Prostate Cancer Treatment Assessment Factors
John L. Fox, MD, MHA: As physicians, we all want to improve the longevity and quality of life of patients. Because medicine is specialized and fragmented, the urologist primarily seeks ways to improve prostate cancer patient survival when they have advanced prostate cancer. I don’t think we’re looking any further at how we can improve overall life expectancy. If we were to do this, we would recognize that since 1995, cardiovascular mortality has exceeded prostate cancer mortality in patients with prostate cancer and we would incorporate this into our decision making.
Unfortunately, I don’t think we have a good mechanism to look at overall mortality in these patients and incorporate cardiovascular risk factors into treatment decision-making. Going forward, if we want to reduce the total cost of care, we need to think about the relative trade-offs of these therapies. Ideally, if we could find a way to improve overall life expectancy, reduce prostate cancer mortality, and reduce cardiovascular mortality, that would be ideal. Ultimately, the question is whether there is good evidence to support therapies that reduce cardiovascular mortality, and what is the relative cost? If we had a therapy that reduced the total cost of care, including the cost of the drug, who would argue against that?
Maria Lopes, MD, MS: In general, we look at the efficiency [and] security. Security is generally at a high level in terms of adverse events. More is becoming available in terms of clinical differentiation, particularly with respect to safety, event reduction, number needed to treat to prevent one event, and how different treatment options compare. It becomes really important. Often we do not have this information to be able to make comparisons between regiments. Also, it’s starting to be more targeted in the guidelines to help providers help patients make more informed decisions, as well as for payers. We are in a P&T [pharmacy and therapeutics] committee, trying to set up [or] look at pre-clearances, maybe on what we should include. These become exciting opportunities to consider patient segmentation, and perhaps be proactive in terms of analysis to identify opportunities to educate providers, as we holistically examine the impact of treatment on other comorbid conditions and total costs.
John L. Fox, MD, MHA: Each health plan has a pharmacy and therapeutics committee where we evaluate new therapies for the treatment of any condition, including prostate cancer. The main thing we are looking at is the effectiveness of this treatment in terms of reducing the unintended consequences of this disease, which in this case would be death. But we don’t consider the safety or toxicities associated with that in our decisions. It is the role of the medical oncologist and the patient to weigh the risks and benefits of these therapies. That said, unless there is a black box warning on a drug, these adverse effects or unintended consequences of a treatment are ignored. In this space, should we consider unintended cardiovascular consequences? We probably should be. The thing is, it’s not commonly factored into our decision-making process. In other words, the preponderance of evidence, although not strong, suggests that GNRH antagonists reduce cardiovascular risks compared to cardiovascular agonists. But they’re not in a privileged position, and we don’t need antagonist versus agonist.
Transcript edited for clarity.