Similar effectiveness in treatment options for low-risk prostate cancer

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

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

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

    The ICER report included a review of existent 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 ICER report concluded 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 watchful waiting. Of course, 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, prostate active surveillance seems to be 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.

    The known evidence on radical prostatectomy, brachytherapy, and IMRT was reviewed 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 prostate cancer treatment in men 65 and over. One conclusion is that 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. On the other hand, the ICER report also concluded that, based on Medicare payments, active surveillance costs are lower that any other treatment. For instance prostate watchful waiting costs are 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.

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    Source: Massachusetts General Hospital



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