In Prostate Cancer, High-Tech Treatment Driving Costs Up

March 24, 2011 — In recent years, the treatment of prostate cancer has been a story of "out with the old and in with the new," which has dramatically increased costs. But do the new technologies offer benefits that justify these higher costs?

These issues are analyzed in a new study published online March 14 in the Journal of Clinical Oncology.

From 2002 to 2005, there was a "wide and rapid shift" to newer, more expensive, high-tech treatments for prostate cancer — namely, minimally invasive radical prostatectomy (MIRP) and intensity-modulated radiation therapy (IMRT), according to the study authors.

Specifically, MIRP use increased from 1.5% of all diagnoses in 2002 to 28.7% in 2005 (P < .001).

For radiotherapy, IMRT use increased from 28.7% in 2002 to 81.7% in 2005 (P < .001). For men receiving brachytherapy, supplemental IMRT also increased significantly, from 8.5% to 31.1% (P < .001).

This transition away from traditional surgery and radiotherapy resulted in an additional $350 million in expenditures among prostate cancer patients for 2005 alone, the study reports.

The study was headed by Paul L. Nguyen, MD, from the Dana-Farber Cancer Institute in Boston, Massachusetts. The usage and cost information in the study were obtained from Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data.

Money issues aside, the problem with this shift from old to new is that there have been no randomized clinical trials comparing IMRT and MIRP with the traditional methods of 3-dimensional (3-D) conformal radiation therapy and open radical prostatectomy, say the authors.

Retrospective comparative studies indicate a "marginal benefit" with the new approaches, they point out. But are the benefits of the new technologies "large enough to justify their higher cost?" ask Dr. Nguyen and colleagues.

That's a question in need of a big-picture answer, according to Andre Konski, MD, who wrote an editorial that accompanies the study.

IMRT and MIRP are "two of the newer weapons in the War on Cancer," writes Dr. Konski, who is from Wayne State University in Detroit, Michigan.

But "the healthcare landscape is much different today than in 1971 when the War on Cancer was declared" he writes. The "higher cost of care needs to be balanced with competing economic realities in an environment of limited resources," he declares.

Dr. Konski would like to see a comparative-effectiveness study done in prostate cancer — both for surgery and radiotherapy.

However, both he and the study authors think that will be especially "difficult" with radiotherapy. Dr. Konski says there is now a "bias of radiation oncologists" toward IMRT.

Meanwhile, the cost of healthcare in the United States continues to climb, says the editorialist.

"Although healthcare spending growth decelerated in 2009 in the United States, it still increased 4.0% in 2009, reaching $2.5 trillion and making healthcare products/services 17.6% of the gross domestic product compared with 16.6% in 2008," writes Dr. Konski.

The authors of the study link the uptake of the new prostate cancer treatments with the overall healthcare spend. "This pattern of rapid adoption may provide some empirical evidence for why healthcare costs account for 17% of the US gross domestic product," they write.

Rapid Adoption and Related Costs

During the 2002 to 2005 study period, the cost of IMRT was nearly $11,000 greater per case than that of traditional 3-D conformal radiation therapy, according to Medicare data.

IMRT is more expensive because of the "more intense physics planning and quality-assurance time, as well as treatment delivery time and software and hardware costs," they also write.

The big cost difference between IMRT and traditional radiation has not gone unnoticed. Private insurance companies have begun to use "benefit management companies to review and approve the use of IMRT before any therapy begins," Dr. Konski points out.

The cost difference between the newer laparoscopic or robotic MIRP and traditional open radical prostatectomy was much less dramatic — just $236. However, this figure comes from Medicare data on fees reimbursed to surgeons only, which does not indicate what private insurers paid, and "does not nearly reflect" the underlying cost difference, write the study authors.

MIRP is more expensive because of "the greater cost of disposables, equipment, and increased operating room time during a lengthy learning curve," the study authors explain.

Marginal Benefits

The study authors review some of the literature on MIRP and radical prostatectomy in their paper.

An observational study (JAMA. 2009;302:1557-1564), comparing outcomes after MIRP and open radical prostatectomy, found that MIRP "appeared to be associated with" a shorter hospital stay (2 vs 3 days), fewer transfusions (2.7% vs 20.8%), fewer postoperative respiratory complications (4.3% vs 6.6%), and fewer anastomotic strictures (5.8% vs 14.0%).

However, MIRP was also associated with an increased risk for genitourinary complications (4.7% vs 2.1%), more diagnoses of incontinence (15.9 vs 12.2 per 100 person-years), and more erectile dysfunction (26.8 vs 19.2 per 100 person-years).

With regard to external radiation, the study authors say that "retrospective studies seem to consistently suggest that IMRT is associated with a significant reduction in long-term rectal bleeding, compared with [3-D conformal radiation therapy]." The study authors do not point out any other differences.

Comparative-effectiveness research is needed, not only to assess efficacy, but also to assess cost, conclude the study authors.

The authors have disclosed no relevant financial relationships.