Implications For Cost-Cutting in the Management of Prostate Cancer

ORLANDO, FL – The high cost of managing prostate cancer could be substantially reduced if physicians incorporated results from three important studies presented at the 2011 ASCO Genitourinary Cancers Symposium held here on February 17-19, 2011. The take-home messages from these studies are as follows:

  • Intermittent androgen suppression (IAD) is as effective as continuous androgen deprivation (CAD) in men with prostate cancer and a rising PSA after definitive primary treatment such as radical prostatectomy or radiotherapy. This means that patients could receive about one-quarter of the amount of these costly drugs per year with no detrimental effect on outcome.
  • Robotic-assisted laparoscopic radical prostatectomy (RALP) has a much steeper learning curve than assumed and should be restricted to surgeons who treat a high volume of patients with prostate cancer. This has huge financial implications, given the exponential growth in adoption of robotic techniques across the U.S.A.
  • Imaging is being utilized in a substantial number of patients where it is not only unnecessary, but is also not recommended.


An Intergroup randomized Phase III trial found no difference in survival between IAD vs CAD in men with rising PSA after radical therapy for prostate cancer (Abstract 3). These results were called “practice changing” by lead author Laurence Klotz, MD, Professor of Surgery at the University of Toronto, Canada, and Oliver Sartor, MD, Tulane University, New Orleans, LA, who was a formal discussant of the trial. Dr. Klotz said this trial provides level 1A evidence that IAD should be the new standard of care for most patients with PSA recurrence after radical therapy. Smaller trials have also shown no difference between the two strategies in terms of survival.

“Patients in the IAD arm were on therapy only 27% of the time, “reducing the cost of therapy on average by 73%,” said Dr. Klotz.

The interim analysis of this trial included 1386 patients with rising PSA and non-metastatic prostate cancer after radical therapy. Median survival was 8.8 months in the IAD arm versus 9.1 months in the CAD arm. Time to development of castration resistance was close to 10 years and favored IAD. No difference in adverse events was reported between the two arms, with the exception of more hot flashes in the CAD arm. Time to development of castration resistance was close to 10 years and favored IAD. No difference in adverse events was reported between the two arms, with the exception of more hot flashes in the CAD arm.

Joel B. Nelson, MD, University of Pittsburgh, PA, said that the totality of evidence should influence physicians who routinely treat patients with CAD to change their practice to IAD. “In this era of health care reform, we are pushed to reduce expenditures. Androgen deprivation therapy constitutes a significant portion of the Medicare budget, and if these drugs are not necessary continuously, that will be cost-saving,” he stated.

Robotic Prostate Surgery

It is not easy to learn how to perform robotically- assisted laparoscopic radical prostatectomy (RALP) surgeries at an expert level so as to achieve <10% of positive margins in the tumor specimen – a goal that is considered acceptable for radical prostatectomy. A retrospective review of RALP procedures performed by three different high-volume surgeons at three different centers over a 6-year period found that it took a total of 1,600 RALP procedures to gain this level of competence. These findings are concerning, since an estimated 70,000 of the 90,000 radical prostatectomies performed each year in the US are done robotically. Moreover, more than 70% of RALP surgeries are done by surgeons who do fewer than 100 cases per year.

According to lead author of this study, Prasanna Sooriakumaran, MD, PhD, Visiting Fellow in Urology at the Weill Cornell Medical College in New York City, “Our study suggests there is a long learning curve to become competent at achieving negative surgical margins, which is the goal of prostate cancer surgery. We recommend that RALP be performed by surgeons who see a high volume of patients.”

“Even for surgeons who perform hundreds of RALP procedures each year, it takes a long time to get to the stage where they are getting the best possible cancer control results. Our results show that it takes a significant amount of experience to achieve good cancer cure rates and low positive surgical margins with this operation,” said Dr. Sooriakumaran.

Dr. Sooriakumaran hopes these data will stop the exponential rise of purchasing robots to be used by relatively naïve surgeons. “The operation is not easy to perform. It is expensive. It would be more sensible to use robotic surgery at Centers of Excellence to optimize results,” he stated.

Imaging Study

A retrospective review of a large SEER-Medicare database of men with newly diagnosed prostate cancer found that about one-third of men with low- and intermediate-stage prostate cancer received unnecessary imaging contrary to AUA and NCCN guidelines stipulating that imaging be reserved for patients with high-risk features (Abstract 120). According to lead author, Sandip M. Prasad, MD, University of Chicago Medical Center, Chicago, IL, this accounts for an estimated $35 million in wasted money, which represents about 10% of the National Cancer Institute’s total annual research budget for prostate cancer. Another worrisome finding, although not related to cost-savings, was that almost 40% of high-risk men were not receiving recommended imaging tests that would help guide management.

The database included 30,183 men; 9,640 were diagnosed with low-risk prostate cancer; 12,966 were diagnosed with intermediate-risk prostate cancer; and 7,577 men were diagnosed with high-risk prostate cancer. The study found that 36% of low-risk men, 49% of intermediate-risk men, and 61% of high-risk men underwent radiographic imaging.  “These percentages should have been 0%, 0%, and 100%, respectively,” Dr. Prasad stated. “These figures are cause for concern.”

He suggested that many doctors may be practicing “defensive medicine” and ordering unnecessary imaging to leave no stone unturned. Bone scan was the most frequently ordered test in all three risk groups.

By Alice Goodman

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