An economic analysis of conservative management versus active treatment for men with localized prostate cancer

Ten-year work burden after prostate cancer treatment

INTRODUCTION

We aim to characterize the magnitude of the work burden (weeks off from work) associated with prostate cancer (PCa) treatment over a 10-year period after PCa diagnosis and identify those at greatest risk.

MATERIALS AND METHODS

We identified men diagnosed with PCa treated with radical prostatectomy, radiation therapy, or active surveillance/watchful waiting within CaPSURE. Patients self-reported work burden and SF36 general health scores via surveys before and 1,3,5, and 10 years after treatment. Using multivariate repeated measures generalized estimating equation modeling we examined the association between primary treatment with risk of any work weeks lost due to care.

RESULTS

In total, 6693 men were included. The majority were White (81%, 5% Black, and 14% Other) with CAPRA low- (60%) or intermediate-risk (32%) disease and underwent surgery (62%) compared to 29% radiation and 9% active surveillance. Compared to other treatments, surgical patients were more likely to report greater than 7 days off work in the first year, with relatively less time off over time. Black men (RR 0.64, 95% CI 0.54-0.77) and those undergoing radiation (vs. surgery, RR 0.46, 95% CI 0.41-0.51) were less likely to report time off from work over time. Mean baseline GH score (73 [SD 18]) was similar between race and treatment groups, and stable over time.

CONCLUSIONS

The work burden of cancer care continued up to 10 years after treatment and varied across racial groups and primary treatment groups, highlighting the multifactorial nature of this issue and the call to leverage greater resources for those at greatest risk.

Palliative TURP Combined with Intermittent ADT Is A Curative Therapy to Some Elderly Men with Localized Prostate Adenocarcinoma

Background: Radical prostatectomy is the preferred therapeutic option for patients with localized prostate adenocarcinoma whose life expectancy is greater than 10 years. But for elderly patients, this may not be the best option. In clinical work, we have observed that palliative transurethral resection of prostate (pTURP) combined with intermittent androgen deprivation therapy (ADT) has achieved significant good results in the treatment of elderly patients with localized prostate adenocarcinoma. Methods: Retrospective analysis was conducted on 30 elderly patients aged 71 to 88 years who were hospitalized for urinary retention from March 2009 to March 2015. These patients were diagnosed as localized prostate adenocarcinoma with stage T1 to T2 and benign prostatic hyperplasia (BPH) through MRI and prostate biopsy. Fifteen cases (group A) were given pTURP and intermittent ADT after surgery. Fifteen cases (group B) were given sustained ADT. Serum total prostate specific antigen (TPSA), testosterone, alkaline phosphatase (ALP), prostate acid phosphatase (PAP), International Prostate Symptom Score (IPSS), Quality of Life (QOL) score, maximum urinary flow rate (Qmax), average urinary flow rate (Qave), prostate volume and post-void residual urine (PVR) data were followed up for 5 years, and the differences between the two groups were compared. Results: The 5-year cumulative survival rate of group A was 100%. Prostate specific antigen (PSA) progression-free survival was 60.00%. The average duration of intermittent ADT was 23.93 months. Prostate volume reduction was significantly. The dysuria in all patients was significantly improved. Nine patients had TPSA lower than 4 ng/ml and had no local progression and metastasis. At the same time the 5-year cumulative survival rate of group B was 80%. PSA progression-free survival was 26.67%. Six cases of dysuria improved. There was no significant difference in serum TPSA, ALP and PAP between the two groups in five years (P>0.05). Serum testosterone, IPSS score, QOL score, prostate volume, Qmax, Qave, and PVR were significantly different between the two groups in five years (P<0.05). Conclusion: pTURP for elderly patients with localized prostate adenocarcinoma and BPH combined with intermittent ADT is an effective treatment. It is able to solve dysuria. The overall ADT time is short. The risk of progression to castrated resistant prostate cancer is low. Some of them have achieved tumor-free survival.

Validation of an Algorithm for Claims-based Incidence of Prostate Cancer

BACKGROUND

Prostate cancer is a commonly studied outcome in administrative claims studies, but there is a dearth of validated case identifying algorithms. The long-term development of the disease increases the difficulty in separating prevalent from incident prostate cancer. The purpose of this validation study was to assess the accuracy of a claims algorithm to identify incident prostate cancer among men in commercial and Medicare Advantage US health plans.

METHODS

We identified prostate cancer in claims as a prostate cancer diagnosis within 28 days after a prostate biopsy and compared case ascertainment in the claims with the gold standard results from the Georgia Comprehensive Cancer Registry (GCCR).

RESULTS

We identified 74,008 men from a large health plan claims database for possible linkage with GCCR. Among the 382 prostate cancer cases identified in claims, 312 were also identified in the GCCR (positive predictive value [PPV] = 82%). Of the registry cases, 91% (95% confidence interval = 88, 94) were correctly identified in claims. Claims and registry diagnosis dates of prostate cancer matched exactly in 254/312 (81%) cases. Nearly half of the false-positive cases also had claims for prostate cancer treatment. Thirteen (43%) false-negative cases were classified as noncases by virtue of having a biopsy and diagnosis >28 days apart as required by the algorithm. Compared to matches, false-negative cases were older men with less aggressive prostate cancer.

CONCLUSIONS

Our algorithm demonstrated a PPV of 82% with 92% sensitivity in ascertaining incident PC. Administrative health plan claims can be a valuable and accurate source to identify incident prostate cancer cases.

Long-Term Clinical Outcomes of Radical Prostatectomy versus Watchful Waiting in Localized Prostate Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The present study aimed to compare the long-term clinical and functional outcomes of patients with clinically localized prostate cancer treated with radical prostatectomy compared to the watchful waiting.

METHODS

PubMed, Cochrane Central Register of Controlled Trials and reference lists of relevant marker studies were scrutinized from inception to Jan 2018. Two reviewers conducted data abstraction and quality assessment of included trials independently. Quality of included studies were assessed by using Cochrane checklist. Inverse-variance and Mantel-Haenszel estimates under random effects model were used to pool results as relative risks with 95% confidence interval. Heterogeneity was assessed by using I².

RESULTS

Three randomized controlled trials with 1568 participants were included. Compared to watchful waiting, radical prostatectomy had no significant effect on all-cause mortality at 12-year follow-up. However, radical prostatectomy had significant effect on reducing prostate-cause mortality at 12-year follow-up. We found significant lower prostate-cause mortality in patients with PSA>10 and GS≥7 scores who had undergone radical prostatectomy compared with patients in watchful waiting group. In addition, younger patients undergoing surgery developed lower distant metastases rate compared to another approach. Watchful waiting had a significant effect on erectile and urinary incontinence during 2 years.

CONCLUSION

There was no significant difference between radical prostatectomy and watchful waiting on all-cause mortality. However, the radical prostatectomy was associated with statistically lower prostate-cause mortality and metastases rates. Compared with older men, younger men experienced better clinical outcomes. Moreover, watchful waiting had better effect on reducing erectile dysfunction and urinary incontinence among patients during 2 years compared to radical prostatectomy.

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.

Radiation costing methods: a systematic review

OBJECTIVE

Costs for radiation therapy (rt) and the methods used to cost rt are highly diverse across the literature. To date, no study has compared various costing methods in detail. Our objective was to perform a thorough review of the radiation costing literature to identify sources of costs and methods used.

METHODS

A systematic review of Ovid medline, Ovid oldmedline, embase, Ovid HealthStar, and EconLit from 2005 to 23 March 2015 used search terms such as "radiation," "radiotherapy," "neoplasm," "cost," " cost analysis," and "cost benefit analysis" to locate relevant articles. Original papers were reviewed for detailed costing methods. Cost sources and methods were extracted for papers investigating rt modalities, including three-dimensional conformal rt (3D-crt), intensity-modulated rt (imrt), stereotactic body rt (sbrt), and brachytherapy (bt). All costs were translated into 2014 U.S. dollars.

RESULTS

Most of the studies (91%) reported in the 33 articles retrieved provided rt costs from the health system perspective. The cost of rt ranged from US$2,687.87 to US$111,900.60 per treatment for imrt, followed by US$5,583.28 to US$90,055 for 3D-crt, US$10,544.22 to US$78,667.40 for bt, and US$6,520.58 to US$19,602.68 for sbrt. Cost drivers were professional or personnel costs and the cost of rt treatment. Most studies did not address the cost of rt equipment (85%) and institutional or facility costs (66%).

CONCLUSIONS

Costing methods and sources were widely variable across studies, highlighting the need for consistency in the reporting of rt costs. More work to promote comparability and consistency across studies is needed.

Decision analysis model evaluating the cost of a temporary hydrogel rectal spacer before prostate radiation therapy to reduce the incidence of rectal complications

PURPOSE

We conducted a decision analysis to evaluate the cost effectiveness of a newly Food and Drug Administration approved rectal spacer gel (SpaceOAR, Augmenix) for the reduction of rectal toxicity of prostate radiation therapy (RT).

METHODS

A decision tree model (TreeAge Pro) was used to compare the strategy of pretherapy placement of a spacing hydrogel before RT to RT alone. The model compared costs associated with rectal complications because of rectal toxicity over a 10-year period across 3 different RT modalities. Rectal toxicity rates were estimated from studies on conformal RT dose escalation, high-dose stereotactic body radiotherapy (SBRT) and low-dose SBRT. Rectal toxicity reduction rates (baseline reduction 70%) were estimated from recently published 15 month data using a rectal spacer. Direct and indirect cost estimates for established grades of rectal toxicity were based on national and institutional costs. Reduction in short-term complications were assumed to carry forward to a reduction in long-term toxicity. One-way and two-way sensitivity analyses were performed.

RESULTS

The overall standard management cost for conformal RT was $3,428 vs. $3,946 with rectal spacer for an incremental cost of $518 over 10 years. A 1-way sensitivity analyses showed the breakeven cost of spacer at $2,332 or a breakeven overall risk reduction of 86% at a cost of $2,850. For high-dose SBRT, spacer was immediately cost effective with a savings of $2,640 and breakeven risk reduction at 36%. However, 2-way spacer cost to risk reduction sensitivity analyses were performed.

CONCLUSION

The use of a rectal spacer for conformal RT results in a marginal cost increase with a significant reduction in rectal toxicity assuming recently published 15 month rectal toxicity reduction is maintained over 10 years. For high-dose SBRT it was cost effective. Further studies would be necessary to validate the long-term benefits of rectal spacers.

Active surveillance for low-risk prostate cancer

Overtreatment of prostate cancer has become evident as studies comparing radical prostatectomy vs watchful waiting have shown that radical treatment benefits only a proportion of patients. Active surveillance was introduced as a management option for prostate cancer at low-risk of progression with the aim to closely observe for disease progression or change of tumour characteristics and offer active treatment if and when necessary. Active surveillance has been reserved for patients with Gleason 6 localised disease and low PSA; however, selection criteria may be widened as intermediate-term outcomes demonstrate excellent safety, efficacy and patient acceptance.

A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers

Permanent radioactive seed implantation provides highly effective treatment for prostate cancer that typically includes multidisciplinary collaboration between urologists and radiation oncologists. Low dose-rate (LDR) prostate brachytherapy offers excellent tumor control rates and has equivalent rates of rectal toxicity when compared with external beam radiotherapy. Owing to its proximity to the anterior rectal wall, a small portion of the rectum is often exposed to high doses of ionizing radiation from this procedure. Although rare, some patients develop transfusion-dependent rectal bleeding, ulcers or fistulas. These complications occasionally require permanent colostomy and thus can significantly impact a patient's quality of life. Aside from proper technique, a promising strategy has emerged that can help avoid these complications. By injecting biodegradable materials behind Denonviller's fascia, brachytherpists can increase the distance between the rectum and the radioactive sources to significantly decrease the rectal dose. This review summarizes the progress in this area and its applicability for use in combination with permanent LDR brachytherapy.

The clinical and economic implications of specimen provenance complications in diagnostic prostate biopsies

PURPOSE

Inaccurate diagnoses of prostate cancer can result from transposition or contamination of patient biopsy specimens, which are known as specimen provenance complications. We assessed the clinical and economic burden of specimen provenance complications in prostate biopsies in the United States.

MATERIALS AND METHODS

We performed a comprehensive, systematic review of the literature to approximate the effect of specimen provenance complications on direct medical costs, patient QALYs and medicolegal costs. Data were extracted from published studies on specimen provenance complications rates, prostate cancer treatment efficacy, treatment cost, litigation/settlement costs after false diagnoses of prostate biopsies and patient quality of life. Sensitivity analysis was done to identify factors that most influenced the outcomes and assess the robustness of the findings.

RESULTS

Of the estimated 806,251 primary and secondary prostate biopsies performed annually in the United States 20,322 specimen provenance complications were projected to result in 4,570 clinically meaningful false diagnoses and an expected loss of 634 QALYs. The total burden of specimen provenance complications was projected to exceed $879.9 million or $3,776 per positive cancer diagnosis. This estimate was most sensitive to the indemnity cost per false-positive case and the rate of transpositions at independent reference laboratories.

CONCLUSIONS

The societal burden of specimen provenance complications in patients who undergo prostate biopsy exceeds $880 million annually in the United States. This analysis framework may be useful as policy makers, health organizations and researchers seek to decrease false diagnoses of prostate cancer and the consequent effects of delayed or unnecessary treatment. Further study is warranted to quantify the economic burden among additional diseases.

CCL2 promotes integrin-mediated adhesion of prostate cancer cells in vitro

PURPOSE

Chemokines undergo alterations during neoplasia. However, knowledge about their functional significance in prostate cancer (PCa) progression is still sparse. Since chemokine (C-C motif) ligand 2 (CCL2) is significantly up-regulated in patients with PCa, aim of the current study was to assess whether CCL2 contributes to invasive behavior of prostate cancer cells in vitro.

METHODS

The human PCa cell line PC3 was stimulated with CCL2. Cell growth was investigated by MTT dye reduction assay. Cell adhesion was analyzed by measuring attachment to a human endothelial cell (HUVEC) monolayer and immobilized collagen. Cell migration was assessed by a chemotactic assay. Integrin expression on the cell surface was evaluated by Western blot. Blocking studies were performed with anti-integrin α3, anti-integrin α6 and anti-integrin β4 monoclonal antibodies.

RESULTS

PC3 cell growth 72 h after CCL2 exposure was significantly increased, compared to controls. Activation of tumor cells by CCL2 significantly enhanced tumor cell adhesion to HUVEC and immobilized collagen. CCL2, added for 4 or 24 h, elevated α6 and β4 (4 > 24 h) integrin expression. α3 was enhanced after 4 h, but reduced after 24 h. Blocking either α3, α6 or β4 led to significant suppression of tumor cell binding to immobilized collagen.

CONCLUSIONS

CCL2 stimulates PCa cell adhesion and induces alterations in α3-, α6- and β4-integrin expression on the cell surface. Blocking these integrins leads to a significant reduction in cell adhesion.