Costs of Treating Low-Risk Prostate Cancer Analyzed

Fran Lowry

November 05, 2015

Researchers at a large tertiary care center have discovered what it really costs to treat low-risk prostate cancer at their institution. Their results were published online November 2 in Cancer.

Estimates of the cost of treating prostate cancer vary widely. For example, costs of a radical prostatectomy can range from a low of $10,000 to over $135,000, Aaron Laviana, MD, from the University of California, Los Angeles (UCLA), told Medscape Medical News.

That huge discrepancy prompted Dr Laviana and his colleagues to sit down and figure out the cost across the entire care process, from the time a patient checks in for his first appointment to his posttreatment follow-up testing.

They started with detailing the costs associated with treating localized, low-risk prostate cancer.

Dr Aaron Laviana

"All the cost studies that have been done have been arbitrary," he said in an interview. "There is no exact measurement. Some studies are based on hospital charges, others on reimbursement, but when you get down to the nitty gritty of what these costs include, you find out that oftentimes, they don't include anesthesia costs, or surgeon costs, or nursing costs. It's a bundled, arbitrary payment," he said.

"We need to break down each individual cost and see how these all play a role. Often, a patient will get a medical bill, and it just says, 'hospital.' Even when people ask for an itemized bill, it can still be very murky and arbitrary. You hear stories about someone getting several stiches that cost thousands of dollars, and wonder why. This study sheds light on how all the costs are being formulated," Dr Laviana said.

The UCLA team used a technique called time-driven activity-based costing, which is used to detail costs for doing business in industry, for each phase of care from the initial urologic visit through 12 years of follow-up.

Treatments included robot-assisted laparoscopic prostatectomy (RALP), cryotherapy, high-dose-rate (HDR) and low-dose-rate (LDR) brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and active surveillance (AS), which included both traditional transrectal ultrasound (TRUS) biopsy and multiparametric-MRI/TRUS fusion biopsy.

No Cost Left Unanalyzed

"We broke down each of the individual processes for every treatment modality, starting from when the patient was first seen at the clinic, checked in by a clerk, in the waiting room, going to the examining room, noting the amount of time each physician took with each patient, how much time the nurse takes, what their salaries were. We wrote down every single step as the cost per minute," Dr Laviana said.

"We also analyzed the cost per minute of space, the cost of rent, we took the blueprint and calculated the square footage and how much each proportion of a urology clinic went towards the overall rent. We tried to make it as precise as possible."

The analysis showed a substantial cost variation at 5 years, ranging from $7298 for AS to $23,565 for IMRT.

The cost variations remained throughout the 12 years of follow-up.

LDR brachytherapy, at $8978, was notably less expensive than HDR brachytherapy, at $11,448.

Stereotactic body radiation therapy, at $11,665, was notably less expensive than IMRT, with the cost savings attributable to shorter procedure times and fewer visits required for treatment.

Both equipment costs and an inpatient stay, at $2306, contributed to the high cost of RALP, at $16,946.

Cryotherapy ($11,215) was more costly than LDR brachytherapy, largely because of increased single-use equipment costs ($6292 vs $1921).

AS reached cost equivalence with LDR brachytherapy after 7 years of follow-up.

"The relatively low cost of active surveillance, which uses repeated PSA testing and prostate biopsies to monitor for development of more aggressive disease in younger, healthier patients who might benefit from delaying treatment, was the biggest surprise uncovered by our analysis," Dr Laviana noted.

"These costs apply only to those at UCLA. They will be different for each hospital, based on how much their rent is, how much their staff is paid, and other factors," he added.

The next step is to analyze costs for treating high-risk prostate cancer and metastatic prostate cancer, Dr Laviana said.

"Few people have a good sense of what our costs are. There is so much waste in the operating room. We are using equipment, but no one has a solid sense of what the costs are. We're just ordering labs and ordering tests, but there is a huge disconnect there. But we should have a better sense of what we are ordering, how much it matters, and how much it costs, rather than just saying, okay, get this," he said.

The researchers now plan to link their cost analyses to outcomes.

"We may think it is cheaper to withhold some treatment and opt to do others based on cost, but we also need to make sure there are no differences in health outcomes when we do this," he said.

Dr Laviana has reported no relevant financial relationships.

Cancer. Published online November 2, 2015. Abstract

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