Expert perspectives on factors that inform prostate cancer therapy selection while keeping cardiovascular disease in mind.
John L. Fox, MD, MHA: As physicians, all of us want to improve patients’ longevity of life and quality of life. Because medicine is specialized and fragmented, the urologist is primarily looking at ways to improve the patients’ survival from their prostate cancer, when they have advanced prostate cancer. I don’t think we’re looking more comprehensively at how we can improve overall life expectancy. If we were to do that, we’d acknowledge that since 1995, cardiovascular mortality has exceeded prostate cancer mortality in patients with prostate cancer and incorporate that into our decision-making.
Unfortunately, I don’t think we have a good mechanism for looking at overall mortality in these patients and incorporating cardiovascular-risk factors into treatment decision-making. In the future, if we’re going to reduce total cost of care, we need to think about what the relative trade-offs are in those therapies. Ideally, if we could find a way of improving overall life expectancy, reducing prostate cancer mortality, and reducing cardiovascular mortality, that would be ideal. At the end of the day, the question is, is there good evidence to support therapies that reduce cardiovascular mortality, and what’s the relative cost of that? If we had a therapy that reduced the total cost of care, including the cost of the drug, who would argue against that?
Maria Lopes, MD, MS: In general, we look at efficacy [and] safety. Safety usually is at a high level in terms of adverse events. More becomes available in terms of clinical differentiation, particularly with respect to safety, event reduction, numbers needed to treat to avoid an event, and how different treatment options compare. That becomes really important. Many times we don’t have that information to be able to compare across regiments. Also, it starts to be more focused in the guidelines to help providers help patients make better-informed decisions, as well as for payers. We’re in a P&T [pharmacy and therapeutics] committee, trying to put together [or] look at prior authorizations, perhaps on what we should include. These become interesting opportunities to consider patient segmentation, and perhaps be proactive in terms of analytics to identify opportunities to educate providers, as we look holistically at the impact of treatment on other comorbid conditions and total costs.
John L. Fox, MD, MHA: Every health plan has a pharmacy and therapeutics committee where we evaluate new therapies for the treatment of any condition, including prostate cancer. The primary thing we’re looking at is the efficacy of that treatment in terms of reducing the unintended consequence of that disease, which in this case would be death. But we don’t consider safety or toxicities associated with that in our decisions. That’s the role of the medical oncologist and patient to weigh the risks and benefits of those therapies. That said, unless there’s a black-box warning on a drug, those adverse effects, or unintended consequences of a treatment, aren’t considered. In this space, should we be considering the cardiovascular unintended consequences? We probably should be. The fact of the matter is, that’s not commonly considered in our decision-making. In other words, the preponderance of evidence, although it’s not strong evidence, suggests that GNRH antagonists reduce cardiovascular risks compared with cardiovascular agonists. But they’re not in a preferred position, and we don’t require antagonist compared with agonist.
Transcript edited for clarity.