Abstract and Introduction
Background: High-volume surgeons with ≥250 radical prostatectomies provide superior oncological outcomes as evidenced by a lower rate of PSA recurrence (PSAR). The financial benefits of performing prostatectomies at high-volume centers (HVC) are unexplored.
Methods: A base case—referent scenario—where the share of prostatectomies at high- and low-volume centers were evenly divided at 50% was defined. Additional scenarios with increasing shares of prostatectomies at HVC with 10% increments were also modeled. Using a lower probability of PSAR as the only advantage of more experienced surgeons, the savings that would result from fewer recurrences, avoidance of salvage radiation therapy (SRT) and management of fewer men with metastatic cancer were calculated.
Results: The savings associated with performing 80% of radical prostatectomy at HVC were $177, $357 and $559 per prostatectomy at 5, 10 and 20 years, respectively. These savings would offset referral costs of up to $1833 per prostatectomy referral at no additional total societal costs. Given the longer average biochemical failure-free survival with prostatectomies at HVC, referral costs of more than $1833 may be cost effective.
Conclusions: Under the conservative assumption of accounting for lower rates of PSAR as the only benefit of surgery in an HVC, performing prostatectomies at an HVC was associated with savings that may offset part of the initial referral costs.
Prior studies have established the role of experience in improving oncological outcomes of radical prostatectomy (RP) in early-stage prostate cancer.[1,2] Estimates show that >80% of surgeons nationwide have an annual caseload of <10, but perform ~40% of prostatectomies. The impact of experience on outcomes is not limited to prostatectomy and indeed data is emerging in other pathologies such as bladder cancer and even non-cancer surgeries.[4,5] However, despite these outcomes data, the relationship between the improved outcomes and the additional costs of patient referrals to high-volume centers (HVC) remains unclear. This relationship is especially difficult to assess because of the lack of established survival advantage for prostatectomies performed in highly experienced hands.
This study aimed to evaluate, from a societal perspective, the cost implications of preferentially performing RP at HVC in view of improvements in effectiveness of the intervention primarily defined by the oncological outcomes.
Improved oncological outcomes[1,2] associated with performing RP at a HVC can result in overall savings in the costs of prostate cancer care as a result of fewer men requiring salvage radiation therapy (SRT). A lower rate of PSA recurrence (PSAR) may further translate into a lower rate of metastatic failure, assuming similar rates of progression from PSAR to metastatic disease for those that have surgery at HVC. This, in turn, may result in additional savings in costs of care for metastatic disease for patients treated at HVC. The primary objective of this study was defined as estimating the oncological outcomes and the cost savings associated with performing radical prostatectomies at high- vs low-volume centers. The secondary objective was defined as exploring the cost effectiveness of making referrals to a HVC by estimating the maximum referral costs under a willingness to pay of $50 000 per life year gained.
Prostate Cancer Prostatic Dis. 2016;19(1):84-91. © 2016 Nature Publishing Group