Five-year outcomes of men with localized low- or intermediate-risk prostate cancer are comparable after either intensity-modulated radiation therapy (IMRT) or prostate brachytherapy. But the latter treatment costs thousands of dollars less, according to an analysis published online in Brachytherapy.
Radiation oncologists at the Oakland University William Beaumont School of Medicine in Royal Oak, MI, analyzed five-year outcomes of more than 1,300 patients who received one or the other form of radiation therapy over a 17-year period. They also calculated the direct cost of each treatment based on 2010 Medicare reimbursement rates (Brachytherapy, June 22, 2012).
The group found that biochemical control, cause-specific survival, and overall survival were comparable for both types of patients -- low risk and intermediate risk -- regardless of the type of treatment. However, the average costs were dramatically different: as much as $20,000 more for low-risk patients receiving IMRT compared to brachytherapy, and $12,000 more for intermediate-risk patients.
Prostate cancer statistics
The American Cancer Society (ACS) estimates that one of every two men in the U.S. will develop some type of cancer in their lifetime. Nearly half of these cancers (43%) will be prostate cancer. In 2012, this equates to an estimated 241,740 new cases.
The median age of prostate cancer patients is 67 years, according to ACS. The society's most recent statistics, which are for calendar year 2008, show that 42% of all prostate cancer patients ages 65 to 74 undergo radiation therapy, along with 37% of patients ages 75 to 85 and 25% of men younger than 64.
Because so many patients who undergo radiation therapy are probably covered by Medicare, the issue of cost-effectiveness is important regarding prostate cancer treatment now and in the future, wrote lead author Dr. Chirag Shah, of the department of radiation oncology, and colleagues. They pointed out that costs to treat early-stage prostate cancer are expected to escalate due to increased use of IMRT and the aging baby boomer generation.
Outcomes
The study included a patient cohort of 1,328 men, of whom 57% had low-risk prostate cancer. Eligible patients had a prostate-specific antigen (PSA) level of 20 ng/mL or less, a Gleason score of 7 or less, and a clinical stage of T2b or less.
The 869 men (65% of total) who underwent IMRT received a median radiation dose of 75.6 Gy delivered in 42 to 44 fractions. Among those treated with brachytherapy, 252 patients (19%) had high-dose-rate (HDR) brachytherapy, receiving a median dose of 38 Gy delivered in four fractions. Low-dose-rate (LDR) brachytherapy with palladium seeds was administered to 207 patients at a median dose of 120 Gy, and these patients were more likely to receive hormonal therapy before treatment.
Five years following treatment, overall biochemical control, cause-specific survival, and overall survival between the groups that received either brachytherapy or IMRT were comparable. Biochemical control was better for low-risk patients who had IMRT (96.4%) than for patients who had LDR brachytherapy (86.6%), but it was comparable for those who had HDR treatment (90.5%).
For the intermediate-risk group, biochemical control was comparable for the LDR brachytherapy patients (89.4%) and the IMRT patients (87.5%), but it was lower for the HDR brachytherapy patients (75.2%). Otherwise, outcomes were comparable within either the intermediate-risk or low-risk groups, with intermediate-risk patients having slightly lower outcomes than low-risk patients.
Costs
The direct cost of each treatment included the space to deliver treatment, equipment requirements including LDR seeds and HDR source replacement, technical services, staffing requirements, and service contracts. Hormonal therapy costs were also included. Indirect costs for laboratory tests, imaging studies, and follow-up exams were not included because they were similar for all treatment regimens. Costs associated with treatment-related toxicities were also not included because they were comparable among the patient groups.
The average payment made by Medicare per patient was $9,938 for LDR brachytherapy, $17,514 for HDR brachytherapy, and $29,356 for IMRT. The costs to the hospital for each treatment were $2,395, $5,467, and $23,655, respectively.
Follow-up
AuntMinnie.com spoke with co-author Dr. Thomas Lanni Jr. to learn how the study has affected the type of radiation therapy administered to men with localized low- and intermediate-risk prostate cancer. The radiation oncology department has made the physicians of William Beaumont Hospital aware of the analysis. Options for different types of radiation oncology treatment are discussed at dedicated tumor boards and multidisciplinary clinics.
"We present patients with the option of brachytherapy, if they are eligible for the treatment, during our initial consultation with them," Lanni said. "We discuss the treatment, the amount of time each treatment takes, and the side effects."
"For patients who are not averse to the invasiveness of prostate brachytherapy treatment, most of them are very happy to hear about the reduction in the number of visits for treatment compared to IMRT," he continued. "We have seen some increase in the number of patients choosing brachytherapy over external-beam radiation therapy, especially with the continual education of the urologists."
The radiation oncology department has also implemented a number of treatment protocols to try to reduce the number of fractions for both external-beam radiation therapy and brachytherapy. Both options reduce the overall cost of therapy and allow the patients even greater reductions in the frequency of hospital visits, Lanni said.
When asked if the authors had presented their data to the U.S. Centers for Medicare and Medicaid Services (CMS), Lanni said that nothing had been discussed formally.
"However, we have reached out to our commercial payors in regard to some of the clinical outcomes from our patients using these therapies," he said.
