New prostate cancer technologies are they worth the price e electricity bill


“Overall, I’d say there is some evidence that outcomes are slightly better with these new technologies, compared with their more traditional counterparts,” he says. “However, there’s still a lot of uncertainty about this, and findings may change with results of more rigorous studies.”

He adds: “The interesting thing is that all of these changes happened without really good data showing that these new technologies are better. But the surgeons liked it, and the patients liked it, and the companies have been very smart in selling the technologies. In most parts of the world, robotic surgery and IMRT have completely taken over treatment. That’s what people get now.” Obtaining solid data on prostate innovations `challenging’

“The two important measurements are quality-of-life outcomes in terms of urinary and sexual function after treatment,” he says. “Validated questionnaires measure that, but it’s work to complete them. The shortest one is two or three pages long. Someone must hand them to the patient and collect them after the patient fills them out. So having good data on how patients do post-operatively that is measured in a valid way is challenging.”

He further explains that in an observational study, biases can potentially impact how one feels even if the quality of the surgery is the same. For example, a person who is wealthy and young with no co-occurring diseases may feel differently post-surgery than someone from a different socio-economic background, he says.

Thus, Schroeck is eager to learn the results of an ongoing Australian-based randomized trial that is comparing the effectiveness of robotic laparoscopic surgery to that of its predecessor, open radical prostatectomy. Both procedures involve removal of the prostate. But laparoscopy, which means to look inside the abdomen with a special camera or scope, is less invasive than open surgery.

Prostate cancer, the second-leading cause of cancer deaths among men, is most common in men age 65 and older. The disease is usually found in its early stages, typically as the result of a PSA (prostate specific antigen) blood test, and often grows slowly. It may take many years for a tumor to become large enough to be detectable and even longer to spread beyond the prostate. Most men live with the cancer for decades without symptoms and die of other causes even without early surgery.

Dr. Timothy Wilt, a physician-researcher at the Minneapolis VA Health Care System, led the PIVOT study. The landmark VA trial of nearly 20 years concluded that surgery doesn’t significantly reduce all-cause or prostate cancer deaths for men who are diagnosed in the early stages of the disease. Wilt is also well-known for his reviews and meta-analyses on treatments and their cost-effectiveness.

He and his colleague on the PIVOT study, Dr. Philipp Dahm, are skeptical that the new technologies reviewed in Schroeck’s study are worth the expense. They said in a jointly authored email that “none of these therapies have proven superior to their standard [predecessor]. None should make other therapies obsolete from a scientific and clinical outcomes standpoint.”

They add that all three technologies “are part of standard practice, and therein may lie some of the problem. They provide little to no difference in clinical outcomes, such as urinary and sexual function.” New technologies come with huge upfront costs

Radical prostatectomy is when a surgeon removes the walnut-sized prostate. In robot-assisted radical prostatectomy, a surgeon sits at a control panel and moves robotic arms to operate through incisions in the patient’s abdomen, with the goal of removing the prostate. The robot’s arms replicate the surgeon’s hand movements. The procedure is minimally invasive: The incisions are smaller than in traditional open surgery. And it is laparoscopic, meaning the surgeon uses a pencil-thin video camera to view inside the body.

Intensity-modulated radiotherapy has essentially replaced three-dimensional (3D) conformal radiotherapy, a form of prostate cancer treatment that shapes the radiation beams to match the shape of the tumor. IMRT features beams that can provide multiple intensity levels for any single-beam direction and any single-source position. It’s ideal for avoiding organs, such as the rectum or bladder, that lie in close proximity to the cancer.

In proton beam therapy, energy is carried by protons, the positively charged particles in an atom. The proton beams stop after releasing their energy within the intended target, unlike protons in X-rays. Higher doses of radiation can be more safely delivered to tumors with less risk to healthy tissue.

But some of the costs may be offset by better outcomes or less resource use during the procedure, the researchers say. For example, fewer adverse events and shorter hospital stays linked to robotic surgery may counter some of the extra expenses.

• RARP is costlier for hospitals and patients than open surgery. “However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved,” the researchers write.

• IMRT is more expensive from a patient’s perspective than 3D radiotherapy. But IMRT is also more cost-effective, with a cost of less than $50,000 per quality-adjusted life year, which is the threshold economists often use to determine if a treatment is cost-effective.

• Proton beam therapy is costlier than IMRT, but its cost-effectiveness is unclear given the limited comparative data on outcomes. (The researchers compared proton therapy to IMRT because IMRT is basically the standard form of radiation treatment at this time, having replaced 3D radiotherapy about 10 years ago.)

In rating the cost-effectiveness of new versus older technology at this time, Schroeck says: “The cost-difference between RARP and open surgery is the smallest. The cost difference between proton beam therapy and IMRT is the largest; thus, proton therapy has the least potential of being cost-effective.”

“This has been driven largely by provider and patient demand, much more so than by solid scientific data,” he says. “However, as volumes increase and outcomes continue to improve, these new technologies will likely ultimately prove to be worth it. Regarding proton therapy, it is very complex and costly to start a proton therapy treatment center. As such, it is less likely that this technology will disseminate as widely as the other two.” Researcher expects updated analyses on cost-effectiveness

Schroeck’s team says understanding the value of treatment with new technologies will become more important as society and policymakers move to accountable care organizations, which are groups of doctors, hospitals, and health care providers who give high-quality care to Medicare patients; to value-based reimbursement, which ties payments for care delivery to the quality of care provided and rewards providers for efficiency and effectiveness; and to bundled payments, a strategy to reduce health care costs through a payment made to providers for services based on the expected costs of a treatment.

“Since value is defined as outcomes relative to cost, we will need more accurate ways of capturing cost and outcomes of treatment using approaches, such as prospective population-based prostate cancer registries,” Schroeck and his colleagues write. “We encourage physicians and patients to participate in such registries whenever possible.”

“Everything really hinges on producing more certain results in terms of whether the outcomes are really better with the new technologies,” Schroeck says. “I would hope that the Australian trial will shed some more light onto this. “Once this has happened, updated cost-effectiveness analyses will likely be performed.”