A decision analysis comparing 3 active surveillance protocols for the treatment of patients with low-risk prostate cancer.

BACKGROUND: Active surveillance (AS) is a viable management option for approximately 50% of men who are newly diagnosed with prostate cancer. To the authors' knowledge, no direct comparisons between the different variants of AS protocols have been conducted to date. The authors developed a microsimulation decision model to evaluate which of 3 alternative AS protocols is optimal for men with low-risk prostate cancer, and compared each of these with immediate treatment. METHODS: Men who were diagnosed with low-risk prostate cancer at age 65 years were modeled as having been treated with either immediate therapy or via each of 3 AS protocols. Modeled AS protocols represent those in the literature; a modified AS protocol was included in a sensitivity analysis. Immediate therapy included radical prostatectomy, external-beam radiotherapy, or brachytherapy. Outcome measures were quality-adjusted life-years (QALYs) and costs. Cost-effectiveness analysis and deterministic and probabilistic sensitivity analyses were performed. RESULTS: Immediate therapy produced fewer QALYs than all variants of AS. Of the AS protocols evaluated, biennial biopsy was found to be the only efficient option, with an incremental cost-effectiveness ratio of $3490 per QALY compared with immediate therapy. It delayed the need for curative therapy by a mean of 56 months, and was found to be preferred in >86.9% of cases in probabilistic sensitivity analysis. A modified version of low-intensity AS dominated all other options. CONCLUSIONS: For a 65-year-old man with low-risk prostate cancer, AS with biennial biopsy appears to be highly cost-effective compared with common alternatives. An AS protocol using triennial biopsy was found to dominate all other strategies and should be considered for men who are comfortable with a longer period between biopsies. The optimal strategy depends on a patient's tolerance for periodic biopsies and comfort with delaying radical treatment. Physicians should incorporate these patient preferences into decision making.

Benign prostatic hyperplasia: epidemiology, economics and evaluation.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is arguably the most common benign disease of mankind. As men age, the prostate inexorably grows often causing troubling symptoms causing them to seek out care. While traditionally treated by transurethral resection or open surgical removal of the hypertrophied adenoma, today the urologist has numerous medical, surgical and minimally invasive techniques available. In this supplement The Canadian Journal of Urology provides a review of the various techniques and medications available today. MATERIALS AND METHODS: As an introduction to the supplement, the aim of this article is to review the epidemiology and economy of BPH as well as its natural history and diagnosis. A systematic review of available literature was looking for articles on BPH and its epidemiology, economics, natural history and management using PubMed database. RESULTS: The prevalence of this condition is increasing with the population aging and so does the economic burden. The exact etiology of this condition is unknown, but some risk factors have been identified. The diagnostic and treatment of this very common disease should rely on a strong collaboration between primary care physician and urologist. CONCLUSION: There are multiple options in treating BPH including medical, surgical and newer minimally invasive options. The challenge with having a variety of options is to review them with the patient and help the patient select the best treatment option for their condition.

The practice of urologic oncology: some economic realties.

The future practice of urologic oncology in the United States will be influenced by a variety of factors. The national economic crisis has already impacted reimbursement and coverage for clinical care and has had a direct effect on the level of research funding. Unhealthy lifestyles by a significant segment of the American population contributes to a increased risk of most urologic cancers. Compounding these challenges is the aging of the urological workforce and projected significant manpower shortages. These multiple factors must be confronted directly or the future quality of urologic cancer care will be jeopardized.

Urologists on a tightrope: have we lost our balance?

The purpose of this review is to provide an analysis of recent changes in health care delivery and their implications for the future of urological practice. Google searches were conducted using keywords that served as section headings in the manuscript. The confluence of landmark changes in reimbursement, work hours, manpower issues, patients' expectations, litigation, and research funding has already had a marked impact on urological practice and will likely increase further. Urologists will need to intensify their efforts to educate the public and legislators as how to best preserve the most valued elements of urological practice and patient care.

The evolution of health care in America.

The evolution of health care in America had its beginnings even before the founding of the nation. This article divides the evolution of American health care into six historical periods: (1) the charitable era, (2) the origins of medical education era, (3) the insurance era, (4) the government era, (5) the managed care era, and (6) the consumerism era.

Medical malpractice: the good, the bad, and the ugly.

The underpinning of medical practice has always been patient care and patient safety. The past several decades, however, have seen an erosion of the patient-doctor relationship. A number of factors have contributed to the ongoing medical malpractice crisis that continues in the United States. There are three social goals of malpractice litigation: to deter unsafe practices, to compensate persons injured through negligence, and to exact corrective justice. This article examines how well the current system achieves these goals.

Economic impact of tumor markers in bladder cancer surveillance.

OBJECTIVES: Bladder cancer invokes the highest cost per patient from diagnosis to death and is the fifth most expensive cancer to treat overall, exceeding $3.4 billion annually. Current surveillance regimens require intense follow-up contributing to high cost and emotional burden. Bladder tumor markers hold the promise to reduce these costs, yet have not been widely adopted in oncological practice. We assessed the cost-effectiveness of bladder tumor markers in surveillance routines. METHODS: A MEDLINE search of all available literature concerning bladder tumor markers and cost-effectiveness was performed. We reviewed retrospective and prospective studies, reviews, opinion papers, decision analyses, and cost-effectiveness analyses. RESULTS: Bladder tumor markers exist in various stages of development and efficacy. Sensitivity and specificity values have been reported across a wide range, with tumor markers generally possessing a higher sensitivity and lower specificity than urine cytology. Several cost-effectiveness analyses have shown tumor markers significantly lower the cost of bladder cancer surveillance when using a modified regimen that lengthens intervals between cystoscopies. However, many of the studies rely on overconfident sensitivity and specificity estimates and do not incorporate data specific to recurrent bladder cancer. No comprehensive study incorporating utility analysis has been performed. CONCLUSIONS: Bladder tumor markers cannot definitively replace cystoscopy in surveillance regimens given the current evidence. Recent reports suggest potential for tumor markers to control the financial and emotional cost of bladder cancer care and improve quality of life. Until prospective analyses incorporating quality of life outcomes are performed, wider adoption of bladder tumor markers will be hampered.

Urologists on a tightrope--do we have a net?

PURPOSE: The purpose of this review is to analyze the current health care environment and its impact on urological practice. MATERIALS AND METHODS: The medical and lay literature as it pertains to the socioeconomics of health care was reviewed. RESULTS: Analysis of the political and economic factors that influence the delivery of health care today reveals alarming realities. More than 40 million Americans remain uninsured, and with a retrenched economy that number is likely to increase. Neither government nor the private sector has been either willing or able to address the health care problem in a coherent or comprehensive way. As the population ages, the Medicare and Medicaid programs will become further stressed. Employers are increasingly unwilling to finance the health care expenses of their employees. Academic medical centers are facing unique exigencies that, if left uncorrected, will jeopardize the future training of physicians. CONCLUSIONS: In the current environment of a depressed economy, further proposed tax cuts and increased military spending it appears inevitable that the economic restraints on medical care will increase substantially in the foreseeable future.