Active surveillance for prostate cancer results in cost savings

Key Points

Washington-According to one well-refined simulation model, the cost in current dollars of treating 100 prostate cancer patients initially enlisted in an active surveillance program is $2,702,191 over 5 years. This is $1,013,422 less expensive per 100 men than any of the available immediate interventional therapies over the same span and could translate to substantial national savings, according to a joint study from Vanderbilt University, Nashville, TN, and the University of California, Davis.

"Health care dollars are becoming an increasingly limited resource, and what we choose to spend for one treatment limits our abilities to spend for others. Our data demonstrate considerable costs savings for those men enrolled in an active surveillance paradigm, even accounting for those men that leave active surveillance and undergo delayed treatment," Kirk Keegan, MD, the study's first author, told Urology Times.

Dr. Keegan and his co-authors arrived at these findings after analyzing the costs of a variety of prostate cancer treatments and outcomes into a complex Markov model. Their simulation accounts for a calculated number of patients moving from surveillance to interventional therapy during the 5-year run of the model. According to the literature, between 3% and 9% of surveillance patients will move to active therapy in each of the 5 years of surveillance.

Option less costly than surgery, radiation

According to the study, the initial costs of active surveillance were $9,561 per patient. These costs rose to $22,047 at 5 years. By comparison, the cumulative per-patient costs of brachytherapy (initial treatment plus 5 years of follow-up) were $25,780. The cumulative costs of surgery were $31,925; of androgen deprivation therapy, $49,118; of external beam radiation therapy, $57,744; and of external beam radiation plus androgen deprivation, $61,444.

Dr. Keegan, who presented the findings at the AUA annual meeting in Washington, noted that a variety of active surveillance paradigms are being employed nationally. For this simulation, the team applied the regimen used at UC Davis. The surveillance costs included an initial office consultation, two biopsies within the first 3 months of diagnosis, PSA readings and office follow-ups every 3 months for 2 years, and then 6 months for the continuing surveillance regimen. A biopsy is also taken at year 3 and repeated every 2 years thereafter.

"If a patient is referred with an elevated PSA or prostate nodule, he is counseled on the risks and benefits of a prostate biopsy. If the biopsy demonstrates low-volume, low-risk prostate cancer, we proceed with a discussion of all the treatment options, to include active surveillance. If a man elects active surveillance, we will recommend a confirmatory biopsy, typically 6 weeks after the initial biopsy. This confirmatory biopsy allows us to verify that patients do indeed have a small-volume, low-risk cancer, as about 25% of men may be upgraded to higher-volume or more aggressive cancer on repeat biopsy. Some institutions will wait 6 months to a year for a confirmatory biopsy, but we like to give patients the opportunity to breathe a sigh of relief and know that they are truly candidates for surveillance, if they want to choose that route," Dr. Keegan explained to Urology Times.

"Unfortunately, active surveillance is underutilized. About one in six men will be diagnosed with prostate cancer, but only about 10% to 15% of those men will die from their cancer. This means that we overtreat a lot of men, and we overtreat men who do not have aggressive disease."

Dr. Keegan pointed out that it's not known whether such treatment patterns are doctor- or patient-driven, although he said he suspects it's a combination of both.

"An advantage of active surveillance is that it may reduce the risk of overtreatment while preserving the option for definitive treatment. This may effectively tailor treatment to the biologic behavior of an individual's specific prostate cancer," he said.

In closing, Dr. Keegan noted that active surveillance, while costing less overall, actually generated more income over time for urologists and their clinics, owing to the costs of repeated office visits and biopsies. He added that this finding has been published by authors at the University of Miami (Urol Oncol online, May 24, 2011), but was confirmed in the study presented at the AUA meeting.