Costs could be slashed by $320 million if all men with Gleason scores of 6 or lower pursued initial conservative management, says researcher Justin Trogdon, PhD.
Diagnosing and treating localized prostate cancer in men 70 years of age and older has cost Medicare an estimated 3-year total of $1.2 billion, according to results of a retrospective cohort study.
Those costs could be slashed by $320 million if all men with Gleason scores of 6 or lower pursued initial conservative management, said study author Justin Trogdon, PhD, of the University of North Carolina in Chapel Hill.
"The evidence was there for the lack of health benefits, but we thought we could really drive the message home if we pointed out that, by the way, we're spending a lot of money on this," Dr. Trogdon said of the rationale for the study in an interview with Urology Times.
The study, published in JAMA Oncology (Sept. 13, 2018 [epub ahead of print]), was based on an analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Looking at the period between 2004 and 2007, the authors identified nearly 50,000 men who were diagnosed with nonmetastatic prostate cancer at 70 years of age or older. About half of the patients were 76 years of age or older.
They found that the median cost per patient within 3 years of diagnosis was $14,453 (interquartile range [IQR], $4,887-$27,899). Most of the cost was due to treatment, at a median of $10,558 (IQR, $1,990-$23,718).
However, 3-year median total cost per patient was just $1,914 for patients with a 6 or lower Gleason score who had initial conservative management, defined as no treatment within 12 months of diagnosis, Dr. Trogdon and colleagues found.
All told, the $1.2 billion 3-year cost to Medicare represented a substantial sum in these older men who were unlikely to die of prostate cancer, Dr. Trogdon and co-authors concluded.
Published guidelines continue to recommend against PSA screening in men 70 years of age and older, said Dr. Trogdon and colleagues.
In their report, they referenced the PIVOT study (Prostate Cancer Intervention vs Observation Trial), which suggested there is no survival benefit to radical prostatectomy versus observation in older men with localized prostate cancer. They also noted studies showing how treatment of localized prostate cancer results in increases in sexual dysfunction, bowel problems, and other adverse outcomes.
“This is one of those decisions that's pretty clear cut. Screening and treating men for prostate cancer in this age group was not only hurting their health, but it's potentially hurting the pocketbook as well. We just really want to make sure that (physicians) are thinking about all of those dimensions when they're making these decisions,” Dr. Trogdon said.
Next:What can be done to reduce costs?Reducing provision of low-value health care services could result in significant health care savings, according to Dr. Trogdon.
One solution is to adhere more strictly to the guidelines and not screen these older men in the first place, Dr. Trogdon suggested in the interview. If patients are screened, however, putting them on active surveillance and not immediately treating could be a strategy that takes into account both the potential costs of care and potential harms of treatment, he added.
The situation may be improving, given the increasing recognition of prostate cancer overdiagnosis, according to Dr. Trogdon and co-investigators. In a review of more recent SEER data covering the 2009-2013 period, they found declines in prostate cancer incidence and treatment that they said would shave off about $200 million, bringing the total 3-year cost to about $1 billion.
Based on that decrease, the total 3-year cost to Medicare would have declined by $200 million to $1 billion, according to Dr. Trogdon.
“I think in general, the trend is potentially moving in the right direction, but we've still got quite a ways to go,” Dr. Trogdon said.