Parity Among Prostate Cancer Treatments?

Report suggests similar effectiveness among options for managing low-risk prostate cancer

A comprehensive appraisal of the management and treatment options for low-risk prostate cancer found that the rates of survival and tumor recurrence are similar among the most common treatment approaches, although costs can vary considerably. The report was prepared by the Institute for Clinical and Economic Review (ICER), a leader in comparative effectiveness research based at the Massachusetts General Hospital's Institute for Technology Assessment.

Bringing together the findings from three previous reviews completed by ICER, the final summary report, "Management Options for Low-Risk Prostate Cancer: A Report on Comparative Effectiveness and Value," compares multiple approaches to managing the most common non-skin cancer among U.S. men:

• Active surveillance, a "watch and wait" strategy with careful monitoring and referral for surgery or radiation if necessary;
• Radical prostatectomy, surgical removal of the prostate via traditional "open" or robot-assisted approaches;
• Brachytherapy, implantation of radioactive seeds in the prostate;
• Intensity-modulated radiation therapy (IMRT) and proton therapy, two forms of external radiation therapy.

The ICER review found that there are no definitive head-to-head studies comparing these options, but that accumulated evidence from multiple studies over the years suggests that overall survival and the rate of cancer recurrence are quite similar among all options, including active surveillance. There are different risks for certain side effects and complications, but no treatment option stands out as superior overall. Because low-risk prostate cancer is typically slow-growing and may not cause any symptoms, active surveillance is a reasonable option, particularly for men 65 and older, approximately half of whom will never have their cancer progress to the point of requiring treatment.

"ICER's review provides a welcome objective summary of what we know and what we don't know that can help men in conversations with their doctor," stated David Most, PhD, prostate cancer survivor and Founder and President of Health Information Research, Inc., who was a member of the Evidence Review Group that participated in the ICER appraisal process. "Given the numerous sources of information we have on the different management options, it really can be difficult to know what to do. Having a report like this from ICER will help patients make informed healthcare decisions that reflect their values about the risks and benefits among the different options."

The ICER report included a review of published literature on the treatment of low-risk prostate cancer as well as simulation modeling to project the long-term effects of each treatment approach. The evidence on radical prostatectomy, brachytherapy, and IMRT was judged to demonstrate comparable overall clinical effectiveness for most men, while there was not enough evidence to date to make a comparison on proton therapy.

The evidence on active surveillance was stronger for older men, and therefore ICER rated its clinical effectiveness as comparable to immediate treatment for men 65 and over. Long-term outcomes with active surveillance are not yet available, but for younger men active surveillance may still be a reasonable option given that surgery or radiation can be done if regular blood tests and prostate biopsies suggest the cancer is growing.

The ICER report also found that, based on Medicare payments, active surveillance costs approximately $300-$1,000 per year, while brachytherapy and radical prostatectomy procedures cost approximately $10,000. IMRT and proton therapy are more expensive, costing $20,000 and $35,000 per treatment course, respectively.