Active surveillance as an initial management strategy for men with low-risk prostate cancer results in cost savings compared with immediate treatment, regardless of the treatment chosen.
Active surveillance (AS) as an initial management strategy for men with low-risk prostate cancer results in cost savings compared with immediate treatment, regardless of the treatment chosen.
The finding comes from a cost analysis of 93 patients with low-risk prostate cancer who were managed and followed at Genesis Healthcare Partners (GHP) in San Diego.
The cost-effectiveness of initial AS compared with immediate treatment, as well as mitigation of treatment-related side effects, supports consideration of AS as a management strategy in value-based care models, said lead investigator Franklin Gaylis, MD, chief scientific officer at GHP. He presented his group’s findings at the Genitourinary Cancers Symposium in San Francisco.
For the analysis, 93 patients with low-risk prostate cancer as identified by the National Comprehensive Cancer Network had primary clinical data examined.
“Of the 195 patients with low-risk prostate cancer we looked at, 93 had 3 years of uninterrupted follow-up, and this formed the cohort for the analysis,” said Dr. Gaylis, who worked closely with graduate student Kevin McGill. “We looked at every episode of care, abstracted manually from the electronic medical record, and applied a CPT code to the care, and translated it into a dollar amount according to the Medicare Physician Fee Schedule.”
He called the research a “a roll-up-your-sleeves” analysis that examined every chart and episode of care and translated it into what Medicare would pay for that service, whether a test, surgery, radiation, biopsy, consultation, or genomic test.
Characteristics of the 93 patients included were similar to those of the 102 not included. A total of 89% of the men in the study cohort were Caucasian compared with 84% not in the study cohort, Charlson index was 1 or 2 in 24% and 23%, respectively, and 3 or 4 in 66% and 69%, respectively.
The results were compared with cost analyses from two other studies. Keegan et al (Cancer 2012; 118:3512-8) used a theoretical cohort and compared the costs of AS to immediate treatment, excluding the costs of managing complications. Laviana et al performed a time-driven activity-based cost analysis that included determination of space, product, and personnel costs (Cancer 2016; 122:447-55). In contrast, the GHP study looked at every episode of care associated with managing low-risk prostate cancer, including complications of treatment.
The GHP study’s 3-year total cost of AS was $4,072, which was significantly lower (p<.001) than that for radical prostatectomy ($9,972), stereotactic body radiation therapy ($26,294), and intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT) ($40,438). More than 40% of the differences in cost could be attributed to treatment selection.
By comparison, Keegan et al, using a theoretical cohort of 120,000 men selecting AS, found a cost saving of $16,042 per patient over 5 years and $9,944 over 10 years for AS compared with immediate treatment. Laviana et al made a process map for each treatment and measured costs to the University of California, Los Angeles to provide the service. They found significant cost variation between competing treatments, with 5-year costs lowest with AS ($7,298) and highest for IMRT ($23,565).
“Ours are primary data that confirm the impressions of these theoretical models,” said Dr. Gaylis. “There’s a paradigm shift toward value-based health care in the United States, the goal of which is to improve quality and reduce cost (ie, improve value). Health care costs in the U.S. continue to rise faster than all other developed countries and are approaching 20% of gross domestic product.
“Physicians will play an important role in controlling costs and ensuring optimal value to the care we provide. This is how we should start engaging the dialogue, from a value-based care point of view, and debate how best to measure cost.”
One criticism of his data is the short follow-up. Dr. Gaylis is expanding the follow-up to 5 years.
“We know that the numbers will change as we go out further, and that’s why we are expanding it to 5 years, but the 3-year data still gives us a sense of the magnitude of the difference in costs between immediate treatment and AS,” he said.
Dr. Gaylis has received honorari from, is a consultant/adviser to, and is on the speakers’ bureau for Janssen; is a consultant/adviser for UROGPO; and has received research funding from Astellas Medivation.