What it really costs to manage/treat low-risk prostate cancer

In a new article in the journal Cancer, a research group associated primarily with the University of California, Los Angeles, have provided detailed information on the costs of first-line management of low-risk prostate cancer.

The paper by Laviana et al., along with a media release from UCLA Health, indicate wide variation in the costs for the various available treatments and management options that seems to have remained remarkably stable over a 12-year period. (Do please note that the authors were measuring the actual costs associated with service provision, not what was being charged by the institution, i.e., the fees!)

The authors developed “process maps” encompassing every each phase of care for a new patient from the initial urologic visit through 12 years of follow-up for seven different categories of management:

  • Robotic-assisted laparoscopic prostatectomy (RALP)
  • Cryotherapy
  • High-dose-rate brachytherapy (HDR BT)
  • Low-dose-rate brachytherapy (LDR BT)
  • Intensity-modulated radiation therapy (IMRT)
  • Stereotactic body radiation therapy (SBRT)
  • Active surveillance (AS) — incorporating transrectal ultrasound (TRUS) biopsy and multiparametric MRI/TRUS fusion biopsy

For each form of management, the research team included all costs for materials, equipment, personnel, and space per per unit of time and based on the relative proportion of capacity used to develop what is known as a time-driven activity-based cost (TDABC) for each form of management.

The research team summarize their findings as follows:

  • There was significant variation in TDABC at 5 years.
    • $7,298 for AS
    • $8,978 for LDR BT
    • $11,215 for cryotherapy
    • $11,665 for HDR BT
    • $11,665 for SBRT
    • $16,946 for RALP
    • $23,565 for IMRT
  • AS became cost-equivalent to LDR-BT only at 7 years of follow-up

Quoted in the UCLA media release, Laviana states that:

This is the first study to truly investigate the costs of various treatments for prostate cancer over the long-term. As we move from traditional fee-for-service reimbursement models to accountable care organizations and bundled payments to curb growing health care expenditures, understanding the true costs of health care is essential. Traditional costing methods often lack transparency and can be arbitrary, preventing the true costs of a disease or treatment from being understood. This is important, as patients often receive a hospital bill with arbitrary charges that may or may not reflect their true treatment costs. This costing methodology creates an algorithm that allows organizations to assess their costs and see where they may be able to improve. Altogether, by maintaining similar quality, this will improve the overall value of care delivered.

It has long been complained that the amounts that patients and payers are actually charged for provision of healthcare services are based on arbitrary rates (so-called “charge master” rates) that have nothing whatsoever to do with the costs involved. It is also well understood that fees and other billable amounts can vary radically from one area of the country to another and from institution to institution within a particular area.

If the data provided by Laviana et al. are accurate, we now have a reasonable cost baseline against which to assess what institutions actually charge for certain types of prostate cancer service. It is hardly surprising that it may cost more to get treated by an outstanding and highly-qualified prostate cancer specialist at a major cancer center than by a competent urologist at a community hospital in a suburb of Demoines, IA. However, it is also worth bearing in mind that the cost of the equipment involved was probably closely comparable at each of the treatment sites.

The UCLA media release also note that the research team

... plans to link the costing analysis to rigorously assessed quality measurements and outcomes trials to see which treatments provide the greatest value. They also plan to expand this study to assessing all levels of prostate cancer to see how the cost of care varies with localized high-risk prostate cancer as well as metastatic disease to analyze the burden of prostate cancer on end-of-life care.

9 Responses

  1. Thanks for this very interesting article.

    I’ve looked at both linked publications regarding the numbers of biopsies used in the active surveillance figures, but this information is not stated. Perhaps it is in the full paper. The biopsy protocol for an active surveillance program is likely a significant driver of cost as it can vary from virtually annual biopsies, which was once the Johns Hopkins approach, to as few as three or four over the patient’s lifetime, the approach typically used by Dr. Laurence Klotz and colleagues at the University of Toronto, Sunnybrook.

  2. I agree with Jim to a point. I’ll reach out to Chris King and see if I can get a free copy of the paper or his take on active surveillance costs. I am certain costs for biopsy are present but I don’t think they are as much as various MRI procedures and evaluations. In any case, I always suspected that the costs of AS for 10 years for low-risk guys will far exceed any treatment costs for true Gleason 6 men (Epstein Grade 1).

    Unless you want to do proton therapy, which is not an option at UCLA.

  3. I assume this includes the facility costs including salaried radiologists, anesthesiologists, and pathologists. What about other professional fees? Could you clarify?

    Also, if anyone has information as to the mark-up from costs to charges including expenses and profit, this would be interesting.


  4. Dear John:

    It is my understanding that the costs included in this set of data did indeed include all facilities costs and related professional fees. The mark-ups charged by different hospitals are a matter of utter speculation and vary vastly from institution to institution in ways that only further eliminate any degree of transparency about the true costs of healthcare in America.

  5. It’s hard for me to believe that the cost of HDR brachy monotherapy, which includes up to 2 overnight hospital stays, was only $11,448. The $11,665 for SBRT was similar to what my insurance paid UCLA for the treatment, but does not include about $9,000 paid for the placement of fiducials.

  6. Allen:

    The data given in this paper is not data on what was being paid for the procedures. It is data on what it cost the institution to provide the treatments.

  7. Thanks for clarifying that. It helps me see how arbitrary and inflated the bills insurers and patients receive are. I did have a chance to read the full text now. It doesn’t include the full process maps for each procedure, so I can’t check if it included two overnight stays in the hospital for HDR brachy. If the hospital has excess capacity, the variable cost of the room for 2 nights is small. The author did make some peculiar assumptions with active surveillance. He assumed annual mpMRI/US fusion biopsies (cost $1,072 each), and that 50% would switch to RP (cost $14,619) after 5 years. Based on these assumptions, AS is as costly as RP after about 12-13 years. In the Sunnybrook AS study, half remained untreated after 20 years.

  8. Allen:

    Studies like this are never perfect because the authors always have to make a variety of assumptions that may not seem appropriate to others. I have no idea why the authors made the specific assumptions that they did make.

  9. Thanks for your research, Allen. Yes, those “peculiar assumptions with active surveillance” seem way toward the excess staging and cost end of the range to me. It would be interesting to see the same cost factors applied using the Klotz approach for biopsies and imaging.

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