AJMC: In Treating Prostate Cancer, Choices for Patients and Challenges for Clinicians, Payers

Not long ago, the range of options for a man diagnosed with prostate cancer was fairly narrow: surgery, radiation, or limited chemotherapy choices. Today, there are so many new therapies on the market, with so many possibilities for drug combinations and sequencing, that the questions for clinicians are complex: It's not just which therapy or which drug, but for how long and when do you switch?

FOR IMMEDIATE RELEASE SEPTEMBER 18, 2013

In Treating Prostate Cancer, Choices for Patients and Challenges for Clinicians, Payers

PLAINSBORO, N.J. — Not long ago, the range of options for a man diagnosed with prostate cancer was fairly narrow: surgery, radiation, or limited chemotherapy choices. Today, there are so many new therapies on the market, with so many possibilities for drug combinations and sequencing, that the questions for clinicians are complex: It’s not just which therapy or which drug, but for how long and when do you switch?

The blessing of many new choices for prostate cancer patients, the challenges those choices bring, and the best environment for clinical decision-making were discussed in the latest expert panel convened recently by The American Journal of Managed Care.

The discussion, moderated by AJMC co-editor-in-chief A. Mark Fendrick, MD, also examined specific agents used in the treatment of prostate cancer, including new immunotherapies. Panelists were:

  • David Crawford, MD, section head of Urologic Oncology and professor of Urologic and Radiation Oncology, University of Colorado at Denver, University of Colorado Hospital;
  • Daniel George, MD, director, Prostate Clinic, Genitourinary Oncology, Duke Cancer Institute;
  • Neal D. Shore, MD, medical director of the Carolina Urologic Research Center, Myrtle Beach, South Carolina.

All three panelists took issue with the May 2012 recommendation from the United States Preventive Services Task Force (USPSTF), which said that the PSA test used for prostate cancer screening could actually do harm to those men who do not understand its consequences. The USPSTF recommended against widespread screening, even though the PSA test has been credited with significantly reducing prostate cancer mortality rates since the 1980s.

Crawford, who has published widely on the subject, said that the PSA test “was too successful” in some ways, but that not screening was the wrong response when 30,000 men still die from the disease each year. “You need to separate diagnosis from treatment,” he said.

Shore said the PSA test has value if used “judiciously.” The biggest risk, he said, would be making “a blanket decision not to screen.”

Excitement and Challenges

Once prostate cancer is identified, about 60 percent of those who test positive for prostate cancer require active intervention, including some form of chemotherapy. The costs associated with treatment can vary, depending on how early the cancer is caught and how aggressive it is. The panelists all advocated a multidisciplinary, “team” approach to treatment. The patient should be aware of the full range of options and not end up with a treatment just because that’s the specialty of the doctor he visited.

What’s both challenging and promising now, according to George, are the numbers and potential combinations of therapies available to clinicians, even though, he said, “we don’t necessarily have the data on using these in sequence or in combination.”

As George explained, the choices today are not different forms or brands of the same drug class, but completely different treatment alternatives. “These are not ‘me-too’ drugs,” he said. The panel discussed the merits and potential combinations of abiraterone (Zytiga) and sipuleucel-t (Provenge), among others.

Thus, treatment for prostate cancer holds more promise than ever. “We may be able to convert this disease into a chronic disease,” Crawford said.

Payment and Disparities

But how, Fendrick asked, do insurers, employers and Medicare and Medicaid decide what to cover from among all these new agents and combinations? “It’s harder for the payer community to get the right treatment to the right patient at the right time,” he said.

Crawford speculated that any high short-term cost of figuring out what will save a patient’s life will prove worth the investment in the long run, as the cost of treatment comes down. Clinicians have been using targeted screening and treatment for a longer period than people realize, he said, and the use of biomarkers and genetic tests to better match the treatment to the patient will only advance.

Shore, who comes in contact with many patients who lack access to the most innovative therapies, said that guidelines from the National Comprehensive Cancer Network (NCCN) become critical, because their recommendations determine whether Medicare and Medicaid will fund a drug or drug combination.

For all the promise in prostate cancer treatment, however, Shore said enormous disparities exist. “There is virtually upwards of 100 percent differential in mortality through much of the Southeast of the United States and in virtually in every urban metropolitan city of this country, and it speaks to receiving inadequate care, inadequate screening, inadequate treatment, and that’s real low hanging fruit to do away with that disparity.”

To listen to the full discussion, click here.

CONTACT: Nicole Beagin (609) 716-7777 x 131

nbeagin@ajmc.com

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