Ten-Year Cost of Active Surveillance Akin to Prostatectomy

Nick Mulcahy

July 24, 2012

July 24, 2012 — The cost of providing active surveillance for 10 years to a man with prostate cancer is about the same as the cost of initially performing surgery, according to an economic analysis published in the July 15 issue of Cancer.

The researchers estimated that 10 years of active surveillance costs $28,784 and that an initial radical prostatectomy — and the related 10 years of office follow-up — costs $31,612.

However, some other treatments for prostate cancer are much more expensive than these 2 options. The most expensive treatments include initial image-guided radiation therapy with short-term androgen-deprivation therapy (ADT), which costs $61,131 at 10 years, and long-term ADT, which costs $84,055 at 10 years.

Active surveillance could provide "considerable cost savings," compared with initial treatments, conclude the researchers, led by Kirk Keegan, MD, from the Department of Urologic Surgery at Vanderbilt University in Nashville, Tennessee.

How considerable? Dr. Keegan and his coauthors project that if just half of 1 year's new cases of prostate cancer were followed with active surveillance, the cost savings at 5 years would be $1.9 billion.

In other words, if 120,000 patients (50% of the estimated 240,000 new cases annually in the United States) were placed on active surveillance, in 5 years, the savings to the healthcare system — from just that single cohort of men — would be nearly $2 billion. This estimation assumes that 30% of the cohort would switch to active treatment within the first 5 years.

There are many caveats and disclaimers associated with this analysis, the researchers acknowledge.

The biggest is probably the fact that the cost projections for active surveillance are based on prostate biopsy every other year after the second year. In other words, biopsies are not taken annually, which is the frequency practiced at "some" institutions, the authors say.

"A yearly biopsy regimen results in significantly elevated healthcare costs," they write.

The economic analysis addresses 2 very different and powerful concerns. On the one hand, it provides a provocative blueprint for cost savings for an expensive healthcare item in the United States. On the other hand, it provides some financial incentive for urologists who perform radical prostatectomy to mix up their case management.

Recently, a group of prominent urologists suggested that the poor uptake of active surveillance among clinicians is partly financial. "Active surveillance is labor intensive and reimbursed relatively poorly," Peter Carroll, MD, from the University of California, San Francisco, and colleagues noted in their essay published last year (J Clin Oncol. 2011;29:3669-3676).

However, Dr. Keegan and colleagues suggest that, over the long run, reimbursement becomes more rewarding with active surveillance — for urologists. The same is not true for medical oncologists who dispense long-term ADT or for radiation oncologists who perform image-guided radiation therapy. Even at 10 years, the cumulative reimbursement for active surveillance cannot catch up with the costs associated with these relatively expensive initial treatments and subsequent office visits.

Dr. Keegan's team is the first to look at costs at 5- and 10-year intervals for the whole gamut of prostate cancer treatments. A previous study found that at 15 years, active surveillance provided at least a 43% cost reduction, compared with initial prostatectomy (Urology. 2010;76:703-707); however, it did not look at all the treatment options for prostate cancer.

Protocol and Assumptions About Cost

The current active surveillance protocol at the University of California, Davis was the basis of the active surveillance cost estimates.

The protocol consists of an initial office consultation, 2 prostate biopsies within the first 3 months (diagnostic and confirmatory), pathology costs, professional and technical fees, prostate-specific antigen (PSA) values, and office visits every 3 months for 2 years and every 6 months thereafter. As noted above, repeat prostate biopsy was performed after the second year of follow-up and every other year thereafter.

Individual Costs for Active Surveillance

Procedure Cost ($)
Prostate biopsy 1102
Pathology costs 660
Professional/technical fees 635
Office consultation 428
Office visit 118
PSA measurement 52
Urologist reimbursement for biopsy 433

For the economic analysis, the researchers assumed that 7.0% of the 120,000 men on active surveillance will exit observation and receive treatment (years 1 to 5), and that 4.5% will do so later on (years 6 to 10). In total, 30% and 45% will exit by years 5 and 10, respectively, which is in keeping with clinical studies.

In the analysis, the men exiting active surveillance were distributed between different forms of common treatment for localized prostate cancer, including (listed with associated probability) radical prostatectomy (0.4), image-guided radiation therapy with or without ADT (0.25 and 0.1, respectively), prostate brachytherapy (0.15), and ADT monotherapy (0.1).

Importantly, the economic analysis excluded costs associated with the management of treatment-related complications. These costs would have made active surveillance even more attractive, the authors suggest.

"As more complications are associated with radical therapy over surveillance, incorporating these costs into the model would likely only serve to widen the costs savings of an active surveillance paradigm," they write.

Cancer. 2012;118: 3512-3518. Abstract


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