Each year, the diagnosis of prostate cancer in men ages 70 and older led to Medicare costs in excess of $1.2 billion over the ensuing 3 years, the lion’s share of that going toward treatment, the first analysis of its kind has shown.
Switching patients with lower-risk disease (Gleason score ≤6) from “low value” treatment to conservative approaches such as active surveillance would potentially yield $320 million in savings over that 3-year period, Ronald Chen, MD, MPH, of the University of North Carolina at Chapel Hill, and colleagues reported.
“Elderly patients, especially those with comorbidities, are unlikely to die of prostate cancer or benefit from screening,” Chen’s group wrote in JAMA Oncology. “Reducing detection of localized prostate cancer in elderly patients represents a potential source of significant cost savings for the U.S. Medicare program.”
They noted that among all diagnosed patients with the typically slow-growing disease, the 15-year relative survival runs as high as 95%.
The retrospective study included 49,692 elderly men diagnosed with non-metastatic prostate cancer from 2004 to 2007. The median cost per patient within 3 years of diagnosis was $14,453 (interquartile range $4,887 to $27,899), with treatment costs of $10,558 accounting for most of it (interquartile range $1,990 to $23,718).
Included in the overall cost of $1.2 billion was $451 million spent on men with a Gleason score of 6 or lower.
Franklin Gaylis, MD, of the University of California San Diego, commented to MedPage Today that healthcare inflation in the U.S. is destined to be almost 20% of gross domestic product (GDP) within the very foreseeable future, more than double the percentage of GDP spent on healthcare seen in most developed countries.
“It is unsustainable,” said Gaylis, who was not involved with the research. “These types of studies are extremely important in that they show us where we can reduce costs appropriately.”
A community study of men with low-risk prostate cancer from Genesis Healthcare Partners in San Diego, presented this year at the American Urological Association meeting, found that on average active surveillance costs $4,000 over a 3-year period per patient — compared with $40,000 for intensity-modulated or image-guided radiation therapy, $26,000 for stereotactic body radiation therapy, and $10,000 for radical prostatectomy.
Gaylis said he agrees with current guidelines that recommend screening be limited to men who have at least a 10-year life-expectancy, but cautioned that a study done by investigators at his own institution found that 70% of men with metastatic disease had never been screened for prostate cancer.
“I don’t think screening should be withheld from men over 70, but I think there should be a better selection process based on life expectancy and general health which includes a shared-decision approach with the patient,” he said. “We need to screen and treat smarter [and] there is a need for better biomarkers which can accurately predict who should be screened and treated for prostate cancer.”
The nationwide, population-based cohort study from Chen’s team was based on data from the Surveillance, Epidemiology and End Results (SEER) system linked to Medicare claims records, from which men 70 years of age and older with localized prostate cancer were identified.
Medicare costs associated with the diagnosis, workup, treatment, follow-up, and morbidity management were then analyzed and costs were estimated from 2007-2011 SEER data. Roughly half of the group ranged between 70 and 75 years of age, with the rest over 75.
Overall, 42% of those 70 and older had a Gleason score of 6 or lower, and the median per-patient cost over the 3-year period for these patients was $12,616. Those initially managed conservatively for at least 12 months had a 3-year median total cost of $1,914.
Median per-patient total costs for prostate cancer care were lower for men over the age of 75, driven mostly by differences in treatment. But these costs still added up to $601 million over 3 years; the researchers calculated $132 million in potential savings if those with a Gleason score of 6 or lower initially received conservative management.
Active surveillance has now become routine for men with a Gleason score of 6 or lower, the investigators pointed out. Based on the fact that treatment costs were estimated to account for about 80% of the overall cost of prostate cancer care per patient in the current analysis, they estimated that the decrease in overtreatment should yield a 34% drop in Medicare spending “totaling $413 million over 3 years for each annual cohort.”
Chen and co-authors had no conflicts of interest to disclose.