Original articleClinical—prostateActive surveillance vs. treatment for low-risk prostate cancer: A cost comparison☆
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.
References (27)
What is the best approach for screen-detected low volume cancers?—The case for observation
Urol Oncol
(2008)- et al.
Radical prostatectomy: Long-term cancer control and recovery of sexual and urinary function (“trifecta”)
Urology
(2005) - et al.
Hypofractionated accelerated radiotherapy using concomitant intensity-modulated radiotherapy boost technique for localized high-risk prostate cancer: Acute toxicity results
Int J Radiat Oncol Biol Phys
(2008) - et al.
Careful selection and close monitoring of low-risk prostate cancer patients on active surveillance minimizes the need for treatment
Eur Urol
(2010) - et al.
A multi-institutional evaluation of active surveillance for low risk prostate cancer
J Urol
(2009) - et al.
Prostate cancer
J Urol
(2007) - et al.
Local cost structures and the economics of robot assisted radical prostatectomy
J Urol
(2005) - et al.
Benefit of intensity modulated and image-guided radiotherapy in prostate cancer
Cancer Radiother
(2010) - et al.
Dosimetry and preliminary acute toxicity in the first 100 men treated for prostate cancer on a randomized hypofractionation dose escalation trial
Int J Radiat Oncol Biol Phys
(2006) - et al.
Stereotactic body radiotherapy for localized prostate cancer: Interim results of a prospective phase II clinical trial
Int J Radiat Oncol Biol Phys
(2009)
The second decade of prostate brachytherapy: Evidence and cost based outcomes
Urol Oncol
Cancer statistics, 2010
CA Cancer J Clin
Robotically-assisted laparoscopic radical prostatectomy
BJU Int
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.