Akhil Abraham Saji, MD

GU Oncology Now

The National Cancer Institute estimates nearly 270,000 new cases of prostate cancer will be diagnosed in the United States in 2023, and approximately 14% to 15% of patients with prostate cancer will also be diagnosed with advanced-stage disease.<a href="https://seer.cancer.gov/statfacts/html/prost.html" target="_blank" rel="noopener">1</a>,<a href="https://pubmed.ncbi.nlm.nih.gov/29162421/" target="_blank" rel="noopener">2</a>Prostate cancer is the second most common malignancy causing cancer-related death in the United States. It is critical that physicians and health care providers understand the financial costs of prostate cancer care so that they can help patients make educated decisions regarding treatment options.<a href="https://seer.cancer.gov/statfacts/html/prost.html" target="_blank" rel="noopener">1</a> This brief review highlights the main research available on the financial costs related to the treatment of localized prostate cancer&mdash;and the associated outcomes&mdash;in the United States.Radical prostatectomy and radiation therapy continue to be the mainstay options for the treatment of localized prostate cancer. Common modalities for radical prostatectomy include open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and robot-assisted laparoscopic radical prostatectomy (RALP). Based on the American Board of Urology case logs, the vast majority (more than 85%) of prostatectomies in the United States are completed using a robot-assisted approach, but some urologists still utilize ORP and LRP.<a href="https://www.sciencedirect.com/science/article/abs/pii/S1078143916000338" target="_blank" rel="noopener">3</a>A comprehensive meta-analysis by Bolenz et al published in European Urology revealed several interesting findings regarding the different modalities.<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283812010123" target="_blank" rel="noopener">4</a> Overall, costs for ORP were lower&mdash;several studies cited a mean per-patient cost between $5305 and $7476&mdash;and patients treated with ORP incurred relatively low posttreatment outpatient care costs. In comparison, minimally invasive techniques such as LRP had mixed reports. Some authors found that LRP was less expensive than ORP overall due to shorter hospital stays. They realized the importance of considering hospital length of stay when identifying the most cost-effective prostatectomy modality.The Intuitive Da Vinci Robotic platform, which is the most commonly utilized platform in the United States, can cost in excess of 2 million USD, plus the cost of maintenance.<a href="https://www.intuitive.com/en-us/products-and-services/da-vinci" target="_blank" rel="noopener">5</a> Studies that compared robotic platforms with ORP have shown conflicting results. For example, the first analysis of its kind by Mouraviev et al found that ORP tended to have lower mean costs when considering direct surgical costs alone; however, when considering total hospital care costs, including length of stay and pathologic assessment, RALP had a significantly lower cost than ORP.<a href="https://www.sciencedirect.com/science/article/abs/pii/S0090429506024393" target="_blank" rel="noopener">6</a> Similarly, Schroeck et al conducted a meta-analysis demonstrating that in most studies comparing RALP with ORP, RALP was more expensive, but when factors such as higher RALP volume or shorter hospital length of stay and shorter operative time were taken into account, the costs began to even out.<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283817302397" target="_blank" rel="noopener">7</a> Furthermore, when analyzing the studies included from a health system (payer) perspective, the authors found that the improved quality of life and cancer control outcomes achievable with RALP indicate that the cost of RALP may actually be lower than the cost of ORP in the long term.Radiation therapy for prostate cancer has also seen a renaissance over the last 20 years. Radiation oncologists frequently utilize new technologies such as proton beam radiation therapy (PBRT) or intensity-modulated radiotherapy (IMRT) in lieu of conventional radiotherapy techniques. IMRT improves the accuracy of radiation therapy delivery to the target site, decreasing the risk of unnecessary radiation to surrounding organs, which results in lower toxicity.<a href="https://www.redjournal.org/article/S0360-3016(16)00052-3/fulltext" target="_blank" rel="noopener">8</a> PBRT offers similar benefits due to the sheer size of a proton compared with the electrons used in traditional radiation therapy. The protons delivered to the target organ have a very precise delivery range for their radiation dose. The upfront costs related to PBRT are substantial, however. The baseline cost of a cyclotron facility is $150 million USD.<a href="https://www.nature.com/articles/bjc2013100" target="_blank" rel="noopener">9</a>Several studies have compared the costs of traditional conventional radiotherapy with IMRT techniques, with varying results.<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283817302397" target="_blank" rel="noopener">7</a> Most articles have reported an increase in treatment-related costs when utilizing IMRT compared with conventional radiation therapy; however, the studies that reported lower overall costs also had longer follow-up times, suggesting that costs will decline as centers gain more experience with IMRT and improved patient outcomes will result in lower long-term overall costs. In their meta-analysis, Schroeck and colleagues found that when adjusting for quality-adjusted life years (QALY), despite the higher overall costs in most cases of IMRT, the gains in QALYs rendered the IMRT treatment cost-effective in comparison with traditional radiation therapy.Regarding PBRT, most studies in the literature have compared its outcomes with those of IMRT. For example, in a retrospective series, Yu et al analyzed the costs for patients covered by Medicare receiving either IMRT or PBRT.<a href="https://academic.oup.com/jnci/article/105/1/25/877565" target="_blank" rel="noopener">10</a> According to the median Medicare reimbursement data, there was a median increase in cost of $13,853 for PBRT compared with IMRT. Furthermore, the authors reported decreased rates of early genitourinary toxicity compared with IMRT (5.9% vs 9.5%), which is consistent with the mechanism of PBRT; however, the benefits dissipated at 12 months.<a href="https://academic.oup.com/jnci/article/105/1/25/877565" target="_blank" rel="noopener">10</a>An estimated 84% to 85% of patients who are newly diagnosed with prostate cancer will have localized disease. Therefore, the cost of treatment needs to be carefully considered, as health care costs in the United States continue to rise. Retrospective analyses from patients receiving treatment from 2000 to 2010 reveal that the majority of care-related costs are incurred in the initial year of diagnosis and treatment.<a href="https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10365.x" target="_blank" rel="noopener">11</a> In 2009, an estimated $2.5 billion was spent on the initial treatment of prostate cancer alone. Cost estimates range from approximately $13,000 per patient during the first year of treatment and grow steadily to approximately $18,000 per patient during the first 4 years after diagnosis.<a href="https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10365.x" target="_blank" rel="noopener">11</a> A more recent analysis published in JAMA in 2018 provided similar data that revealed an overall cost of $14,453 within the first 3 years of prostate cancer diagnosis.<a href="https://jamanetwork.com/journals/jamaoncology/fullarticle/2701720" target="_blank" rel="noopener">12</a>Studies comparing surgical treatment with radiation showed the cost of surgery to be slightly lower. Patients who underwent surgical therapy incurred costs of $31,666, with most of that cost coming from inpatient hospital care.<a href="https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10365.x" target="_blank" rel="noopener">11</a> Meanwhile, patients undergoing initial radiation therapy incurred costs of $42,554, and more than half of that cost was related to outpatient resource utilization.<a href="https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10365.x" target="_blank" rel="noopener">11</a> The introduction of further minimally invasive prostatectomy techniques that will allow many more patients to be discharged home within 24 hours of surgery is expected to result in lower initial costs of prostatectomy.As the US population continues to age, with an estimated 1.5 billion individuals predicted to be over the age of 65 by 2050, finding cost-effective and efficient treatment modalities that do not sacrifice oncologic and quality-of-life outcomes must be a priority.<a href="https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10365.x" target="_blank" rel="noopener">11</a> Regardless of the treatment modality, when providing medical counseling and going through the decision-making process, clinicians must take into account the health care costs that patients and the health care system will incur.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.&nbsp;References:<ol>
<li>Cancer Stat Facts: Prostate Cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Accessed February 21, 2023. <a href="https://seer.cancer.gov/statfacts/html/prost.html" target="_blank" rel="noopener">https://seer.cancer.gov/statfacts/html/prost.html</a></li>
<li>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:<a href="https://pubmed.ncbi.nlm.nih.gov/29162421/" target="_blank" rel="noopener">10.1016/j.euf.2017.10.014</a></li>
<li>Oberlin DT, Flum AS, Lai JD, Meeks JJ. The effect of minimally invasive prostatectomy on practice patterns of American urologists. Urol Oncol. 2016;34(6):255.e1-255.e5. doi:<a href="https://www.sciencedirect.com/science/article/abs/pii/S1078143916000338" target="_blank" rel="noopener">10.1016/j.urolonc.2016.01.008</a></li>
<li>Bolenz C, Freedland SJ, Hollenbeck BK, et al. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol. 2014;65(2):316-324. doi:<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283812010123" target="_blank" rel="noopener">10.1016/j.eururo.2012.08.059</a></li>
<li>Da Vinci by Intuitive. Intuitive. Accessed February 21, 2023. <a href="https://www.intuitive.com/en-us/products-and-services/da-vinci" target="_blank" rel="noopener">https://www.intuitive.com/en-us/products-and-services/da-vinci</a></li>
<li>Mouraviev V, Nosnik I, Sun L, et al. Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: a single-institution experience. Urology. 2007;69(2):311-314. doi:<a href="https://www.sciencedirect.com/science/article/abs/pii/S0090429506024393" target="_blank" rel="noopener">10.1016/j.urology.2006.10.025</a></li>
<li>Schroeck FR, Jacobs BL, Bhayani SB, Nguyen PL, Penson D, Hu J. Cost of new technologies in prostate cancer treatment: systematic review of costs and cost effectiveness of robotic-assisted laparoscopic prostatectomy, intensity-modulated radiotherapy, and proton beam therapy. Eur Urol. 2017;72(5):712-735. doi:<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283817302397" target="_blank" rel="noopener">10.1016/j.eururo.2017.03.028</a></li>
<li>Wortel RC, Incrocci L, Pos FJ, et al. Late side effects after image guided intensity modulated radiation therapy compared to 3D-conformal radiation therapy for prostate cancer: results from 2 prospective cohorts. Int J Radiat Oncol Biol Phys. 2016;95(2):680-689. doi:<a href="https://www.redjournal.org/article/S0360-3016(16)00052-3/fulltext" target="_blank" rel="noopener">10.1016/j.ijrobp.2016.01.031</a></li>
<li>Efstathiou JA, Gray PJ, Zietman AL. Proton beam therapy and localised prostate cancer: current status and controversies. Br J Cancer. 2013;108(6):1225-1230. doi:<a href="https://www.nature.com/articles/bjc2013100" target="_blank" rel="noopener">10.1038/bjc.2013.100</a></li>
<li>Yu JB, Soulos PR, Herrin J, et al. Proton versus intensity-modulated radiotherapy for prostate cancer: patterns of care and early toxicity. J Natl Cancer Inst. 2013;105(1):25-32. doi:<a href="https://academic.oup.com/jnci/article/105/1/25/877565" target="_blank" rel="noopener">10.1093/jnci/djs463</a></li>
<li>Roehrborn CG, Black LK. The economic burden of prostate cancer. BJU Int. 2011;108(6):806-813. doi:<a href="https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10365.x" target="_blank" rel="noopener">10.1111/j.1464-410X.2011.10365.x</a></li>
<li>Trogdon JG, Falchook AD, Basak R, Carpenter WR, Chen RC. Total Medicare costs associated with diagnosis and treatment of prostate cancer in elderly men. JAMA Oncol. 2019;5(1):60-66. doi:<a href="https://jamanetwork.com/journals/jamaoncology/fullarticle/2701720" target="_blank" rel="noopener">10.1001/jamaoncol.2018.3701</a></li>
</ol>

Cost of Localized Prostate Cancer Care Impacts Decision-Making for Clinicians, Patients

Localized

This review highlights the main research available on the financial costs related to the treatment of localized PC—and the associated outcomes—in the US.