Advanced Prostate Cancer Care and Financial Toxicity

Nearly 270,000 new cases of prostate cancer are diagnosed annually, and some patients present with de-novo metastatic prostate cancer at the time of diagnosis.¹ Prostate cancer is estimated to be the second leading cause of cancer-related death worldwide, with approximately 360,000 deaths per year.² Mortality rates tend to be highest in patients of African descent and are elevated in Sub-Saharan Africa as well as African regions such as Zambia and the Caribbean.² Some authors have noted an accelerated metastatic prostate cancer diagnosis rate of 2.74% per year since the US Preventive Services Task Force recommendation changes in 2012.³

A new diagnosis of metastatic prostate cancer can often have a significant financial impact, or financial toxicity, on patients and their family members. This review highlights the existing research regarding the financial toxicity of advanced prostate cancer.

Costs continue to rise for oncologic care in the United States for a variety of reasons, including the growing cost of chemotherapy regimens and the increasing number of cost-sharing programs used by many US insurance companies.⁴ Financial burden is compounded by the fact that many patients with urologic malignancies are often diagnosed later in life when they are nearing retirement.⁴ The current theory is that financial stress may result in negative oncologic outcomes. Studies have shown that patients undergoing financial stress experience higher rates of malignancy relapse or even death due to an inability to or decreased chance of being able to adhere to treatment protocols.⁴

Well-studied risk factors for financial toxicity among all cancer types include younger patient age (less savings), lower baseline income, and use of adjuvant therapies.⁴ Many of the expenses born by patients are related to “direct” costs they are billed for (eg, medication costs, copayments for insurance, payments for coinsurance, and diagnostic imaging costs).⁴ Other expenses that may contribute to a patient’s financial toxicity most considered by clinicians include the cost of parking, the cost to travel to the site of care, and the cost differentials that may occur between what the insurer will cover and what the patient owes.⁴ Unfortunately, some authors have found that close to 50% of patients (42.4%) may deplete all assets within 2 years of a cancer diagnosis.⁵

Commonly used therapies for metastatic prostate cancer have the potential to be very costly for patients. Androgen deprivation therapy is one of the primary mechanisms clinicians utilize to delay the progression of metastatic prostate cancer. Clinicians can utilize a luteinizing hormone-releasing hormone (LHRH) agonist or antagonist as first-line therapy and, in some settings, may opt for surgical bilateral orchiectomy.⁶ A commonly used LHRH agonist such as Lupron Depot (leuprolide acetate) can cost up to $5,866 for a 3-month injection.⁷ In a news article published by National Public Radio, Paul Hinds, a patient, spoke about his personal experience with the incredible cost of managing  metastatic prostate cancer. He was charged $73,812 for a combination of two 3-month Lupron Depot injections. The cost was ultimately negotiated down to $27,568 by the UnitedHealthcare insurance company, but Mr. Hinds was still responsible for nearly $7000 in out-of-pocket costs.⁷ Other medications used in the hormone-sensitive setting can be similarly expensive, including Firmagon (deguelin), which ranges from $586.14 to $914.51 per monthly dose.⁸

Medications such as abiraterone acetate plus prednisone (AAP), enzalutamide, and apalutamide are also concerningly expensive. Abiraterone acetate is commonly administered at 1000 mg/day and has an average wholesale price of $217.74 per pill, resulting in a per-day cost of treatment of at least $434 if the patient does not have preferential drug pricing through an insurance company.⁹ Fortunately for patients, generic versions of AAP have been released as patents have expired, including a 250 mg version of abiraterone acetate, which was released at the end of 2018 by Janssen Pharmaceuticals at a significantly reduced cost.

A similar story can be seen with enzalutamide, which is administered in this setting at 160 mg/day; however, each 80 mg tablet can cost the patient up to $273 per day, or more than $14,000 for a 60-tablet supply.¹⁰ To help patients afford such costly therapeutic options, many drug companies such as Xtandi’s Pfizer/Astellas have created patient assistance programs that can reduce costs.¹¹

Patients who progress to metastatic castration-resistant prostate cancer (mCRPC) often have to deal with high costs of therapy beyond the hormone-sensitive setting. Therapeutic options for mCRPC include chemotherapy, radiation, and adjunctive medications such as bisphosphonates or immunotherapies, which can be extremely expensive. For example, Provenge (sipuleucel-T), an immunotherapy often used for asymptomatic to minimally symptomatic mCRPC, can cost nearly $105,000 per year.⁶ Patients with more advanced disease may require palliative radiation treatments, which can cost up to $7000 per treatment episode.⁶

Patients and families can employ a variety of strategies to manage the financial toxicity of metastatic prostate cancer. Clinicians should encourage patients to discuss their financial concerns during the treatment process and consider the costs of all options. Clinicians should also be aware of payment assistance programs that can help offset the direct costs that patients and their families might experience. Finally, patients with metastatic prostate cancer may be eligible for participation in new clinical trials that may facilitate access to cutting-edge oncologic care and therapies available for free or at nominal cost to the patient.

Akhil Abraham Saji, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include urology education and machine learning applications in urologic care. He is a founding and current member of the EMPIRE Urology New York AUA section team.

 

References:

1. Cancer Stat Facts: Prostate Cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Accessed March 26, 2023. https://seer.cancer.gov/statfacts/html/prost.html
2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. doi:10.3322/caac.21492
3. Kelly SP, Anderson WF, Rosenberg PS, Cook MB. Past, current, and future incidence rates and burden of metastatic prostate cancer in the United States. Eur Urol Focus. 2018;4(1):121-127. doi:10.1016/j.euf.2017.10.014
4. Imber BS, Varghese M, Ehdaie B, Gorovets D. Financial toxicity associated with treatment of localized prostate cancer. Nat Rev Urol. 2020;17(1):28-40. doi:10.1038/s41585-019-0258-3
5. Gilligan AM, Alberts DS, Roe DJ, Skrepnek GH. Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer. Am J Med. 2018;131(10):1187-1199.e5. doi:10.1016/j.amjmed.2018.05.020
6. Norum J, Nieder C. Treatments for metastatic prostate cancer (mPC): a review of costing evidence. Pharmacoeconomics. 2017;35(12):1223-1236. doi:10.1007/s40273-017-0555-8
7. Allen A. It cost $38,398 for a single shot of a very old cancer drug. NPR. October 26, 2022. Accessed March 26, 2023. https://www.npr.org/sections/health-shots/2022/10/26/1131130875/it-cost-38-398-for-a-single-shot-of-a-very-old-cancer-drug
8. Firmagon prices, coupons and patient assistance programs. Drugs.com. Accessed March 26, 2023. https://www.drugs.com/price-guide/firmagon
9. Abiraterone prices, coupons and patient assistance programs. Drugs.com. Accessed March 26, 2023. https://www.drugs.com/price-guide/abiraterone
10. Xtandi prices, coupons and patient assistance programs. Drugs.com. Accessed March 26, 2023. https://www.drugs.com/price-guide/xtandi
11. Helping eligible patients find ways to pay for XTANDI. Xtandi® (enzalutamide). Accessed March 26, 2023. https://www.xtandi.com/financial-support