Active Surveillance the Least Costly Management Strategy for Low-Risk Prostate Cancer

San Francisco, CA—Active surveillance is less costly than immediate treatment of low-risk prostate cancer, regardless of the specific treatment, according to findings from a cost analysis at a single institution presented at the 2018 Genitourinary Cancers Symposium. The cost-effectiveness of initial active surveillance compared with immediate treatment, as well as mitigation of treatment-related side effects, supports consideration of active surveillance as a management strategy in value-based care models, said lead investigator Franklin Gaylis, MD, FACS, Medical Director, Genesis Healthcare Partners (GHP), San Diego, who presented the study results.

Over 3 years of follow-up, active surveillance was half as costly as radical prostatectomy, and 10 times less costly than intensity-modulated radiation therapy (IMRT) or image-guided radiation therapy (IGRT), Dr Gaylis said.

The analysis included primary clinical data for 93 patients with low-risk prostate cancer who were managed and followed at GHP. “Of the 195 patients with low-risk prostate cancer we looked at, 93 patients had 3 years of uninterrupted follow-up, and this formed the cohort for the analysis,” Dr Gaylis said. “We looked at every episode of care, abstracted manually from the electronic medical record, and applied a CPT [Current Procedural Terminology] code to the care, and translated it into a dollar amount according to the Medicare Physician Fee Schedule.”

The investigators compared the results with cost analyses from 2 previous studies. Keegan and colleagues used a theoretical cohort of men selecting active surveillance for prostate cancer and compared the costs of active surveillance with immediate treatment, excluding the costs of managing complications (Keegan KA, et al. Cancer. 2012;118:3512-3518). Laviana and colleagues performed a time-driven activity-­based cost analysis that included treatment modality and personnel costs for patients with low-risk prostate cancer (Laviana AA, et al. Cancer. 2016;122:447-455). By contrast, the GHP study included the cost of treatment complications.

A Paradigm Shift

In the GHP study, the 3-year total cost of active surveillance was $4072, which was significantly lower (P <.001) than radical prostatectomy ($9972), stereotactic body radiation therapy ($26,294), and IMRT or IGRT ($40,438). More than 40% of the cost difference could be attributed to treatment selection.

Keegan and colleagues found a cost-savings of $16,042 per patient for active surveillance over 5 years and $9944 over 10 years compared with immediate treatment. Laviana and colleagues made a process map for each treatment and measured the costs to the University of California, Los Angeles, to provide the service. They found significant variation between competing treatments: the 5-year costs were lowest ($7298) for active surveillance and highest ($23,565) for IMRT or IGRT.

“Ours are primary data that confirm the impressions of these theoretical models,” Dr Gaylis observed. “There’s a paradigm shift toward value-based healthcare in the United States, the goal of which is to improve quality and reduce cost. Healthcare costs in the US continue to rise faster than all other developed countries and are approaching 20% of gross domestic product. Physicians will play an important role in controlling costs and ensuring optimal value to the care we provide. This is how we should start engaging the dialogue, from a value-based care point of view, and debate how best to measure cost.”

A shortcoming of the data is the brief duration of follow-up, Dr Gaylis said. He and his colleagues are expanding the follow-up to 5 years. “We know that the numbers will change as we go out further, and that’s why we are expanding it to 5 years, but the 3-year data still gives us a sense of the magnitude of the difference in costs between immediate treatment and AS [active surveillance],” he concluded.

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