Hypothetical cost savings associated with “observation” for low-risk prostate cancer

A newly published article in JAMA Oncology has reported hypothetical costs savings to Medicare of $320 million over a 3-year time frame if men of > 70 years with low-risk prostate cancer are simply “observed” as opposed being given immediate treated.

This article by Trogdon et al. offers an interesting and simultaneously worrisome set of findings, and so we have tried, below, to clarify its possible implications.

First and foremost, these types of hypothetical cost savings need to be placed in a clinical context, and that clinical context is as follows:

  • “Observation” of men initially diagnosed with low-risk prostate cancer is inclusive of all men who do not receive immediate treatment (by whatever means) and so these men may be appropriately and initially managed by almost any form of care that is designed to monitor the clinical status of their prostate cancer.
  • Types of appropriate monitoring can therefore range from watchful waiting without intensive surveillance (say in a man of 85 years of age with multiple comorbid conditions and a life expectancy of < 5 years) to highly intensive active surveillance (say in a man of 69 years of age just diagnosed with clinical stage T1c, three cores of Gleason 6 disease, a PSA level of 6, and a life expectancy of at least another 15 and maybe 20 years).
  • Furthermore, observation may not be an acceptable choice for all men diagnosed with low-risk prostate cancer who are on Medicare.

The paper by Trogdon et al. provides the following information:

  • It is based on data from the SEER-Medicare database for men diagnosed with non-metastatic prostate cancer between 2007 and 2011.
  • It included data from 49,692 men of age 70 years or older.
  • 25,981 (52.3 percent) of these men were 76 years or older.

Their findings with regard to the costs of care for these men were:

  • The average (median) per-patient cost within 3 years after prostate cancer diagnosis was $14,453.
  • Most of this cost (an average of $10,558) was associated with treatments administered within a 3-year period.
  • Men diagnosed with a Gleason score of 6 or lower who pursued initial conservative management (i.e., no treatment within 12 months of diagnosis) had a 3-year median total cost of $1,914 per patient.
  • The estimated total cost to the Medicare program over 3 years after the detection of prostate cancer in men aged 70 years or older is approximately $1.2 billion.
  • Greater use of active surveillance for the first-line management of patients with a Gleason score of 6 or lower could reduce this cost by $320 million over that 3-year period.

The “New” Prostate Cancer InfoLink is certainly of the opinion that there are major potential cost savings possible for Medicare if there is increased application of active surveillance and other forms of conservative management of low-risk prostate cancer. However,  …

We would also want to be very clear that the application of conservative forms of management needs to be based on the appropriateness of such management in well-defined patients and the willingness of each individual patient to be managed by the use of such techniques. Potential for cost savings should not, in and of itself, become a justification for managing men conservatively without their full buy-in to an appropriate form of conservative management — inclusive of appropriate follow-up care through the use of necessary tests, scans, and biopsies in order to address risk for progression over time.

It is also not entirely clear whether the estimated total cost to the Medicare  program of $1.2 billion (over 3 years after the detection of prostate cancer in men aged 70 years or older) is an estimated current cost or was an estimated cost as of the period from 2007 to 2011. If it was the latter, we would need to know if this was still the same for the period from 2015 through 2017 since there appears to have been a major change in the numbers of older men being “observed” after an initial diagnosis with low-risk prostate cancer since 2011.

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