The cost of prostate Ca care: What counts for AS?

Author(s):

"AS is very cost effective over the short term compared to prostatectomy and radiation, but there a number of factors may impact actual AS cost savings over the long term," writes Leonard G. Gomella, MD.

Health care costs are a concern. When considering the expense of prostate cancer care, this disease often takes center stage. While advanced prostate cancer care costs are significant, early low-risk prostate cancer is a common target for cost savings, as many men may not require aggressive treatment and can be spared the inconvenience and expense of side effects.

At this year’s Genitourinary Cancers Symposium, Gaylis and fellow urologists from a group in San Diego conducted a 3-year analysis of the cost of active surveillance (AS) versus active treatment (surgery or radiation) for low-risk prostate cancer. Their findings support that AS is a beneficial management strategy for low-risk prostate cancer from a cost perspective supporting consideration as a value-based care model by Medicare.

On the surface, this study validates previous modeling studies in support of substantial AS cost savings compared to active treatment. However, the data also illustrate the challenges of practice-specific cost analysis.

The follow-up is only 3 years and in a limited number of men (195), with approximately half undergoing AS and the rest receiving treatment, suggesting many men who received treatment were younger (not Medicare age). The average number of biopsy sessions was two per AS patient, and only six men had at least one MRI. Four men who had genomic testing drove up the cost of AS about $5,000 per patient.

While no uniform standards exist for AS, groups such as the National Comprehensive Cancer Network suggest repeat biopsy should be considered annually and that MRI and genomic assays have a role (and an expense). There is also concern that African-American men may not fare well on AS.

AS cost savings are dependent on patient age; in younger men, the savings may end at 7 years. AS uncertainties that impact cost include future surgery or radiation and biopsy-related complications. Thirty to 50% of men on AS will undergo treatment, and this is not seen in this analysis.

This presentation supports AS cost savings at 3 years. However, the study authors’ approach to AS in low-risk prostate cancer may not be representative of guidelines or other practice patterns. AS is very cost effective over the short term compared to prostatectomy and radiation, but there are a number of factors that may impact actual AS cost savings over the long term.