(UroToday.com) The Society of Urologic Oncology (SUO) annual winter meeting included an advanced prostate cancer session and a presentation by Dr. Kelvin Moses discussing financial and toxicity considerations when managing advanced prostate cancer.
Dr. Moses started by highlighting that the treatment landscape of advanced prostate cancer has drastically changed over the last two decades:
Furthermore, based on these new approvals, particularly over the last 5-6 years, there have been substantial changes in first-, second-, and third-line treatment of metastatic hormone-sensitive prostate cancer. Dr. Moses notes that there are several factors to consider when choosing treatment, including (i) patient preferences, (ii) disease state/volume of disease, (iii) age, (iv) comorbidity/fitness, (v) prior therapy, and (vi) treatment specific toxicity/cost. Based on all of these new treatments (and with different mechanisms), there are many common side effects of treatment in advanced prostate cancer, including fatigue, hot flushes, depression, erectile dysfunction, loss of libido, loss of muscle mass/strength, weight gain, cardiovascular events, bone pain, fractures, falls, urinary obstruction/clot retention, seizures, rash, and arthralgia/back pain. Hot flushes are particularly common and troublesome for patients with the following options for managing patients1:
Recently published work from Dr. Moses’ group2 assessed the relationship of sarcopenia, myosteatosis, and obesity with overall survival in men with metastatic or castrate-resistant prostate cancer (CRPC). This study was a retrospective analysis of men with metastatic or CRPC who had a CT of the abdomen/pelvis presenting to the Vanderbilt Comprehensive Prostate Cancer Clinic from 2012 to 2017. Among 182 men in this study, 37.4% were obese, 53.3% sarcopenic, and 59.3% had myosteatosis. Over a median follow-up of 33.9 months, body mass index was associated with reduced mortality (HR 0.93, p=0.02), as was visceral adiposity (HR 0.99, p=0.003). Furthermore, men with high body mass index without sarcopenia/myosteatosis lived significantly longer than men with high body mass index with sarcopenia/myosteatosis or normal body mass index men. The survival curves for obesity, sarcopenia and myosteatosis are as follows:
Based on these results, Dr. Moses emphasized that routine clinical workup should include calculation of body mass index, as well as a morphometric analysis of CT imaging to identify patients at risk for poor prognosis.
With regards to lifestyle and symptom management, Dr. Moses provided the following recommendations:
- 4-5 days of 30 minutes of cardiovascular exercise per week
- Consultation with a cardio-oncologist
- Participation in a prostate cancer support group
- Consultation with a sexual health nurse practitioner for consideration of PDE5 inhibitor or surgical intervention for erectile dysfunction
- Medical management of depression with low dose SSRI (which may also help with hot flushes) and/or a consultation with psychiatry or psycho-oncology
For the remainder of his presentation, Dr. Moses focused on cost-effectiveness considerations for treatment. In a recently published study, Sung et al.3 aimed to compare the cost-effectiveness of five treatment options (ADT alone, or ADT plus one of the following: docetaxel, abiraterone, enzalutamide, or apalutamide) in mHSPC from the US payer perspective to guide treatment sequence. This study found that compared to ADT alone, docetaxel plus ADT provided a 0.28 QALY gain at an ICER of US$12,870 per QALY. Abiraterone plus ADT provided an additional 1.70 QALYs against docetaxel plus ADT, with an ICER of US$38,897 per QALY. Compared to abiraterone plus ADT, enzalutamide plus ADT provided an additional 0.87 QALYs at an ICER of US$509,813 per QALY. Apalutamide plus ADT was strongly dominated by enzalutamide plus ADT. Given the willingness to pay a threshold of US$100,000 per QALY, abiraterone plus ADT represented high-value health care (likely secondary to abiraterone now being available as a generic therapy). As follows is the cost-effectiveness acceptability curve from this study:
Dr. Moses then provided the following points with regards to how treatment costs are affecting patients:
- Launch prices of new cancer drugs have increased 10% each year over the past 20 years
- Financial responsibility has increasingly shifted to patients
- 64% of cancer patients report stress/worry regarding paying their medical bills
- Increased risk of death is associated with patients who declare bankruptcy
- The financial strain appears to impact health-related quality of life and may even affect symptom burden
- Patients are forced to adopt coping strategies
Patient-reported financial toxicity can be broken down by direct costs and indirect costs:
- Direct costs: treatment-related (co-pays, deductible), supportive costs (ie. lotion during radiation)
- Indirect costs:
- Time to receive treatment/recovering from illness
- Time lost due to premature death
- Workplace absenteeism/employment disruptions
- Reduced productivity
- Increased burden on informal care-givers
- Childcare expenses
- Loss of income due to early retirement or cancer-related death
- Travel time to treatment
Future directions in this space include needing a better understanding of financial toxicity in advanced prostate cancer (what are the indirect costs?) and assessing the interventions that can help mitigate financial toxicity in this population of men and how we as clinicians can partner with these services to provide better patient care.
Dr. Moses concluded his presentation with the following take-home messages:
- The treatment landscape of advanced prostate cancer is rapidly changing with no guideline consensus on sequencing of treatments
- Given the lack of comparative survival data, treatment choice is based on disease site/volume and toxicity profiles
- Side effects are common and there is a need for clinical trials (pharmaceutical and lifestyle management) to develop more effective therapies and combat them
- Financial toxicity is an increasingly important patient-centered outcome to consider in treatment and shared-decision making
Presented by: Kelvin A. Moses, MD, Ph.D., Director of the Comprehensive Prostate Cancer Clinic, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 Society of Urologic Oncology (SUO) Winter Annual Meeting, Orlando, FL, Wed, Dec 1 – Fri, Dec 3, 2021.
References:
- Hutton B, Yazdi F, Bordeleau L, et al. Comparison of physical interventions, behavioral interventions, natural health products, and pharmacology to manage hot flashes in patients with breast or prostate cancer: Protocol for a systematic review incorporating network meta-analyses. Systematic Reviews. 2016;4:114.
- Xu MC, Huelster HL, Hatcher JB, et al. Obesity is associated with longer survival independent of sarcopenia and myosteatosis in metastatic and/or castrate-resistant prostate cancer. J Urol. 2021 Mar;205(3):800-805.
- Sung WYW, Choi HCW, Luk PHY, et al. A cost-effectiveness analysis of systemic therapy for metastatic hormone-sensitive prostate cancer. Front Oncol. 2021 Feb 24;11:627083.