Managed Care Implications in Castration-Resistant Prostate Cancer

Published Online: December 30, 2013
Indu Lew, PharmD
The management of prostate cancer (PrCa) and especially castration-resistant disease can be complex, challenging, and costly. Significant developments in the field of oncology have led to the further development of safe and effective therapies that are better targeted to particular tumor types and to individual patients. This is evident in castration-resistant prostate cancer (CRPC), where 5 new therapies proved to increase overall survival have debuted in just the past few years. With new therapies, however, come new treatment paradigms and new potential costs. It is vital that managed care clinicians and providers analyze the burden and the costs of cancer in the United States, especially those relating to PrCa and especially CRPC. This will allow a better understanding of how costs and issues relating to healthcare utilization affect the treatment of patients with CRPC, and impact individualized therapy and management decisions.

(Am J Manag Care. 2013;19:S376-S381)
The Burden and Costs of Cancer in the United States

Significant and rapid clinical progress has been made in the field of oncology over the past 2 decades, mainly due to the development of effective targeted therapies for numerous different types of cancer. With these developments, the overall incidence of cancer has declined since the 1990s, with survival improving for many types of cancer, including prostate cancer (PrCa).1,2 It has been estimated that as of 2010, there were approximately 13.8 million men and women in the United States still alive who had a history of cancer.2 The prevalence of cancer survivorship is expected to be even greater in the future, with the population of survivors projected to reach 18.1 million in 2020, due to the aging and growth of the US population as well as improved survival following diagnosis consequent to advances in screening, detection, and treatment.2,3 This increasing number of cancer survivors will receive continuous medical care throughout the trajectory of their disease, starting with diagnosis, and including short-term side effects, late or lasting impacts of disease, and its treatment. Because the incidence of cancers is highest among elderly patients, with people 65 years or older accounting for 8 million of the 13.8 million cancer survivors who were alive in 2010, the impact of this population growth on cancer prevalence may be greater than the declining incidence rates for some forms of cancer. Overall, the number of cancer survivors and cancer-related expenditures is likely to increase substantially in the United States.1 Trends toward a greater intensity of healthcare service utilization and increasing costs of cancer care are expected to result in an increased general cancer-related burden in this country. Estimating and projecting the economic burden of cancer, including healthcare expenditures, loss of productivity, and morbidity and mortality, for patients and their families is an increasingly important issue for healthcare policy makers, health systems, physicians, employers, and society overall.3

Along with incidence and survival, practice patterns for the management of cancer have been constantly evolving for the majority of tumor types, and it is especially important to assess the cost burden in this particularly dynamic facet of healthcare. One recent study published in 2011 evaluated the costs of cancer care in the United States by utilizing cancer incidence and survival models from the Surveillance, Epidemiology and End Results (SEER) program data. Taking into account the assumptions of constant incidence, survival, and associated costs, the study projected 13.8 and 18.1 million cancer survivors in 2010 and 2020, respectively. Based on the growth and aging of the US population, medical expenditures for cancer in the year 2020 were projected to reach at least $158 billion (in 2010 dollars), which represents an increase of 27% over 2010, according to an analysis by the National Institutes of Health.1

Identifying phases of care, including the initial period following diagnosis, the last year of life, and the interim between these 2 milestones, the average annualized costs of care were highest in the last year of life among all cancer types. However, the largest increases in costs between 2010 and 2010 were estimated to be in the continuing phase of care for PrCa (42% estimated increase from approximately $6.02 billion to $8.81 billion [in 2010 US dollars]), followed by female breast cancer (32% estimated increase from approximately $6.85 billion to $8.90 billion [in 2010 US dollars]). It was also estimated that if costs of care increase annually by 2% in the initial and last year of life phases of care, the total costs of cancer care in 2020 would actually reach $173 billion, a massive 39% increase over 2010 costs.1 With PrCa associated with such a substantial clinical and cost utilization burden, it is important to explore the healthcare utilization and economic burden related to PrCa and its implications for managed care practice and cost management.

The Costs Associated With PrCa in the United States: Different Study Foci and Different Data

Determining the actual cost burden of PrCa and its management can be challenging, and analyses may vary depending on the focus and the parameters researched. Various analyses have evaluated the economic burden of PrCa by examining the costs associated with different phases of care, the short- and long-term costs of various treatment modalities, and estimates of the potential lifetime economic burden associated with the disease. While analyses may vary in focus, each provides a valuable set of data and insights into the costs of disease management and the potential impact of these expenditures on patients and providers.3-5

Costs Related to Phase of Care

The various costs associated with cancer care are often reported from the time of initial diagnosis or from the time of a specific cancer-related event for a select group of patients with cancer, defined by clinical characteristics (ie, incidence costs), or for all survivors of that cancer type in a specific year (ie, prevalence costs).3 Costs and expenditures may vary depending upon the phase of care. In a study by Yabroff et al, which evaluated the economic burden of cancer in the United States, it was estimated that the prevalence costs of care for PrCa was $11.9 billion in 2010, which reflected the absolute number of cancer survivors by phases of care and by annualized phase-specific cost estimates. A larger proportion of prevalence costs was found in the continuing phase of care, as opposed to the initial phase of care or within the last year of life, since PrCa is a tumor type associated with longer survival than other cancer types (ie, lung and pancreatic cancers). Costs tend to be concentrated during the initial treatment phase and end-of-life care. Although the annual costs accumulated during the continuing phase tend to be lower, those costs may exceed the costs associated with early and late treatment, especially in cancers associated with long-term survival.1,3

Short- and Long-Term Costs: The Impact on Disease Management

PDF is available on the last page.