The cost value of medical versus surgical hormonal therapy for metastatic prostate cancer

Long-term health care costs for prostate cancer patients on androgen deprivation therapy

BACKGROUND

Comparing relative costs for androgen deprivation therapy (adt) protocols in prostate cancer (pca) requires an examination of all health care resources, not only those specific to pca. The objective of the present study was to use administrative data to estimate total health care costs in a population-based cohort of pca patients.

METHODS

Patients in Ontario with pca who started 90 days or more of adt at age 66 years or older during 1995-2005 were selected from cancer registry and health care administrative databases. We classified patients (n = 21,818) by regimen (medical castration, orchiectomy, anti-androgen monotherapy, medical castration with anti-androgen, orchiectomy with anti-androgen) and indication (neoadjuvant, adjuvant, metastatic disease, biochemical recurrence, primary nonmetastatic). Using nonparametric regression methods, with inverse probability weighting to adjust for censoring, and bootstrapping, we computed mean 1-year, 5-year, and 10-year longitudinal total direct medical costs (2009 Canadian dollars).

RESULTS

Mean first-year costs were highest for metastatic disease, ranging from $24,400 for orchiectomy to $32,120 for anti-androgen monotherapy. Mean first-year costs for all other indications were less than $20,000. Mean 5-year and 10-year costs were lowest for neoadjuvant treatment: approximately $43,000 and $81,000 respectively, with differences of less than $4,000 between regimens. Annual costs were highest in the first year of adt. Orchiectomy was the least costly regimen for most time periods, but was limited to primary and metastatic indications. Outpatient drugs, including pharmacologic adt, accounted for 17%-65% of total first-year costs.

CONCLUSIONS

Compared with combined therapies, the adt monotherapies, particularly orchiectomy when clinically feasible, are more economical. Our methods exemplified the use of algorithms to elucidate clinical information from administrative data. Our approach can be adapted for other cancers to expand the range of studies using Canadian administrative data.

Efficacy and safety of gonadotropin-releasing hormone agonists used in the treatment of prostate cancer

Androgen deprivation therapy (ADT) is the most effective systemic treatment for prostate cancer. ADT has been shown to have a high rate of response and to improve overall survival in patients with metastatic prostate cancer. In addition, multiple studies have shown that adding ADT to external beam radiation therapy leads to improvement in cure rates and overall survival in prostate cancer patients. The most commonly used ADT is gonadotropin-releasing hormone (GnRH) agonist therapy. Although GnRH agonist therapy has significant benefits for patients with prostate cancer, it has also been shown to have significant side effects, including fatigue, hot flashes, decreased libido, decreased quality of life, obesity, diabetes mellitus, coronary artery disease, decreased bone mineral density, and increased risk of fractures. Therefore, it is crucial that the benefits of ADT be weighed against its potential adverse effects before its use.

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.

Prospective randomised controlled trial comparing sub-epididymal orchiectomy versus conventional orchiectomy in metastatic carcinoma of prostate

Androgen blockade (surgical or medical castration) is a standard procedure for patients with metastatic carcinoma prostate. Sub-epididymal orchiectomy involves removal of testis leaving behind epididymis. This epididymal stump over a period gives a pseudo testicular feel within the scrotum. We present a prospective randomized study to assess the functional utility of this procedure and compare it with total orchiectomy in terms of achieving castrate levels. From July 2005-Jan 2008, 60 patients with metastatic carcinoma prostate were alternately randomised and allotted to two groups, 30 underwent sub-epididymal orchiectomy (group A) and remaining 30 (group B) underwent total orchiectomy. Age: 56-80 years. Serum PSA: 55-268 ng/ml. Preoperative serum testosterone: Group A-300-650 ng/ml and group B-320-640 ng/ml. Postoperative serum testosterone: group A-2-18 ng\ml and group B-7-15 ng\ml on day 7 after surgery. Operating time-26-40 mins for group A and 20-34 mins for group B. Follow up-6 weeks and 3 months. At 3 months patients were asked to grade appearance of scrotum for asthetic value on a scale of 1-100 using visual analogue score. Postoperative serum testosterone reached castrate levels in seven days (both groups). Duration of surgery in both groups was comparable. Complications-wound infection in 1 patient (group A) & 1 scrotal hematoma (group B). Satisfaction score for group A (83.5 ± 9.7) was significantly (p < 0.05) better (95%CI-18.58-28.42), compared to that of group B (60 ± 9.4) by using't' test. Sub epididymal orchiectomy is comparable to total orchiectomy in terms of achieving castrate levels with similar operating time. It has significant advantage in terms of mental satisfaction to patients. It is a simple and safe procedure that can be conveniently performed in an outpatient clinic setting using pure local anaesthesia.

An update on androgen deprivation therapy for prostate cancer

Androgen deprivation therapy (ADT) with gonadal testosterone depletion is the frontline treatment for advanced prostate cancer. Other hormonal interventions have a role in the treatment of prostate cancer. We sought to examine systematically the evidence for hormonal interventions in prostate cancer, risks of ADT, and interventions that mitigate these risks. Search results for therapeutic studies were focused primarily on randomized controlled clinical trials, and the Jadad scale criteria were used to evaluate the quality of these studies. Four trials of the efficacy of intermittent ADT versus continuous ADT were included. One randomized study analysis and six postrandomization analyses were included on the effects of ADT on cardiovascular mortality. Seven randomized controlled trials of pharmacologic interventions were included for the treatment of metabolic effects due to ADT. One randomized trial of GnRH antagonist versus GnRH agonist was included. Six phase I/II clinical trials of secondary hormonal therapies with novel mechanisms of action were included. Randomized studies completed to date indicate that intermittent ADT might be equivalent to continuous ADT. Although adverse effects of ADT include risk factors for cardiovascular disease, effects on cardiovascular mortality are uncertain. Bone loss and increased risk of fracture may be effectively treated with pharmacologic interventions. Benefits of ADT must be balanced with a consideration of the risks.

Medical care cost of patients with prostate cancer

OBJECTIVE

To analyze variations in direct medical care cost of patients with prostate across two racial groups after controlling for age, disease stage, and comorbidity.

METHODS

In this retrospective cohort control study, we randomly selected 120 newly diagnosed prostate cancer patients (60 African Americans and 60 White) from the administrative database of a large urban academic hospital. Medical care costs data and clinical data were obtained. The control group consisted of 240 men without cancer, and matched by age and race. Demographics, clinical variables and treatment patterns were compared across race using t-test and chi2. Mean medical care costs for prostate cancer patients were compared by race, using bootstrap and log t-test. Regression models were used to estimate the incremental cost of prostate cancer, and to analyze the association between race and direct medical care cost.

RESULTS

Whites were more likely to receive radical prostatectomy, whereas African Americans were more likely to receive radiation therapy. The incremental cost of prostate cancer was 1.30 times higher than controls. Charlson comorbidity was a significant predictor of type of treatment received and cost. Race was not associated with total direct medical care cost after controlling for age, Charlson comorbidity and stage of cancer at diagnosis.

CONCLUSIONS

Charlson Comorbidity score was a predictor of type of treatment and direct medical care cost. While analyzing the association between race and cost of care, potential bias-inducing factors such as clinical characteristics at diagnosis and provider characteristics (physician and hospital) must be addressed.

The economic consequences of prostate and bladder cancer in the UK

OBJECTIVE

To compare the costs of managing prostate and bladder cancer and relate them to current expenditure on research, as the increasing prevalence of both necessitates the adequate direction of resources.

METHODS

All new prostate and bladder cancers diagnosed in 2001-2002 were identified from British Association of Urological Surgeons Section of Oncology database (national and local). The total cost of diagnosing, treating and following patients for 5 years was estimated as the sum of direct costs (National Health Service) and indirect costs (loss of earnings). Annual research fund allocation (RFA) for each cancer were obtained from the National Cancer Research Institute UK.

RESULTS

There were 15 099 and 7703 patients with newly diagnosed prostate (mean age 72.3 years) and bladder cancers (mean age 71.3 years). The total cost for prostate cancer was estimated at 92.74 million UK pounds, with hormonal therapy alone costing 63.1 million UK pounds. The total cost for bladder cancer was 55.39 million UK pounds, of which superficial disease cost 35.25 million. The mean cost per patient was more for bladder than for prostate cancer (8349 UK pounds vs. 7294). The RFA allocation during this period was 20.56 million UK pounds and 4.62 million UK pounds for prostate and bladder cancer, respectively, and the respective RFA allotment per pound spent on the mean cost of disease management per patient was 2818 UK pounds and 553 UK pounds.

CONCLUSION

Individual patient management is more costly for bladder cancer but less is invested in research than for prostate cancer. This study suggests a need to re-evaluate future strategies.