Two public health issues are often cited by proponents of health care reform. One is that the United States (US) outspends other developed countries per capita on health care with no appreciable benefit and that cance care is a major contributor to that cost. Mariotto and colleagues1 have estimated that in 2010, total cost of US cancer care was $124.57 billion with $11.85 billion attributed to prostate cancer. With the graying of the American population this number will only become staggeringly larger. In fact, they estimate $157.77 billion in overall cancer expenditures in 2020 with the largest increases in the ongoing care of patients with prostate (42%) and breast cancer (32%). More concerning is that these estimates are based only upon increases in the US population and do not factor in the costs of new technologies and therapeutics. A conservative estimate that the cost of prostate cancer care when coupled with increasing survival could rise to $16.3 billion annually, a 38% increase from 2010 to 2020.
Are we getting our money’s worth for prostate cancer care? Phillipson and colleagues2 reviewed per capita spending in European countries for a variety of cancers including prostate cancer over a 16 year period. They noted that US cancer patients experienced greater survival gains than their European counterparts even after considering higher US costs. The additional survival gain was highest in prostate cancer, estimated at $627 billion, with the findings not driven solely by earlier diagnosis.
Since older Americans represent a relatively small part of the population yet account for over 50% of cancer cases, government funded health care resources pay a large portion of these expenditures. According to an editorial in a major financial newspaper, the government needs to enact $716 billion in Medicare cuts to pay for the millions of Americans who will participate in new publicly funded health insurance. The new health care law created an Independent Payment Advisory Board to help decide which treatments should be covered in an attempt to control costs, similar to programs in some European socialized care systems.
With the statistics noted above, prostate cancer will surely be at the top of the list for any health care cost cutting. Sides are lining up on how to manage resources to reduce these growing expenses.
The Coverage and Analysis group at the Centers for Medicare and Medicare Services recently requested the U.S. Agency for Healthcare Research & Quality (AHRQ) to review radiation treatments for clinically localized prostate cancer. Benefits of radiation compared to no treatment could not be determined and the comparative effectiveness on survival between different forms of radiation was also inconclusive. Higher priced proton beam therapy for prostate cancer has begun to see a rise in insurance company denials based on some assessments of no appreciable benefit in this disease. Robotic prostatectomy costs and the price tags of the latest medications for prostate cancer have been called into question on many fronts.
Professional and patient advocacy groups are being proactive in expense reductions by promoting the “less is more” concept for prostate cancer care. This includes reducing unnecessary imaging for early disease and encouraging the expanded use of active surveillance.
A recent JAMA survey indicated that physicians strongly believe that other health care stake holders, including lawyers, insurance companies, hospitals, pharmaceutical companies, and patients themselves all also bear responsibility for reducing healthcare costs. Cooperation between all parties will be essential to maintain the quality of care while being fiscally sound.
Prostate cancer is and will remain a high value target for cost containment. When these reductions begin to take shape, careful consideration and unbiased discussions will be needed to preserve the dramatic advances achieved in prostate cancer care over the last 20 years.
Leonard G. Gomella, MD Thomas Jefferson University Philadelphia, PA
© The Canadian Journal of Urology™; 20(5); October 2013