Original article
Clinical—prostate
Active surveillance vs. treatment for low-risk prostate cancer: A cost comparison

https://doi.org/10.1016/j.urolonc.2011.04.005Get rights and content

Abstract

Objective

Radical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS.

Methods and materials

We collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience.

Results

The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years).

Conclusions

The cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.

Introduction

Prostate cancer (PC) is the most common solid cancer among men in the United States with an annual incidence of approximately 217,730 [1]. The introduction of prostate specific antigen (PSA) for PC screening has resulted in a dramatic increase in its incidence. There has also been a significant stage migration with an increased number of newly diagnosed patients having low-risk disease [2].

Open radical retropubic prostatectomy (RRP) is a well established curative treatment for low-risk PC (PC). However, RRP is associated with quality of life impairment in the form of erectile dysfunction and incontinence [3]. Robotic-assisted radical prostatectomy (RARP) was first introduced in 2000 by Binder and Kramer as a minimally invasive procedure for localized PC [4]. RARP is suggested to have equivalent oncological outcome as RRP and faster recovery and, hence, shorter hospital stay [5]. The cost of the robot is estimated to be $1.5 million to install and additional $1,300 for each RARP for disposable instruments [6]. Although RARP has increased the cost of health care, it is the most commonly performed procedure for PC in the United States [7]. External beam radiotherapy (EBRT) and brachytherapy (BT) are management alternatives for low-risk PC that have equivalent oncological outcome to radical prostatectomy (RP) [8], [9].

While 17%–20% of men are diagnosed of PC during their lifetime, only 3% die from PC [10], [11]. The relatively low PC mortality compared with the incidence supported the idea that not every PC patient needs treatment. Active surveillance (AS) has emerged as a viable management option for PC patients who are at a very low risk of progression and death from PC. AS is a strict monitoring approach with regular digital rectal examination (DRE), PSA testing, and surveillance biopsies. AS aims to avoid and delay treatment and its complications for those who are less likely to die from PC.

The high incidence of PC has resulted in a significant economic burden on the health care system. Optimal health care planning involves providing the best available care with the lowest possible cost. Our aim is to compare the cumulative medical cost of managing low-risk PC by RRP, RARP, EBRT, BT, and AS.

Section snippets

Materials and methods

We collected data on the cumulative medical cost for managing low-risk PC by RRP, RARP, EBRT, BT, and AS over a 10-year period. For reporting the professional fees, 2010 Medicare reimbursement values of our region in Miami, Florida were used to maintain the uniformity of the study. Reimbursement values are available to public on the website (http://medicare.fcso.com/). For inpatient costs other than professional fees, we obtained the mean inpatient costs of clinically localized PC patients who

Results

The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years), while for RARP the cumulative costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The cumulative costs of EBRT are $20,730 (1 year), $20,969 (2 yeas), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The cumulative costs of AS are $1,154 (1 year), $2,308 (2

Discussion

The United States has by far the most expensive health care system that is rapidly growing exceeding the inflation rate [16]. The rapid rise of heath care cost is a potential threat to the efficiency of the health care system. Several attempts have been made to understand the reasons for the rising cost of health care and more so to find a solution [16], [17]. The cost of health care is mainly derived from the government (45%), employer (36%), and patients (15%). The leading expenditures of the

Conclusion

The initial and cumulative cost of EBRT and RARP is higher than BT, RRP, and AS at our institution. AS has a different pattern of cost distribution compared with treatment with low initial cost and steady cost increase due to the yearly biopsy. At 10 years follow-up, the cumulative cost of AS remains lower than it from RRP, BT, and much lower than RARP and EBRT. When considering the days lost from work with treatment and the priceless quality of life, AS stands as a cost effective approach for

Acknowledgments

The authors acknowledge the support from “CURED” and Mr. Vincent A. Rodriguez and the help from Andy Salcedo and Ana Martinez in obtaining the financial data.

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  • Cited by (0)

    The authors acknowledge the support from “CURED” and Mr. Vincent A. Rodriguez, and the help from Andy Salcedo and Ana Martinez in obtaining the financial data.

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