Treatment-Specific Out-of-Pocket Costs for Patients Undergoing Localized Prostate Cancer Journal Club - Christopher Wallis & Zachary Klaassen

January 5, 2023

In this UroToday Journal Club Christopher Wallis and Zachary Klaassen highlight the Urologic Oncology publication entitled Out-of-pocket costs for commercially insured patients with localized prostate cancer.  Financial burdens may contribute to long-term effects on patient's health-related quality of life. However, costs are rarely included in shared decision-making conversations, and most studies available have focused on the insurer's perspective for cost-effectiveness evaluation, rather than the cost born by individual patients' out-of-pocket costs. This study sought to examine the first-year out-of-pocket costs associated with common localized prostate cancer treatments among patients who are commercially insured in the US.

Biographies:

Christopher J.D. Wallis, MD, Ph.D., Assistant Professor in the Division of Urology at the University of Toronto.

Zachary Klaassen, MD, MSc, Urologic Oncologist, Assistant Professor Surgery/Urology at the Medical College of Georgia at Augusta University, Georgia Cancer Center


Read the Full Video Transcript

Christopher Wallis: Hello, and thank you for joining us for this UroToday discussion of a recent publication, Assessing Out-of-Pocket Costs for Commercially Insured Patients With Localized Prostate Cancer. I'm Chris Wallis, an Assistant Professor in the Division of Urology at the University of Toronto. With me today is Zach Klaassen, Assistant Professor in the Division of Urology at the Medical College of Georgia.

Seen here is the citation for this recent publication in Urologic Oncology that we contributed to along with the team at Vanderbilt. Localized prostate cancer is a complex disease space with many treatment options that may be guideline-recommended for any given patient. These include active surveillance, surgery, and radiotherapy. Shared decision making is therefore key for patients with localized prostate cancer, and is often based on discussions of efficacy, toxicity, functional outcomes, patients' values and priorities, and physician recommendations.

However less considered is the financial burden associated with treatment. We know that financial burden may contribute to long-term effects on patients' health-related quality of life. However, costs are rarely included in shared decision-making conversations, and most studies available have focused on the insurer perspective for cost-effectiveness evaluation, rather than the cost born by individual patients out-of-pocket costs.

Thus, we sought to examine the first-year out-of-pocket costs associated with common localized prostate cancer treatments among patients who are commercially insured in the US. To do so, we relied on the IBM Watson Health MarketScan Commercial Claims and Encounters Database. This provides de-identified patient-level data among patients who are commercially insured for all health services they receive. This includes health insurance enrollment, inpatient and outpatient medical claims, as well as outpatient pharmacy claims. And for each claim, we can capture the total amount reimbursed stratified by that born by the insurer and that for the patient.

In this study, we accrued a study population of patients with incident prostate cancer defined through this flow diagram here. We first examined all patients with prostate biopsies and then restricted this to men aged 18 years or greater at index. We required continuous enrollment for 180 days prior to biopsy and excluded men who had hospitalizations in the 30 days prior to biopsy. We then required linkage to a prostate cancer diagnosis and subsequent enrollment in a health plan for at least 12 months to allow outcome ascertainment.

In terms of exposures, we considered the initial treatment approach, whether surgery, radiotherapy, or observation, regardless of whether secondary treatments were needed. Surgery included both open and robotic surgery and radiation included a standard IMRT, stereotactic radiotherapy, proton beam radiotherapy, as well as low and high dose-rate brachytherapy. The observation was defined as the absence of treatment within one year following the biopsy. This initial treatment approach was used to categorize patients, and we then examined the use of ADT.  Each of these was captured using CPT and HCPCS codes.

The primary outcome was out-of-pocket cost born by the patient as the sum of co-insurance, co-payments, and deductibles. Secondarily, we considered total costs, including both patient-born and insurer-born costs. All costs were inflation-adjusted to 2018 US dollars, and the outcome was stratified into the first six months versus six to 12 months following a diagnosis. We considered patient-level covariates, including age, comorbidity, insurance type, pre-index health costs, employee relation, region of residence, and index year to adjust our models.

In terms of modeling, we used propensity score weighting to adjust differences in patient-level characteristics between the treatment approach. We use generalized estimating equations using the log link and Gamma distribution to assess the association between treatment approach and cost in this propensity score-weighted cohort. Because the use of ADT is non-independent of treatment with use more common in patients receiving radiotherapy, it was not included in the propensity score, and we've performed stratified analysis according to ADT use.

Now I'm going to hand it over to Zach to walk through the results of this analysis.

Zachary Klaassen: Thanks, Chris. These are the baseline characteristics divided by the treatment group. This is a big table one. So I've divided this into two different slides. We can see here on the left, this is prior to propensity score weighting, and on the right is following the propensity score weighting analysis.  In terms of surgery, there were 15,854 patients who underwent surgery, 5,265 underwent radiation, and 9,241 had no treatment. The median age among these patients was just under 60 years of age. The most common insurance plan was a PPO or an EPO at just under 60%. There is relatively equal delineation in terms of the region across the US, with the majority of patients being Charlson Comorbidity Index of zero at over three-quarters of the patients.

In terms of the type of employee relation for insurance, most of these patients were on their own insurance at more than three-quarters of the patients. In terms of concurrent ADT, the majority of patients did not have concurrent ADT, except for 33.9% of patients undergoing radiation had concomitant ADT.  To finish off table one, we looked at the pre-index out-of-pocket healthcare costs at six months. The median out-of-pocket cost for surgery was $457, $479 for radiation, and no treatment was $475.

This is an important table looking at the counts and costs associated with each treatment approach. In terms of the no treatment cost, the crude median out-of-pocket cost was $1,123, with the mean total crude cost for no treatment of $8,336. This certainly goes up with both radiation and radiotherapy. In patients undergoing surgery, the crude out-of-pocket cost was $2,578. The total cost to the healthcare system was $34,014. Moving down to radiotherapy, the crude median out-of-pocket cost was comparable to surgery at $2,402, but was more than surgery in terms of the crude total cost at more than $46,000.

This table looks at the propensity score weighted comparison of total treatment costs adjusted to 2018 USD by the period of diagnosis. So we can see here in the top half of this table, this is total spending from months zero to six, with $23,928 for no treatment, $39,831 for surgery, and $55,871 for radiation. When we look at months six to 12, we see that no treatment costs were $10,646, compared to $14,093 for surgery and $22,132 for radiation. So both in the zero to six months and six to 12 months, in terms of total treatment costs, which is essentially the cost to the healthcare system, radiation was more costly than surgery and no treatment.

This is a similar table, but looking at out-of-pocket treatment, so the cost to the patient, and we see that in the first six months, no treatment costs were $1,746, surgery costs at $2,983, and radiation costs at $3,139. At months six to 12 for all three modalities, essentially similar costs, with no treatment costing $788, surgery costing $824, and radiation costing $866.

So several discussion points from this cost analysis specifically focus on out-of-pocket costs. This study accurately quantified out-of-pocket costs associated with prostate cancer management and is essential to provide patients with informed expectations of how the cost of their treatment may affect their financial and overall wellbeing.

Active treatment incurred significantly higher out-of-pocket costs compared to no local treatment, with minimal differences in out-of-pocket costs for radical prostatectomy and radiotherapy. What we know is that the financial implications of treatment are rarely discussed, with two-thirds of cancer patients desiring to have these discussions with their physician, but only one-third of physicians having these discussions with their patients.  The main limitation of the study was that this study evaluated privately insured individuals. And so these findings may not be generalizable to patients insured by other means, such as Medicare or Medicaid.

So in conclusion, out-of-pocket costs associated with common management strategies for localized prostate cancer and privately insured patients ranged from $2,359 to $3,608 within the first year of diagnosis. These findings suggest lower financial toxicity associated with active surveillance as treatment of any kind.  Either radiotherapy or radical prostatectomy was associated with significantly higher out-of-pocket costs compared to no treatment. And as we discussed, there was little difference between patients that were treated with radiotherapy or radical prostatectomy.  Importantly, these findings may better inform shared decision-making and provide clear financial expectations for patients and their families.

Thank you very much for your attention. We hope you enjoyed this UroToday Journal Club discussion.
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