Technologic Evolution in the Treatment of Prostate Cancer

The past decade has witnessed a host of technologic improvements in prostate cancer therapy. The three major modalities offered in most managed care plans include radical prostatectomy, external-beam radiation therapy (EBRT), and interstitial brachytherapy (seed implant). Continued technologic advancement has led to incremental improvements in the safety and effectiveness of each modality. However, these improvements have led to a significant increase in the cost of treatment.

The different treatment modalities have been variably affected by this cost increase. Robotic tools such as the da Vinci surgical system allow the surgeon to perform a radical prostatectomy with small incisions and unmatched precision. This improvement in technique has been associated with a cost increase compared to traditional open surgery and conventional laparoscopy.[1,2] Intensity-modulated radiation therapy (IMRT) permits more accurate targeting and prostatic dose escalation, while minimizing radiation dose to the bladder and rectum, but with the use of this novel technique, the cost of EBRT has skyrocketed.[1,3,4] Image-guided radiotherapy (IGRT) as well as stereotactic body radiotherapy (SBRT) are other emerging technologies that are also contributing to this increase in cost.

This increased cost of newer treatment modalities has to be weighed against competing interests. Managed care organizations may decide that the increased cost of newer therapies is not justified by the moderate improvements in outcome they produce. While this conclusion may seem reasonable from a societal perspective, it may conflict with the physician's imperative to fully inform patients under his care of the treatments that comprise the current standard of care, regardless of the economic arrangements under which he practices. Failure to offer managed care patients techniques within the standard of care is not only unethical, but may have costly legal ramifications. Practitioners involved in such situations could face legal action by patients who are not cured or who otherwise suffer complications that might have been avoided with newer technology or treatment modalities within the standard of care.

For example, as clinicians at the VA Puget Sound Health Care System and Group Health Cooperative active in the treatment of prostate cancer, we face stark choices in keeping up with technologic change because of the financial constraints inherent in our organizations. Our purpose in writing this article is to summarize current clinical, financial, and legal issues raised by recent technologic improvements. Clinicians and administrators alike must navigate a course that maintains a defensible standard of care within the confines of a limited budget while confronting the reality of rapidly rising health-care costs.

Radical Prostatectomy

Radical prostatectomy evolved from traditional open to conventional laparoscopic to robotic surgery in the course of 15 years. Both the academic and private urologic communities have embraced robotic surgery. Most centers purchase the robot. Theoretical advantages of this technology include less invasive surgery, less blood loss, quicker hospital discharge, and quicker recovery time, which should translate into less lost wages on the part of the patient. However, comparison of length of hospital stay in one large series revealed no difference between radical retropubic prostatectomy and robot-assisted laparoscopic prostatectomies.[5]

There is also a widely held belief that this technologic breakthrough leads to less incontinence and better potency preservation. For instance, one study asserted that postoperative urinary continence after robot-assisted laparoscopic radical prostatectomy was as high as 90%.[6] In one questionnaire-based analysis of outcomes after robotic radical prostatectomy with or without nerve-sparing and prostatic fascia–sparing techniques, investigators reported that 97% of the patients who underwent this procedure could have an erection adequate for intercourse, compared to 74% of the patients who underwent conventional open prostatectomy.[7] These percentages for robotic surgery are favorable; however, randomized comparisons of outcomes between robot-assisted vs conventional radical prostatectomies have not been performed.

As robotic surgery becomes standard in the community, hospital administrators will have increasing difficulty attracting oncologic surgeons if the robotic tools are unavailable in their facilities. Most importantly, patients themselves are beginning to push for robotic technology due to encouragement from private and public information sources including TV, print advertisements, and the Internet.

Although it may offer some clinical advantages, robotic surgery has increased the cost of prostatectomy substantially. Based on Medicare reimbursement for the year 2007, the total allowable reimbursement for a radical prostatectomy as an inpatient procedure is approximately $17,000.[3,4] In contrast, the robot has a $1 million purchase cost, a $100,000 to $200,000 annual maintenance fee, and approximately $2,000 to $3,000 in disposables per case.[1,8] The costs for the robot increase the cost of prostatectomy from approximately $17,000 to $25,000/patient (Figure 1).