoperative nomogram, and current clinical practice were compared using a decision analytic model. The modeled treatment for low-risk patients was watchful waiting. The modeled treatments for high-risk patients were local radiation, hormonal therapy, and watchful waiting. Costs, utilities, and transition probabilities were obtained from the literature. Costs and effects were discounted at 3% per year. The time span modeled was 10 years after prostatectomy. Monte Carlo simulation was performed to estimate cost and effectiveness; sensitivity analysis was performed to examine the impact of uncertainty in the parameter values.

RESULTS

The expected quality-adjusted life years (QALYs) for the Prostate Px test, nomogram, and current practice were 8.11, 7.39, and 6.47, respectively. The expected costs were $US17 549, $US14 162, and $US14 104, respectively. The incremental cost-effectiveness ratio of the Prostate Px was $US4704/QALY compared with the nomogram, and $US2100/QALY compared with current practice. The incremental cost-effectiveness ratio of the nomogram was $US63/QALY compared with current practice. These ratios are well below the common willingness-to-pay limit of $US50 000/QALY. Expected effectiveness was highest for the Prostate Px test, followed by the nomogram. Expected cost was slightly higher for Prostate Px than for either alternative; nevertheless, the Prostate Px was cost effective compared with both the nomogram and current practice. The nomogram was cost effective compared with current practice. The acceptable cost effectiveness of the Prostate Px test and the nomogram compared with current practice were not sensitive to changes in the values used to inform the model within clinically plausible ranges. The superior performance of both Prostate Px test and nomogram over current practice resulted from identifying high-risk patients likely to benefit from adjuvant treatment, while sparing the low-risk patients the added cost and toxicity of treatment.

CONCLUSION

Incorporation of risk-prediction tools in the initial management of patients after prostatectomy resulted in increased QALYs at an acceptable increase in cost relative to current practice.

Is proton beam therapy cost effective in the treatment of adenocarcinoma of the prostate?

PURPOSE

New treatments are introduced routinely into clinical practice without rigorous economic analysis. The specific aim of this study was to examine the cost effectiveness of proton beam radiation compared with current state-of-the art therapy in the treatment of patients with prostate cancer.

MATERIALS AND METHODS

A Markov model was informed with cost, freedom from biochemical failure (FFBF), and utility data obtained from the literature and from patient interviews to compare the cost effectiveness of 91.8 cobalt gray equivalent (CGE) delivered with proton beam versus 81 CGE delivered with intensity-modulated radiation therapy (IMRT). The length of how many years the model was run, patient's age, probability of FFBF after treatment with proton beam therapy and IMRT, utility of patients treated with salvage hormone therapy, and treatment cost were tested in sensitivity analyses.

RESULTS

Analysis at 15 years resulted in an expected mean cost of proton beam therapy and IMRT of $63,511 and $36,808, and $64,989 and $39,355 for a 70-year-old and 60-year-old man respectively, with quality-adjusted survival of 8.54 and 8.12 and 9.91 and 9.45 quality-adjusted life-years (QALY), respectively. The incremental cost effectiveness ratio was calculated to be $63,578/QALY for a 70-year-old man and $55,726/QALY for a 60-year-old man.

CONCLUSION

Even when based on the unproven assumption that protons will permit a 10-Gy escalation of prostate dose compared with IMRT photons, proton beam therapy is not cost effective for most patients with prostate cancer using the commonly accepted standard of $50,000/QALY. Consideration should be given to limiting the number of proton facilities to allow comprehensive evaluation of this modality.

Looking Back at PCPT: Looking Forward to New Paradigms in Prostate Cancer Screening and Prevention

OBJECTIVES

Provide a critical summary of the latest interpretation of findings from the Prostate Cancer Prevention Trial (PCPT).

METHODS

Findings from PCPT and recently published post-hoc analyses are reviewed.

RESULTS

PCPT demonstrated that finasteride can reduce the prevalence of prostate cancer, permitted the first large-scale assessment of the performance characteristics of prostate-specific antigen for prostate cancer screening, and identified new-onset erectile dysfunction as an early predictor of cardiovascular events.

CONCLUSIONS

PCPT has and will continue to yield valuable information regarding future strategies for prostate cancer prevention and detection, benign prostatic hyperplasia, and other matters of public health importance.

Cumulative cost pattern comparison of prostate cancer treatments

BACKGROUND

Studies that compare prostate cancer treatment costs show wide variation. None compare all contemporary treatment costs, and most focus on initial treatment costs. The authors compared healthcare utilization and cost patterns of prostate cancer treatments over a span of 5.5 years in 4553 newly diagnosed patients stratified by age and risk group.

METHODS

Contemporary treatment and evaluation patterns for prostate cancer were identified by using CaPSURE, a national disease registry of men with prostate cancer that included ongoing clinical data collection from 31 academic and community urology practices and biennial patient-reported outcome questionnaires that included demography, medical condition, comorbidity, risk measures, and healthcare utilization. Costs of outpatient visits, medications, and hospitalizations were applied from various national sources. Recurrent events analysis (MCF) accounted for left and right censorship. A mixed effects regression model with bootstrapping for skewed cost data quantified the relation between MCF cost, age, and risk.

RESULTS

Prostate-related costs in the first 6 months after treatment were 11,495 dollars, (from 2586 dollars for watchful waiting (WW) to 24,204 dollars for external beam radiation. After 6 months, average cost was only 3044 dollars. Annual cost is 7740 dollars, highest for androgen deprivation therapy (12,590 dollars) and lowest for watch waiting (5843 dollars). Risk and age were significantly related to initial treatment choice. Cumulative cost (42,570 dollars) allowed a better estimate of treatment pattern costs.

CONCLUSIONS

The cost burden of prostate cancer is high, but it varies by treatment type even when controlling for disease, age, and stage. Cumulative cost analysis allowed inclusion of adverse events and disease recurrence costs, making new cost comparisons evident among treatments.

The cost of prostate cancer chemoprevention: a decision analysis model

BACKGROUND

The Prostate Cancer Prevention Trial found reduced prostate cancer prevalence for men treated with finasteride. The public health cost of wide-scale chemoprevention is unclear. We developed a model to help clarify the cost effectiveness of public use of prostate cancer-preventive agents.

METHODS

A Markov decision analysis model was designed to determine the lifetime prostate health-related costs, beginning at the age of 50 years, for men treated with finasteride compared with placebo. Model assumptions were based on data from the Prostate Cancer Prevention Trial, a literature review of survival and progression rates for patients treated with radical prostatectomy, and costs associated with prostate cancer disease states.

RESULTS

Chemoprevention with finasteride resulted in a gain of 8.7 [corrected] life years per 1,000 men at a cost of $1.107 million [corrected] per life year saved (LYS). However, if finasteride is assumed to not increase the incidence of high-grade tumors, it renders a gain of 16.9 [corrected] life years per 1,000 men at a cost of $578,400 [corrected] per LYS; finasteride must cost $160 per year [corrected] to reach $100,000 [corrected] per LYS. When applied to a population at higher risk (lifetime prevalence >or=40%) [corrected]for developing prostate cancer, the cost of finasteride must be reduced from its current cost ($62/month) to <$15/month [corrected]for the cost effectiveness to fall below $50,000 [corrected] per LYS.

CONCLUSIONS

Given the natural history of treated prostate cancer, implementation of chemoprevention would require an inexpensive medication with substantial cancer risk reduction to be cost effective. Targeting populations at higher risk for developing prostate cancer, however, allows for considerable flexibility in the medication cost to make prostate cancer chemoprevention a more attainable goal.

Using decision analysis to determine the cost-effectiveness of intensity-modulated radiation therapy in the treatment of intermediate risk prostate cancer

BACKGROUND

The specific aim of this study is to evaluate the cost-effectiveness of intensity-modulated radiation therapy (IMRT) compared with three-dimensional conformal radiation therapy (3D-CRT) in the treatment of a 70-year-old with intermediate-risk prostate cancer.

METHODS

A Markov model was designed with the following states; posttreatment, hormone therapy, chemotherapy, and death. Transition probabilities from one state to another were calculated from rates derived from the literature for IMRT and 3D-CRT. Utility values for each health state were obtained from preliminary studies of preferences conducted at Fox Chase Cancer Center. The analysis took a payer's perspective. Expected mean costs, cost-effectiveness scatterplots, and cost acceptability curves were calculated with commercially available software.

RESULTS

The expected mean cost of patients undergoing IMRT was $47,931 with a survival of 6.27 quality-adjusted life years (QALYs). The expected mean cost of patients having 3D-CRT was $21,865 with a survival of 5.62 QALYs. The incremental cost-effectiveness comparing IMRT with CRT was $40,101/QALYs. Cost-effectiveness acceptability curve analysis revealed a 55.1% probability of IMRT being cost-effective at a $50,000/QALY willingness to pay.

CONCLUSION

Intensity-modulated radiation therapy was found to be cost-effective, however, at the upper limits of acceptability. The results, however, are dependent on the assumptions of improved biochemical disease-free survival with fewer patients undergoing subsequent salvage therapy and improved quality of life after the treatment. In the absence of prospective randomized trials, decision analysis can help inform physicians and health policy experts on the cost-effectiveness of emerging technologies.

Long-term hormone therapy and radiation is cost-effective for patients with locally advanced prostate carcinoma

BACKGROUND

In Radiation Therapy Oncology Group (RTOG) trial 92-02, after men received neoadjuvant hormone cytoreduction and radiotherapy for locally advanced prostate carcinoma, they were randomized to receive either 2 years of long-term androgen-deprivation (LTAD) or no further treatment (short-term androgen-deprivation [STAD]). The specific objective of the current study was to determine whether LTAD was a cost-effective treatment for patients with locally advanced prostate carcinoma.

METHODS

The cost-effectiveness of LTAD was tested using a Markov model that was designed using proprietary software. The analysis took a payor's perspective. Unit costs were obtained by estimation using a global Medicare fee schedule. Costs and outcomes were discounted by 3%. Distributions were sampled at random from the treatment utilities, transition probabilities, and costs using a second-order Monte Carlo simulation technique.

RESULTS

The expected mean cost was 32,564 dollars for LTAD compared with 33,039 dollars for STAD after accounting for the additional cost of salvage treatment for men who were treated with STAD. The mean number of quality-adjusted life years (QALYs) for men who received LTAD was 4.13 QALYs compared with a mean of 3.68 QALYs for men who received STAD. The cost-effectiveness acceptability curve analysis showed a 91% probability that LTAD was cost-effective compared with STAD. Although overall survival was similar in the LTAD and STAD groups, the patients who received LTAD experienced gains in QALYs and had lower costs, because LTAD prevented biochemical failure and the necessitating salvage hormone therapy.

CONCLUSIONS

The current analysis showed that LTAD was cost-effective for the entire population studied in RTOG trial 92-02.

Economic analysis of a phase III clinical trial evaluating the addition of total androgen suppression to radiation versus radiation alone for locally advanced prostate cancer (Radiation Therapy Oncology Group protocol 86-10)

PURPOSE

To evaluate the cost-effectiveness of adding hormone therapy to radiation for patients with locally advanced prostate cancer, using a Monte Carlo simulation of a Markov Model.

METHODS AND MATERIALS

Radiation Therapy Oncology Group (RTOG) protocol 86-10 randomized patients to receive radiation therapy (RT) alone or RT plus total androgen suppression (RTHormones) 2 months before and during RT for the treatment of locally advanced prostate cancer. A Markov model was designed with Data Pro (TreeAge Software, Williamstown, MA). The analysis took a payer's perspective. Transition probabilities from one state of health (i.e., with no disease progression or with hormone-responsive metastatic disease) to another were calculated from published rates pertaining to RTOG 86-10. Patients remained in one state of health for 1 year. Utility values for each health state and treatment were obtained from the literature. Distributions were sampled at random from the treatment utilities according to a second-order Monte Carlo simulation technique.

RESULTS

The mean expected cost for the RT-only treatments was 29,240 dollars (range, 29,138-29,403 dollars). The mean effectiveness for the RT-only treatment was 5.48 quality-adjusted life years (QALYs) (range, 5.47-5.50). The mean expected cost for RTHormones was 31,286 dollars (range, 31,058-31,555 dollars). The mean effectiveness was 6.43 QALYs (range, 6.42-6.44). Incremental cost-effectiveness analysis showed RTHormones to be within the range of cost-effectiveness at 2,153 dollars/QALY. Cost-effectiveness acceptability curve analysis resulted in a >80% probability that RTHormones is cost-effective.

CONCLUSIONS

Our analysis shows that adding hormonal treatment to RT improves health outcomes at a cost that is within the acceptable cost-effectiveness range.

Radikale Prostatektomie bei Männern unter 56 Jahren mit Prostatakarzinom

BACKGROUND

Prostate cancer is the most frequent malignant tumor in men; 10% of the patients are younger than 56 years at the time of diagnosis and are usually still working. The aim of this study was to evaluate the costs of the disease within the first 3 years from diagnosis.

MATERIAL AND METHODS

A total of 200 patients (aged <56 years) after radical prostatectomy with curative intent were asked for their social status, professional training and job before and after radical prostatectomy, disablement, length of hospital stay, rehabilitation, early retirement, part-time retirement, retraining program, job-creating measures, and working conditions after radical prostatectomy.

RESULTS

Of the 200 patients queried, 177 (88.5%) answered the questionnaire. Prior to the radical prostatectomy 163 patients were employed. They were off work for a mean time of 104.4 days, 83.4% of them received inpatient rehabilitation treatment after surgery, 121 (74.2%) regained full fitness for work, 9 (5.5%) retired on grounds of age, 21 (12.9%) had an early retirement because of the disease, and 12 (7.4%) became unemployed. Within the first 3 years after diagnosis, the following mean costs had to be paid: 465.79 <euro> by the patient, 6569.76 <euro> by the employer, 16,356.96 <euro> by the health insurance, 13,304.88 <euro> by the pension scheme, and 3912.57 <euro> by the employment office.

CONCLUSION

The main costs in patients with prostate cancer and radical prostatectomy have to been paid by the health insurance scheme and the pension scheme; 74.3% of the patients regained full fitness for work. The time until reintegration into work was correlated to the extent of physical labor.

Palliative chemotherapy: Historical perspective, applications, and controversies

Despite advances in cancer detection and treatment, cancer continues to be a major public health burden in the United States, and patients with advanced or refractory cancers carry much of this burden. The primary goal of cancer treatment is cure. However, most patients with advanced, metastatic, or recurrent disease do not benefit from this intent. Recent research studies have documented the role of chemotherapy in providing symptom control, preventing complications, prolonging life, and improving quality of life (QOL) in patients with incurable cancers. Although chemotherapy under these conditions is palliative, patients receiving chemotherapy or participating in research trials are excluded from receiving much needed palliative services, such as Hospice, based on current definitions, limitations, and models of palliative care. Application of palliative services on a continuum from the time of diagnosis through the end of life (EOL) has been recognized as beneficial in the treatment of patients with terminal diseases and has been addressed through trials assessing mixed management models, providing palliative and therapeutic options.

THE ECONOMIC BURDEN OF METASTATIC AND PROSTATE SPECIFIC ANTIGEN PROGRESSION IN PATIENTS WITH PROSTATE CANCER: FINDINGS FROM A RETROSPECTIVE ANALYSIS OF HEALTH PLAN DATA

PURPOSE

We evaluated the economic burden of metastatic and prostate specific antigen (PSA) progression in patients with prostate cancer (CaP) using a cancer registry linked administrative database.

MATERIALS AND METHODS

A retrospective cohort evaluation of 2056 patients with CaP was done at Henry Ford Health System from 1995 to 2000. Records were examined for metastatic progression via International Classification of Disease-9-CM codes for metastasis and for PSA progression using accepted definitions based on initial therapy type. Health care resource charges 6 months and 1 year before and after progression were compared using pairwise t tests. A generalized linear model determined the effect of progression on charges and compared initial care, continuing care and terminal care charges in the progressed and nonprogressed groups, while controlling for baseline covariates (stage and age).

RESULTS

Patients with CaP had a mean age of 68 years, were mostly white (52%), had localized (88%) and moderately differentiated (66%) tumors, and a median baseline PSA of 7.0 ng/ml. Of patients 8.9% had metastatic progression at a mean followup of 3.6 years, while 16.1% had PSA progression at 4.5 years. After controlling for baseline covariates metastatic progression resulted in significant increases in charges (US dollars 92523 vs US dollars 58036, p < 0.0001). PSA progressed patients incurred significantly higher charges than nonprogressed patients (US dollars 69321 vs US dollars 58351, p = 0.0039), controlling for followup time, baseline stage, grade and treatment.

CONCLUSIONS

In CaP cases metastatic and PSA progression pose a significant economic burden irrespective of baseline stage, grade and treatment. Treatments that slows or prevents meta-static and PSA progression could offset this cost.