Increased resource utilization in men with metastatic prostate does not result in improved survival or quality of life
Cancer care and end-of-life (EOL) care contribute substantially to health care expenditures. Outside of clinical trials, there exists no standardized protocol to monitor disease progression in men with metastatic prostate cancer (mPCa). We set out to evaluate the factors and outcomes associated with increased surveillance imaging and serum PSA testing in men with mPCa.
Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2004 to 2012, we identified men diagnosed with mPCa with at least six months of follow-up. Extreme users were classified as those who had either received PSA testing greater than once per month, or received cross-sectional imaging or bone scan more frequently than every two months over a six-month period. We utilized multivariable logistic regression to examine patient and provider factors associated with extreme utilization. Association of extreme utilization with survival outcomes, costs, and quality of care at EOL, as measured by timing of hospice referral, frequency of ER visits, length of stay, ICU or hospital admissions were examined.
Overall, we identified 3,026 men with mPCa, of which 791 (26%) were defined as extreme users. Median follow-up for the extreme users was 2.4 years (IQR 1.3-4.0 years) and 2.6 years for the non-extreme users (IQR 1.5-4.2 years). Extreme users were more commonly young, White/non-Hispanic, married, higher earning, and more educated (p<0.001, respectively). Extreme utilization was not associated with improved quality of care at EOL. Yearly healthcare costs following diagnosis were $50,643 among extreme users and $35,493 among others, with costs being 36.4% higher among extreme users (95% CI 27.4%-45.3%, p<0.001).</p>
Increased monitoring among men with mPCa significantly increases healthcare costs, without definitive improvement in survival nor quality of care at EOL. The optimal monitoring of disease progression outside of clinical trial study designs remains to be determined for metastatic prostate cancer. In line with the Choosing Wisely campaign, testing should be reserved for those in whom findings will change management.