Expensive new cancer therapies and technologies are alluring for both physicians and their patients. Prostate cancer, because of the sheer volume of cases and the variability of treatment options, serves as a dynamic disease model in the ongoing debate over how to curb spending and maintain high-quality care.  Two recently published studies looked at the cost implications of rapid adoption of new technologies and how costs of prostate cancer care vary with initial treatment choice. The ASCO Post spoke with the studies' lead authors, Paul L Nguyen, MD, Assistant Professor, Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, and Claire F. Snyder, PhD, MHS, Associate Professor of Medicine, Johns Hopkins School of Medicine.

In with the New, Out with the Old

Dr. Nguyen and fellow researchers examined usage patterns of radiation therapies and surgical procedures in prostate cancer.¹ "Our study was looking to quantify increased utilization of more expensive therapies in prostate cancer, because it is sort of a litmus test for what's going on in the broader health-care discussion," said Dr. Nguyen.

"In radiation therapy, we compared utilization of intensity-modulated radiation therapy (IMRT) vs the less costly three-dimensional conformal radiation therapy (3D-CRT). In surgery we compared robotic and laparoscopic minimally invasive radical prostatectomy with open surgery," explained Dr. Nguyen.

The researchers used SEER-Medicare linked data from 45,636 men aged 65 years or older who were diagnosed with localized prostate cancer from 2002 to 2005 and received definitive surgery or radiation therapy. They determined the costs attributable to prostate cancer by the difference in Medicare payments in the year after vs the year before diagnosis. "We wanted to discover what the cost implications over time were when using more expensive therapies over less costly options," said Dr. Nguyen.

Costs of Rapid Adoption

Dr. Nguyen said that in the surgery cohort they found minimally invasive radical prostatectomy use increased from 1.5% of all diagnoses in 2002 to 28.7% in 2005; in radiotherapy, IMRT use increased from 28.7% in 2002 to 81.7% in 2005. For men receiving brachytherapy, supplemental IMRT also increased significantly, from 8.5% to 31.1%.  During the 2002 to 2005 study period, the cost of IMRT was nearly $11,000 greater per case than that of traditional 3D conformal radiation therapy.

"So we found a substantial increase in the use of these expensive new technologies, and the upward use trend for both therapies was happening before there were any data to show that either was cost-effective, or that the results of minimally invasive surgery were better than the results of open surgery," said Dr. Nguyen.

The study showed that the transition from traditional surgery and radiotherapy to the newer, more expensive approaches resulted in an additional $350 million in expenditures among prostate patients in 2005 alone. Dr. Nguyen pointed out that there have been no randomized clinical trials comparing IMRT and minimally invasive radical prostatectomy with the more traditional approaches of 3D-CRT and open radical prostatectomy.

With regard to benefits of newer technologies, Dr. Nguyen said, "Retrospective studies seem to consistently suggest that IMRT is associated with a significant reduction in long-term rectal toxicity, compared with 3D-CRT, whereas the surgical data comparing the side effects of minimally invasive vs open prostatectomy have been mixed." But he noted that most of the benefits of the more costly therapies were marginal, and the larger question remains: Are the benefits enough to justify the higher costs to our health-care system?

Widespread Use before Data

Dr. Nguyen said, "Based on a 2006 study, IMRT now seems to be a cost-effective approach in prostate cancer. The data show an incremental cost-effectiveness of about $40,000 for a quality-adjusted life year, which falls into the generally accepted range of benefit over cost."

However, Dr. Nguyen stressed that by 2006, when the study was done, almost 90% of prostate cancer patients were already receiving IMRT. "So, as a field, we tend to embrace these new options before there are data to prove their cost-effectiveness. And to preserve our finite medical resources, it is important for us to be able to separate out effective treatments from those that are less effective," said Dr. Nguyen.

According to Dr. Nguyen, it may not be practical to determine the efficacy and cost-effectiveness of all new technologies and therapies by conducting long and costly head-to-head randomized clinical trials, which could result in delaying the deployment of valuable cancer fighting tools. "The most practical way to tackle this issue is probably through large national registries that capture the clinical data from cancer patients undergoing treatments. That way we can learn something from each patient who receives a more expensive therapy. And with that rich body of clinical evidence, we can then better determine which technologies and treatments are cost-effective," said Dr. Nguyen.

Cost Varies with Initial Treatment Choice

A recent study found that initial treatment choice has a strong influence on short- and long-term costs for prostate cancer.² Investigators from the Johns Hopkins School of Medicine and Bloomberg School of Public Health reviewed SEER-Medicare data for 13,769 men, aged 66 years or older, diagnosed in 2000 with early-stage prostate cancer, and followed them for 5 years.

Led by Dr. Snyder,the researchers divided the men into groups based on the treatment they received during the first 9 months after diagnosis: watchful waiting, radiation only, hormonal therapy only, hormonal therapy plus radiation, and surgery. Costs were divided into initial (from 1 month prior to diagnosis through the first 12 months postdiagnosis), long-term (each consecutive 12 months), and total (full 61 months) expenses. "The incremental costs of prostate cancer care were calculated as the difference in medical costs for prostate cancer patients against similar men without cancer," Dr. Snyder toldThe ASCO Post.

Dr. Snyder explained that although costs tended to be highest in the initial year of treatment, they dropped substantially and remained fairly constant for ensuing years of treatment. Watchful waiting had the lowest initial costs of $4,270, with 5-year costs at $9,130. "Initial costs were the highest ($17,474) for men receiving hormonal therapy plus radiation. Hormonal therapy had the second lowest initial costs but the highest total costs ($26,896), telling us that certain treatments may be less expensive for the short term, but may have higher long-term costs," said Dr. Snyder.

Dr. Snyder cautioned that this study focused only on cost and that quality of life and other outcomes need to be considered along with cost when evaluating treatment options. "However, these results give us a picture of the patterns of costs for the different treatment options for prostate cancer-information that may be useful to patients, providers, and policymakers," concluded Dr. Snyder.

Conclusions

The studies led by Drs. Nguyen and Snyder, although looking at different aspects of rising cancer costs, make a strong case that comparative-effectiveness research is needed, not only to assess efficacy, but also to assess cost. Quality retrospective studies give us important data that help shape policy decisions. However, as Dr. Nguyen pointed out, large well-constructed national data banks will ultimately provide the robust clinical outcomes data needed to determine the cost-effectiveness of new therapies as they are introduced into the market. ■

Disclosures: Drs. Nguyen and Snyder reported no potential conflicts of interest.

References

1. Nguyen PL, Gu X, Lipsitz SR, et al: Cost implications of the rapid adoption of newer technologies for treating prostate cancer. J Clin Oncol 29:1517-1524, 2011.

2. Snyder CF, Frick KD, Blackford AL, et al: How does initial treatment choice affect short-term and long-term costs for clinically localized prostate cancer? Cancer 116:5391-5399, 2010.