Utilization, Cost-Effectiveness and Long-Term Side-Effects of Androgen Deprivation Therapy for Patients With Prostate Cancer: Findings From a Large National Retrospective Cohort of Elderly Men
Prostate cancer is the second most common cancer among men worldwide and is the most common type of cancer diagnosed among men in the United States, except non-melanoma skin cancer. Along with surgery, radiation therapy and active surveillance, androgen deprivation therapy (ADT) is a therapy recommended for advanced disease. Despite its undeniable effectiveness in survival, many issues regarding ADT for prostate cancer patients remain controversial, including optimal time to start ADT, duration of treatment, ADT-related long-term side-effects and cost-effectiveness of different treatment strategies. We conducted a retrospective cohort study to examine the utility, cost-effectiveness and long-term side-effects of ADT for patients with prostate cancer with three specific aims: (1) To examine the receipt, time to initiation and duration of ADT among patients with high risk prostate cancer by socioeconomic status, race/ethnicity and geographic region; (2) To assess and compare the incidences of major long-term side-effects in patients treated with ADT and those not treated with ADT. The long-term side-effects included sexual dysfunction, bone fracture, diabetes, coronary heart disease, acute myocardial infarction and dementia; and (3) To determine the cost-utility of common treatment modalities currently available for intermediate and high risk prostate cancer. The data employed in this study was the SEER-Medicare linked database, one of the largest population-based sources of data of elderly population in the United States. Type and exact time of procedures that patients received were ascertained from Medicare claims using Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), International Classification of Disease-ninth revision (ICD-9) and revenue center codes. Incidences of side-effects were identified and estimated using ICD-9 codes in patients who were free of outcomes at baseline. The lifetime costs were estimated from health payer’s perspective and effectiveness of treatment was evaluated as either quality adjusted life years or life years gained. We applied the propensity score method to control for bias and confounding that were inherent to observational study. Various analysis methods such as logistic and linear regression, Kaplan-Meier curve, Cox proportional hazards regression and bootstrap simulation were used. This study confirmed the disparity of using ADT where Black men and men of other races were less likely to access the therapy. Patients in the South of the country initiated the therapy earlier than men living in other regions. We found strong and linear dose-response relationships between ADT and incident bone fractures and diabetes. The use of ADT also affected the development of new coronary heart disease, acute myocardial infarction, and dementia but with lesser extent. Radiation and surgery had deleterious impacts on patient’s sexual function. The radiation + ADT strategy increased median survival by 0.87 years compared to radiation only, at a cost of $51,454 /life year saved and $67,826/QALY from a healthcare payer perspective. Comparing to active surveillance, the incremental cost-effectiveness ratios of radiation + ADT were $54,553/life year gained and $184,352/QALY. In conclusion, this study confirmed the racial/ethnical and geographical disparities of using ADT. It systematically examined all potential ADT associated long-term side-effects and took these complications into consideration when assessing the cost-effectiveness of the therapy.
Nguyen, Chi Ha Hue, "Utilization, Cost-Effectiveness and Long-Term Side-Effects of Androgen Deprivation Therapy for Patients With Prostate Cancer: Findings From a Large National Retrospective Cohort of Elderly Men" (2017). Texas Medical Center Dissertations (via ProQuest). AAI10681940.