A new study compares outcomes among younger men with prostate cancer who are treated with intensity-modulated radiotherapy (IMRT), which is the most commonly used form of radiotherapy (RT) in the United States, against outcomes with two less frequently used technologies, proton therapy and stereotactic body radiotherapy (SBRT).
The investigators report that men treated with proton radiation are less likely to experience adverse urinary effects and erectile dysfunction and more likely to have bowel toxicity at 2 years compared with men treated with IMRT.
The study also reports on cost. Proton therapy was nearly twice as expensive as IMRT, based on private insurance reimbursement costs.
In contrast, the costs of administering SBRT and IMRT did not significantly differ, although SBRT treatment is associated with a modestly higher risk for urinary toxicity than IMRT.
“[T]o our knowledge, this study is unique in its assessment of the toxicity and cost of prostate radiation treatment options in the previously understudied but significant patient population of younger men with private insurance,” Hubert Pan, MD, the University of Texas MD Anderson Cancer Center, Houston, and colleagues write.
Men under age 65 years account for over 40% of all patients with prostate cancer.
“[Our] key findings, coupled with the real-world private insurance cost…will be useful for patients selecting the most appropriate treatment and for researchers designing cost-effectiveness models to guide treatment decisions in prostate cancer,” the authors add.
The study was published online March 21 in the Journal of Clinical Oncology.
Using a large US commercial insurance database of men under age 65, the investigators matched 693 patients who had been treated with proton therapy to 3465 patients who had been treated with IMRT. Another 310 men treated with SBRT were matched to 3100 others treated with IMRT.
Median follow-up for all groups ranged from 18 to 23 months.
One third of men who underwent proton radiotherapy experienced some form of urinary toxicity at 2 years compared with 42% of those who received IMRT (P < .001).
“This urinary benefit with proton radiation was seen across multiple domains, including incontinence, bleeding/irritation, obstruction, and stricture,” the study authors note.
On the other hand, 20% of men who received proton therapy had some form of bowel toxicity at 2 years compared with 15% of IMRT patients (P = .02) — principally in the form of late bleeding or proctitis.
Erectile dysfunction was also less common among men who received proton treatment, at 21% at 2 years vs 28% for those treated with IMRT (P < .001).
The mean cost of administering proton radiation to the payer was $115,501 compared with only $59,012 to administer IMRT (P < .001).
For patients, out-of pocket costs were also higher for men receiving proton therapy, at $2269 compared with $1714 for men receiving IMRT (P < .001).
Not surprisingly, the cost of treating complications was lower for patients receiving proton therapy, at a mean of $1737 at 2 years compared with $2730 with IMRT (P = .008).
However, mean total healthcare costs at 2 years were higher with proton radiotherapy, at $133,220, than with IMRT, at $79,209 (P < .001).
As the investigators observe, the higher cost of using proton radiation to treat patients with prostate cancer reflects the fact that private insurance companies spend nearly twice as much on proton radiation treatment as they do on IMRT.
SBRT vs IMRT
A comparison of toxicities associated with SBRT vs those caused by IMRT revealed no differences in composite rates of urinary, bowel, or erectile dysfunction toxicities between the two modalities.
However, obstruction and retention rates at 2 years were higher with SBRT than IMRT, at 21% and 15%, respectively (P = .003), as were fistula rates, at 1% vs 0.1% (P = .009).
The mean cost to the payer of treating men with SBRT was actually lower than it was for IMRT, at $49,504 vs $57,244, respectively (P < .001).
For patients, the mean out-of-pocket costs — $1015 for receiving SBRT vs $1560 for IMRT — were relatively similar, but the difference between the two treatment modalities was still significant (P < .001).
In contrast, the mean cost of treating complications and total healthcare costs were similar between SBRT and IMRT and were not significantly different at 2 years.
“To our knowledge, this study is the first to identify possible benefit associated with proton radiation compared with IMRT for prostate cancer, with results suggesting decreased multidomain urinary toxicity,” study authors write.
“[But] with the current emphasis on cost-effective health care, our toxicity findings must be considered in the context of differing cost profiles,” they add.
The study was supported by the Cancer Prevention and Research Institute of Texas, the National Cancer Institute and Varian Medical Systems. Pan reports receiving research funding from Varian Medical Systems.
J Clin Oncol. Published online March 21, 2108. Abstract
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