Avoiding Overtreatment Saves Medicare $320M Over 3-Year Period in Older Men With Prostate Cancer

Overtreating men 70 years or older with prostate cancer cost Medicare more than $1.2 billion from 2004 to 2007, according to the results of a retrospective study using the Surveillance, Epidemiology, and End Results—Medicare linked database. Ronald Chen, MD, MPH, and colleagues determined that the median per-patient cost related to diagnosis and workup, treatment, follow-up, and morbidity management was $14,453, within 3 years post diagnosis (TABLE).¹

“As researchers, we wanted to look at opportunities where we could reduce costs and still benefit the patient, especially opportunities where we’re not harming the patient,” said Chen in an interview withTargeted Therapies in Oncology. Reducing overscreening and overtreating of elderly men with newly diagnosed prostate cancer could reduce low-value healthcare services that can result in net harm to patients and also waste resources in the US healthcare system.

The study involved 49,692 men with nonmetastatic prostate cancer. Fifty-two percent (n = 25,981) were 76 years or older. There were 20,982 men (42%) with a Gleason score of ≤6; 16,927 (34%) with a Gleason score of 7; and 9018 (18%) with a Gleason score of 8 to 10.

Prostate cancer is often a slow-growing disease, with a 95% 15-year relative survival rate among patients. Thus, elderly patients, especially those with comorbidities, are unlikely to die of prostate cancer or benefit from screening. This is reflected in published guidelines, including the 2018 recommendation from the United States Preventive Services Task Force, which continues to recommend against PSA screening in men 70 years or older.

Chen, an associate professor of radiation oncology, University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, noted that procedures such as biopsies, medical therapies, scans, and adverse effects contribute significantly to the costs.

“Several guidelines recommend that we stop screening at age 70,” he continued. “The thought is that screening for older men is not going to extend the patient’s life expectancy. In fact, there are harms associated with biopsy and side effects from medical treatments,” Chen said. The researchers saw this study as an opportunity to see how much money could be saved if screening were reduced in older men who would not benefit from it.

The cost to Medicare for detecting prostate cancer in men older than 75 years is $601 million. If conservative treatment (ie, active surveillance) is initially pursued in these men, this cost would be reduced by $132 million (FIGURE).

Chen noted that the National Comprehensive Cancer Network and American Urological Association guidelines both recommend active surveillance for men with a Gleason score of 6 or lower, yet the uptake among practicing clinicians has been slow. Chen hopes his study will continue to raise awareness about these costs and lead to an increase in the uptake of active surveillance as a viable treatment in some of these patients.

Still, to many patients, a diagnosis of prostate cancer may be difficult to receive from their physician and the knee-jerk reaction may be to treat the disease aggressively. Chen acknow-ledges that this is a good point.

“Several years ago, when active surveillance was a new concept, it was a difficult topic to discuss because of the worry about a cancer diagnosis,” he said. But today there are more than 10 years’ worth of safety data, progression data, and survival data. “I think physicians should have enough long-term data to be able to describe to patients that active surveillance is really the best option for Gleason ≤6 prostate cancer.” He added that “active surveillance also means that we actively monitor the cancer. If the cancer happens to progress, treatment at that point will be necessary and would still offer a high percentage of cure.”

The researchers concluded ceasing aggressive treatment of low-risk prostate cancer among elderly patients represents an opportunity to benefit the patients, by preventing harm from treatments that are unlikely to lead to improved survival, while also providing large annual cost savings to Medicare.

Reference:

Trogdon JG, Falchook AD, Basak R, Carpenter WR, Chen RC. Total Medicare costs associated with diagnosis and treatment of prostate cancer in elderly men.JAMA Oncol.2019;5(1):60-66. doi: 10.1001/jamaoncol.2018.3701.