Wesley W. Choi

Cost Implications of the Rapid Adoption of Newer Technologies for Treating Prostate Cancer

PURPOSE Intensity-modulated radiation therapy (IMRT) and laparoscopic or robotic minimally invasive radical prostatectomy (MIRP) are costlier alternatives to three-dimensional conformal radiation therapy (3D-CRT) and open radical prostatectomy for treating prostate cancer. We assessed temporal trends in their utilization and their impact on national health care spending. METHODS Using Surveillance, Epidemiology, and End Results-Medicare linked data, we determined treatment patterns for 45,636 men age ≥ 65 years who received definitive surgery or radiation for localized prostate cancer diagnosed from 2002 to 2005. Costs attributable to prostate cancer care were the difference in Medicare payments in the year after versus the year before diagnosis. RESULTS Patients received surgery (26%), external RT (38%), or brachytherapy with or without RT (36%). Among surgical patients, MIRP utilization increased substantially (1.5% among 2002 diagnoses v 28.7% among 2005 diagnoses, P < .001). For RT, IMRT utilization increased substantially (28.7% v 81.7%; P < .001) and for men receiving brachytherapy, supplemental IMRT increased significantly (8.5% v 31.1%; P < .001). The mean incremental cost of IMRT versus 3D-CRT was

Overuse of Imaging for Staging Low Risk Prostate Cancer

10,986 (in 2008 dollars); of brachytherapy plus IMRT versus brachytherapy plus 3D-CRT was

Determinants of Performing Radical Prostatectomy Pelvic Lymph Node Dissection and the Number of Lymph Nodes Removed in Elderly Men

10,789; of MIRP versus open RP was

The effect of minimally invasive and open radical prostatectomy surgeon volume

293. Extrapolating these figures to the total US population results in excess spending of

Nerve-sparing technique and urinary control after robot-assisted laparoscopic prostatectomy

282 million for IMRT,

Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy.

59 million for brachytherapy plus IMRT, and

491 TIME TRENDS IN THE UTILIZATION OF HIGHER-COST TREATMENTS FOR PROSTATE CANCER, 2002-2007

4 million for MIRP, compared to less costly alternatives for men diagnosed in 2005. CONCLUSION Costlier prostate cancer therapies were rapidly and widely adopted, resulting in additional national spending of more than

1066 COMPLICATIONS OF PRIMARY VS. SALVAGE CRYOTHERAPY FOR PROSTATE CANCER

350 million among men diagnosed in 2005 and suggesting the need for comparative effectiveness research to weigh their costs against their benefits.

587 THE EFFECT OF NEO-ADJUVANT CHEMOTHERAPY ON RADICAL PROSTATECTOMY OUTCOMES IN INTERMEDIATE AND HIGH-RISK PROSTATE CANCER

PURPOSE Routine imaging for staging low risk prostate cancer is not recommended according to current guidelines. We characterized patterns of care and factors associated with imaging overuse. MATERIALS AND METHODS We used SEER-Medicare linked data to identify men diagnosed with low risk prostate cancer from 2004 to 2005, and determined if imaging (computerized tomography, magnetic resonance imaging, bone scan, abdominal ultrasound) was obtained following prostate cancer diagnosis before treatment. RESULTS Of the 6,444 men identified with low risk disease 2,330 (36.2%) underwent imaging studies. Of these men 1,512 (23.5%), 1,710 (26.5%) and 118 (1.8%) underwent cross-sectional imaging (computerized tomography or magnetic resonance imaging), bone scan and abdominal ultrasound, respectively. Radiation therapy vs surgery was associated with greater odds of imaging (OR 1.99, 95% CI 1.68-2.35, p <0.01), while active surveillance vs surgery was associated with lower odds of imaging (OR 0.44, 95% CI 0.34-0.56, p <0.01). Associated with increased odds of imaging was median household income greater than

16 OUTCOMES OF CRYOTHERAPY VS. BRACHYTHERAPY IN MEN WITH LOCALIZED PROSTATE CANCER

60,000 (OR 1.41, 95% CI 1.11-1.79, p <0.01), and men from New Jersey vs San Francisco (OR 3.11, 95% CI 2.24-4.33, p <0.01) experienced greater odds of imaging. Men living in areas with greater than 90% vs less than 75% high school education experienced lower odds of imaging (OR 0.76, 95% CI 0.6-0.95, p = 0.02). CONCLUSIONS There is widespread overuse and significant geographic variation in the use of imaging to stage low risk prostate cancer. Moreover treatment associated variation in imaging was noted with the greatest vs lowest imaging use observed for radiation therapy vs active surveillance.