Quality of Life and Economic Considerations in the Management of Prostate Cancer

Abstract

The purpose of this article was to provide an overview of the morbidity and mortality of prostate cancer, QOL issues and the economic impact of the disease. We searched Medline (from 1990 onwards) for all studies dealing with prostate cancer epidemiology, treatment, screening and staging, and critically reviewed the most relevant articles, focusing on pharmacoeconomic issues. Prostate cancer is the most common cancer in men. In the US, new estimated cases of prostate cancer represented 14.8% of all new cancer cases for 2000, with estimated deaths from prostate cancer comprising 5.8% of all deaths from cancer. Current options for prostate cancer management include radical prostatectomy, cryosurgery, radiotherapy, hormone therapy and watchful waiting. Many of the long-term effects of treatment, such as urinary incontinence, impotence and radiation-induced proctitis, have a large impact on patients' quality of life and, in some patients, may offset the clinical benefits. Regulatory bodies and managed care organisations are assigning increasing importance to the evaluation of QOL benefits as an independent clinical endpoint and a measure of patient satisfaction. Several screening programmes for early detection of prostate cancer, mostly based on prostate-specific antigen (PSA) measurement or digital rectal examination, have been proposed, but their routine implementation in all asymptomatic elderly men has been questioned. There is still no definite proof that patient outcomes are improved by extensive PSA screening. Furthermore, the total cost of a screening programme is difficult to define since it extends well beyond the initial test. Several instruments are used for QOL assessment in prostate cancer, some of which have been specifically developed for, or adapted to, patients with this disease, such as the Functional Assessment Cancer Therapy (FACT) tool, Prostate Cancer Treatment Outcome Questionnaire (PCTO-Q) and Prostate Cancer Specific Quality of Life Instrument (PROSQOLI). More than 50% of treatment costs for prostate cancer are accrued during the patient's last year of life, and total initial care costs decrease with increasing age. In the US, initial average inpatient costs were estimated at $US 2253, in 1995, for men aged > or =80 years, compared with $US 4540 for men aged 35-64 years. In recent years, treatments based on combined modalities (i.e. radiotherapy/prostatectomy plus hormonal therapies) have emerged. Although cost-effectiveness analyses of various treatment options have been attempted, the strength of their conclusions appears to be limited by the lack of homogeneous literature data on the effects of such interventions on survival and morbidity.

Leuprolide acetate 1-, 3- and 6-monthly depot formulations in androgen deprivation therapy for prostate cancer in nine European countries: evidence review and economic evaluation

“…Even though the reviewed studies demonstrated lower costs achieved with surgical castration, the authors concluded that orchiectomy could not be recommended when accounting for the extended indications for temporary hormone deprivation 53. In addition, the cost advantage of orchiectomy versus hormonal treatment may not be evident in all patients when considering the length of hospitalization following surgery and the duration of hormonal treatment being critical in economic evaluation 54. In Sweden, orchiectomy and hormonal treatments were found to be equivalent at 8 days of hospitalization and 18 months of hormonal treatment 55.…”

L-carnitine has a protective effect on the colonic mucosa during abdominopelvic radiotherapy in rats

“…These effects also limit the radiation dose applied, which is the most important factor affecting the efficacy of this treatment 3 .…”

Comparison of Endoscopic Therapies for Chronic Radiation Proctitis: A Systematic Review and Meta-Analysis

“…Up to 20 percent of patients with acute radiation proctitis will have symptoms that are severe enough to necessitate an interruption in radiation treatment [16,28,29]. In patients with persistent or severe bleeding due to chronic radiation Colo-Proctopathy (CRCP) and that fail to respond to sucralfate therapy for four weeks, endoscopic therapy with (APC, formalin, and BEC) are indicated [43][44][45].…”

“…Other effective therapies described are the argon and Nd: YAG laser, cryoablation, bipolar electrocoagulation (BiCap), heater probe, hyperbaric oxygen therapy (HBO), hormonal therapy, antioxidants and metronidazole [26,27]. Several studies including systematic reviews have reported an improvement in symptoms, but it is still not sufficiently clear which therapy is better [28,29].…”