Cost of Active Surveillance

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Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 9/9/2010 12:35 PM (GMT -6)   
This thread is a crude look at the potential costs of Active Surveillance. I am not looking at insurance coverage, so for this discussion just the clinical costs and whether reimbursed by insurance coverage or not is moot. Some of the costs used here are also estimates not actual. For example, I have heard of costs for a biopsy ranging from 1500.00 to 6000.00 even higher. I will consistently use 3,000.00 only because it's very possible to do a TRUS biopsy for that price in the clinic and have them read by a pathologist. If someone would like a second opinion on each biopsy it is possible to pay 5k for each biopsy. 3k-5k would be my estimate.

There are many ways to provide surveillance of prostate cancer as opposed to treat it. These are just a few ways of doing it. I am assuming that we have confirmed prostate cancer, confirmed that a patient can "safely" go with an AS plan, and made the decision to do it already...I am also assuming costs at 2 years, 5 years, and 10 years and that the patient does not enter into an active treatment..

Monitoring of PSA and DRE only:
This patient will under go 2 PSA tests per year, 2 office visits with DRE, and never changes this plan.

PSA Test cost at 150.00 x 2 = 300.00 per year
Office visits with DRE 200.00 x 3 = 400.00 per year
Variable costs: none. Annual cost 700.00 per year

2 years cost: 1,400.00, 5 year cost 3,500.00, 10 year cost 7,000.00

Pros: Involves little commitment by the patient, low cost... Cons: It's likely that no doctor would suggest this method.

From the Johns Hopkins Website urology.jhu.edu/prostate/advice1.php:
"...we recommend a PSA and digital rectal examination at six-month intervals and a yearly prostate biopsy (surveillance biopsy) to monitor the progress of the disease."

PSA Test cost at 150.00 x 2 = 300.00 per year
Office visits with DRE 200.00 x 3 = 400.00 per year
Annual biopsy: 3,000.00
Variable costs: none. Annual cost 3,700.00 per year

2 years cost: 7,400.00, 5 year cost 18,500.00, 10 year cost 37,000.00

Pros: Provides strong monitoring of the cancer. Cons: Annual biopsies are going to eventually scar up a prostate making it possible to create significant side effects. If a patient wanted a second opinion on each biopsy, the costs would almost double.

High End Plan with Imaging
I have derived this plan from something John T posted. I am only showing it for comparative purposes. I imagine this will potentially become quite common.

PSA testing every 3 months: 150.00 * 4 = 600.00 per year
PCA3 test biannually: 350.00 * 2 = 700.00 per year
Office visits with DRE biannually: 200.00 * 2 = 400.00 per year
Cost of a PSA Free test biannually: 350.00 * 2 = 700.00 per year
Cost of a biannual CDU Test: 350.00 * 2 = 700.00 per year
Cost of an annual MRIS: 4,500.00 per year
Variable costs could include minimally invasive CDU biopsies that could cost 1800.00 per year. Annual cost is 7,600.00 per year.

2 years cost: 15,200.00, 5 years cost: 38,000.00, 10 years cost: 76,000.00

------------------------

I would think that most patients would vary the protocol in various years effectively. I also know that some would suggest an 5ARI drug like Proscar or Avodart at a cost of about 2,000.00 per year. Additionally, There is potentially a likelihood that these costs will be more than my conservative estimates. If a person wants to have frequent biopsies and second opinions and such the costs can easily reach 6 figures during the tenure on AS.

No matter how you look at it, Active Surveillance is a billion dollar industry. One that does not involve treatment risks to the centers or doctors prescribing it. If a patient elects to have an intervention at some point, or if the disease requires intervention at some point, all the more better for the ledgers in the medical profession.

I am very open to your thoughts about the costs of AS. Perhaps even your personal experiences with these costs. I am willing to change this so I will add a date of the last update: 9/9/10.

Tony

Post Edited (TC-LasVegas) : 9/9/2010 2:47:04 PM (GMT-6)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/9/2010 12:41 PM (GMT -6)   
Oops, I forgot to include office visits in the High end plan...Correction made.

Tony

Post Edited (TC-LasVegas) : 9/9/2010 12:44:21 PM (GMT-6)


Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3625
   Posted 9/9/2010 1:32 PM (GMT -6)   
It's interesting you bring up costs..While the number of uninsured men number in the millions, you seldom if ever see them posting on these boards..Men with decent insurance simply don't care what medical services and procedures cost...Somebody else is paying for it! What happens to all those uninsured people? I suspect they just get sick and die, completely unaware of why they were so sick until the final month or two..

Someone did a rough tally on what Ralph Blum must have spent on his AS path..$300,000 a year! That might be pure BS but it certainly means that less than 2% of PC victims could follow in those footsteps..

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/9/2010 1:40 PM (GMT -6)   
Or even less than 2%.
I did this breakdown to raise the question about costs because there is a misconception that AS is frowned on by the medical industry due to costs. The fact is that the industry will likely increase revenue with AS not lessen it.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 9/9/2010 1:44:00 PM (GMT-6)


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4081
   Posted 9/9/2010 2:14 PM (GMT -6)   
Tony, interesting figures and a different twist on AS...thanks for sharing.  I have no way of personally upgrading any of your numbers but I'll share an additional perspective.  Let's assume a patient IS a good candidate for AS.  So, if someone offered an insurance policy for $7600 per year that assured the patient would maintain normal sexual performance, normal urinary performance, normal bowel performance and the promise that if treatment was required at a later date that it would be just as effective as at the original diagnosis, then some might feel this insurance policy was a bargain.
 
Agreed that some might argue about the guarantees in this policy but some (Scholz, Scardino, Klotz, Ballentine, et al) might say the policy details are realistic.
 
Anyway, more food for thought...
 
Tudpock (Jim)
Age 62, Gleason 3 + 4 = 7, T1C, PSA 4.2, 2 of 16 cores cancerous, 27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 4/10/10.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!

Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3731
   Posted 9/9/2010 2:31 PM (GMT -6)   
Tony,
That is a brilliant analysis.
Let's take it further. If you compare the costs with a Davinci RP, $25,000 (you can put any treatment here - I happen to know my costs) and add the annual costs of PSA and exams. (No biopsy) We can see there is a cross over point where the higher costs of RP are offset by the lower annual costs. If I live a short time, AS is a better deal economically. If I plan on living a long time, RP (or other treatment) is the better deal.

I prefer to bet that I will live a long time.

Yea, I know some people will rant that there are exceptions and blah blah and I ignored the 3.5% cost of capital. I also ignored the costs of biopsy time and pain. I'm just providing an example. Everyone can diddle the numbers to fit their own case.

Jeff

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 9/9/2010 2:44 PM (GMT -6)   
Tony,

Franchot, an AS brother here at HW, recently posted his costs. Do you recall this posting, and did you compare to these real-life experiences? (I'd go back and search for it, but kinda a busy day here today. His posting was within the last several weeks, but I don't recall what thread it was in.)

Also, how will you account for the value on the other side of the equation of not having to undergo radical treatment?? It's not "priceless", but it's definitely not nothing.

regards

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/9/2010 3:06 PM (GMT -6)   
No need to search too hard I remember it clearly. He was not following what John T suggested was Mark Scholz protocol, even though he himself was seeing Dr. Scholz. But he did confirm that Dr. Scholz did suggest more imaging tests. I would be very interested to follow Franchot over time to see what might change in his protocol..

I did not account for "the other side" as it is not a cost of AS. But if I did account for it, I would have to include several factors. Some patients walk away from RP without severe issues and only PSA tests, Some will experience some leaking and require follow up and pads to go with PSA tests for a year or two but improve over time, extreme few will have to intervene with AUS, Slings, or prosthetics.

But remember, most on AS will eventually intervene and will likely have the side effects anyway. What we don't know is if a 60yo man who opts for intervention at year 8 will have more SE's than if he would have bit the bullet sooner.

That's one of the many missing pieces...

Tony

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 9/9/2010 3:14 PM (GMT -6)   

Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 9/9/2010 3:19 PM (GMT -6)   
QoL is subjective to the individual. Some might say they are perfectly satisfied feeling that they beat cancer even if it means incontinence. Some might say they are tired of losing sleep always worrying what might be happening inside of them.

How do you define and price QoL?

AS does not guarentee QoL...

Tony

Post Edited (TC-LasVegas) : 9/9/2010 3:28:33 PM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 9/9/2010 3:22 PM (GMT -6)   
Tony, I like what you did, at least you got the basics down of the different methods of executing AS. It is not a free ride, no matter how you slice the cake. Personally, I would think most people with insurance, would have the means to do your second scenerio. I think there could be insurance issues with some with the upper end plan you presented.

And to Fairwind: We have brothers here at HW that have no money, no health insurance, no jobs, etc, and some have found satisfactory treatments along the way. Some of them have had doctors with a heart, and others have had to get real creative in finding treatments.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4188
   Posted 9/10/2010 1:37 PM (GMT -6)   
Franchot's real life costs are about $3,000/year for AS, including Color Doppler twice per year. I think that this is a realistic expectation. Considering that follow up costs after any treatment would run at minimum about $1200/ year, the $1800 delta is what you are really dealing with. Most with insurance would pay about $360; those without insurance would have to foot the bill, but they would also have to come up with $20,000 or more immediately to cover treatments.
Quality of life issues must be considered when deciding on any treatment. To some they trump all treatments and to others the fear of progression or just getting closure are more important. I truely believe that most underestimate the QOL issues that any treatment entails.
I personally believe that with the right stats AS is a no brainer and the benefits far outweigh the small risks, and in the end costs are about a wash at 10 years. Everything in PC is a risk/reward situation; sometimes the coin flip comes out in your favor and many times it doesn't. I play the probabilities. The probability for AS are that 70% of the time I will win, and if I lose, I can recover my loss 98% of the time with treatment and be no worse off than if I had never played. You will never find those odds in Vegas.
JT
 

Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 9/10/2010 4:17 PM (GMT -6)   
So would you disagree with the suggestion of having annual MRIS? Do you also believe that CDU is a suitable replacement for tissue sampling?

I personally don't see a need for MRIS unless the disease acts up, but the high end plan is from what you stated, John. That stated, I think anyone relying on CDU and no tissue sample biopsies may in fact be taking some risk.

I read Franchot's explanation it was well outlined. That seems to be the way he is being monitored under Scholz. If I set up that model based on 3k per year it's 30k over ten and it's easy to do the rest of the math...

Right now my post treatment surveillance is about 700.00 per year. That counts 2 PSA's and 2 visits. I don't have a prostate so imaging and PCA3 are unnecessary, and a T level test is optional but I included the cost of two per year. My cost is basically the cost of screening twice a year with no DRE and a T level test...

My insurance is not as good as yours, but very good. I said it's moot in this discussion because I wanted not to show what a patient can expect to pay, but rather that no matter how you approach AS it's not cheap and it is a billion dollar a year industry that will have it's influences. There will be doctors who will see the business aspect of doing AS instead of treatment because the costs will be very close. But a surgeon doing a 2.5 hour surgery can expect to make about 2,100.00 to 3k...The hospital and all the other folks get the rest. But an oncologist working a single case of AS for ten years in his clinic stands to make far more than that surgeon did and has assumed very little risk.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3731
   Posted 9/10/2010 4:31 PM (GMT -6)   
I'm sure there are stats that show how PCa progresses through a prostate over time.
For example: My DX PSA was 23, biopsy was 7/12 up to 70%. One nerve removed one partially spared.
At some point in my life one year, two or three years before DX my PSA must have been below 5 (lower than 23). A biopsy at some point would have been 1/12 with only 5% involvement. Would the surgeon have had a better chance saving both nerves and my bladder neck?
Maybe if I had it done three years ago, I wouldn't be sitting here wearing pee pads.
We'll never know.
I can say that in general, the guys with the better numbers seem to have better results and are quicker to continence. There was a continence and ED study sent around a while ago that sorted men by DX PSA. It clearly showed this relationship. I was off the chart at 23 so I did not pay much attention at the time. Maybe James C has it. Or we can look at Yananow.

If you are young and otherwise healthy, and the tumor is contained and fast growing is there anyone who feels it is better to wait?
Jeff

Uncle Harley
Regular Member


Date Joined Feb 2009
Total Posts : 79
   Posted 9/10/2010 5:06 PM (GMT -6)   
Tony, Your annual $ estimate is pretty accurate for my area. But your cons for the first method are way off base. This is exactly what my Dr has me on. I have full faith in his assesment of my condition & agree with him that this is best for me, AT THE MOMENT. Maybe things have changed in the medical world since you've had your treatment. I guess I went into this whole new world completely blind. On my family Dr suggestion after a high velocity reading, I went to the Uro. The first Dr wanted to do a 12 needle biopsy. Sure, no problem. Well the jack*** did it without any local. Needless to say I'm not seeing him any more. My current Uro is the surgeon for the Uro group & used appropriate local for my 2nd biopsy. I wish my family Dr would have retested me with the warning, no sex before test. I think I would not be a member here if he had. As you can see from my stats, my psa gone down, why I don't know. You, nor anyone else, can provide a compelling reason for me to pursue any treatment other than AS.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 9/10/2010 5:45 PM (GMT -6)   
uncle harley - i was glad to see you check back in here, missed you.

johnt - the longer i am in this PC journey, the more i agree on the QOL issues. I know some of my issues are low % issues, but the point being, they can and do happen, and when they do happen, a person's life can be so utterly miserable, whether dealing with my issues, those with long term incontinence, those dealing with perm ED, etc. No doctor or surgeon can know, with certainty, in advance, how a patient will do after the fact. all the charts and records are meaningless when you become a new stat for bad issues. speaking from one dealing with extreme low QOL, especially since October of last year without even a single day of break, you have my attention.

for men that truly could benefit with proper AS, i wish to God they would pay attention closely, and really make sure that need drastic treatments immediately. just like my twisted path, once it started, there is no turning back. it's not that i regret my initial treatment, with the numbers that i had, but i never anticipated that there could even be a horrible world waiting for me on the other side.

you bring a lot of common sense approach to the subject, again, i wish as a group effort here at HW PC, that over time, more men entering our ranks may give some serious credence to AS if there situation warrants it.

since i have been here, nearly 2 years, at least it can be disussed without ridicule, and also happy that with some more brothers going down the Seed Path, that even relative newcomers at least encourage good thoughts to that as being a good choice, assuming criteria is met of course.

i can honestly say, that if my numbers had been good at dx, and knowing what i know now, mostly from the input and contributions of people like you, i would have gladly gone to AS, as you point out, if the numbers start to sour, your chance of a primary treatment generally are still just as good.

for those that think its all about dr's getting rich off our plight, not saying that some don't do that, but when i look at what my uro/surgeon has made off me since my first biopsy in 2007 up to now, including me seeing him twice a month, and about to have my 8th op by him, he definitely isn't get rich off of me. i have been amazed at times, how much he "eats" on some of my deals, just because he wants to.

with the newly dx men, i wish either they, or their doctors, would really openly discss AS as a legitmate pre-treatment course if they meet a strict set of criteria. gosh, the misery that could be spared, if only a few would at least consider it more than a passing glance.

thanks for your efforts in particular in that area.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4188
   Posted 9/10/2010 7:15 PM (GMT -6)   
Tony,
I personnally think that MRIS is an over kill. I would imagine that some men on the high end of the AS scale may be wise to get an MRIS, but for most I think a color doppler only would suffice. I have enough confidence in CDU that I feel as long as you have a good baseline that any changes can be easily seen. If a change is noticed then a biopsy should and must be taken. The whole principle of CDU is to only biopsy areas that look suspicious, because if you can't see it, it is not large enough to hurt you, and if you do see something you must biopsy it. As Scholtz said there are some cases that psa had remained stable or dropped, but the CDU showed the tumor growing.
I know a lot of people don't buy into this, but seeing it 1st hand and talking to others that have gone through it makes me very comfortable with the process.
I believe that PC has to be large or near the margin in order to be dangerous and a high grade dangerous cancer can be seen growing if scanned every 6 months. Is it 100%, no, but there is no treatment in pc that approaches 100%.
I also believe there is a big difference in a G6 from a G8 or 9. They act a lot different and are not even in the same ball park. I just don't think that G6s turn into G8s overnight or even ever; they may turn into g7 over time or they may not. Even with reoccurrances or positive margins G6s are rarely deadly. Cancer is either agressive or non agressive and as soon as an agressive cancer is identified it must be delt with, and I feel that with proper monitoring agressive cancers can be identified and treated. It's a known fact that many tumors never grow or actually regress. Why would you ever want to treat this type of cancer? I was never in the position to actively choose AS, but would have if I had the low stats and knowing what I know now. Even if I had been diagonosed early I didn't have the information available to make a choice as the only choices ever talked about was surgery or seeds. I'm glad to see that the choice of AS is growing and information about it is being made available to patients.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4188
   Posted 9/10/2010 7:31 PM (GMT -6)   
Tony,
I think you are pushing it by suggesting that doctors would suggest AS to generate more revenue. I know that Scholz is at his patient limit of 1300 and can generate much more revenue by only treating advanced cancer patients with Chemo or HT rather than taking on AS patients.
I think a bigger problem is urologists that have set up radiation centers, as this is a true conflict of interests.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 9/10/2010 9:12 PM (GMT -6)   
I probably can't enter this discussion as a Gleason 9 because it was never an option. I do howver get tired of some of the QOL hulabaloo.

Just because the AS guy may be able get a hard on any time ( and at 60 years old that is not a certainty ), and he doesn't have incontinence issues, doesn't mean his QOL is an A+.

PSA gut checks could be even worse, along with the biopsy preps, doctor visits etc. I honestly believe my QOL is as good, and sometimes even better than someone going throug AS. I think the mental anguish of knowing I have an active cancer growing inside me, along with the other medical stresses would be harder for me to cope with than "being butchered" and suffering from "devastating" side effects.

I continue to live the good life every day, and as each day passes, the PC is a little further back in the rear view mirror. I honestly find it hard to put a value on that.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 9/11/2010 1:02 AM (GMT -6)   
There are three practical issues regarding cost:

1. Can the individual afford it? This is determined by the insurance. If you have none, you can't. If you do, your insurance will pay for it. If they don't cover some of the items on the AS program, the majority of people won't or can't pay for it.

2. What is the cost to society? This means cost-effectiveness. If the program is expensive, with little data to prove benefit, it's hard to justify that insurance or government should pay for it.

3. Physician incentive. This likely effects physicians in private practice. If the physician is on a largely fixed salary, like many academic physicians and some in large group practices, they are somewhat shielded from the effects of economic incentives. For docs in private practice, the largest fees are for major procedures that they perform--surgery or radiation. There's a financial disincentive to perform AS. Personally, I prefer to see a doc who's on salary.

Franchot
Regular Member


Date Joined Jun 2009
Total Posts : 130
   Posted 9/11/2010 3:11 AM (GMT -6)   
In my case, I had a very close friend who was diagnosed with PCa in his late forties. Learning that he had PCa caused him to become extremely depressed followed by bouts of insomnia. He started taking anti-depressants, but he knew he wanted to get this cancer out of him as soon as he could which turned out to be about six months later. His Da Vinci surgery was very successful and when the catheter was removed he didn't drip a drop. He tells me that his sex life is fine by just taking some Viagra. All in all, his quality of life doesn't seem to have suffered much. I would call his outcome an outcome many would be happy with.

When I was diagnosed with the disease a couple of years later, I grilled him on his experiences again and he made it sound like the whole surgery and post surgery ordeal wasn't much of an ordeal at all. He assured me, "Getting a tooth removed was more painful for me. The catheter was the worse thing, but it's only for a couple of weeks." Even though I'd willingly gone through two back surgeries in the past, I just couldn't convince myself that another surgery (this one on my prostate) was something I wanted. If I was going to meet the disease head on, I was leaning towards radiation.

Then I found this site and started reading about the many men who experienced quite a few unfortunate side effects from the various treatments. I continued to research all the different treatment options, finally settling on proton therapy at Loma Linda which I was scheduled to begin in a short amount of time. (Strangely, I was on a one-year waiting list for the procedure, but as soon my excellent insurance cleared I was bumped to the top of the list.)

And then I read John T's posts about all the research that he had done and how he had ended up at Dr. Scholz's office. Heck, Scholz was just up the freeway from me so it seemed silly not to drive twenty miles for one last opinion. I ponied up the money for the initial consultation, found out I was a candidate for AS, and canceled my proton therapy.

For me, living with a slow-growing cancer doesn't bother me. I had been diagnosed with basal cell skin cancer two years before I was diagnosed with prostate cancer so I grew to understand that all cancers are not created equal...and not all cancers are immediately aggressive and devastating. I see that cancer research has progressed a great deal from the time I was a little kid and that people with all sorts of cancer are living longer lives, so I don't worry about the small amount of cancer that I have.

On my last visit to Scholz I asked him what happens next if the AS doesn't pan out. He replied that other treatment plans have to be made and there's no way around that, so his mind is not geared towards going only with AS.

I'm looking at a cost of about $3000 a year to keep on AS. I'm not a wealthy person, but this is a cost I can life with so I don't have to go under the knife or be radiated for many, many weeks. I just go out to dinner a little less, rent $1.00 movies a little more, and wear the same clothes even when they've gone out of fashion.
Age: 54 6' 0" Weight: 176 Caucasian

Rising PSA over the last six years (from when I started being tested) from 3.9 to 5.2 to 4.6 to 4.5 to 4.9 to 3.9.

Free PSA: .71 % Free PSA: 18.2%

DX with PC in January 2009 after biopsy. Bone scan--negative

Consulted Cedars-Sinai Beverly Hills urologist--recommended surgery
Consulted Cedars-Sinai Beverly Hills radiologist--recommended IMRT
Consulted San Diego Cyber-Blade doctor--recommended treatments
Consulted Long Beach radiologist--recommended IGRT
Consulted Loma Linda radiologist--recommended Hypo-fractionated Proton treatments

Insurance approved any treatment I wanted.

Consulted Marnia del Rey urologist Dr. Scholz.
Dr. Scholz referred me to Dr. Bahn for a Color Doppler test.
Scholz and Bahn recommended Active Surveillance, some diet changes, and steady exercise.

I am currently on Active Surveillance.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/11/2010 10:37 AM (GMT -6)   
John I am absolutely pushing it. But I am not suggesting I have seen any cases of "overzealous" testing during AS yet. But I can see where it can and likely will happen. I agree with the MRIS part, it's overkill, but I also think a patient on AS should have a follow up biopsy since it is possible that CDU is not accurate enough to use as a replacement for tissue sampling. I think anyone going on AS can do fine with PSA tests and DRE as Uncle Harley is doing.

In fact I am refreshed knowing that is all Uncle Harley's doctor is doing at this point. But there is an understandable case for biopsies and I would not doubt Uncle Harley that your doctor brings it up in the future.

Franchot thank you once again for your experience with costs. Using your costs as outlined it would be about 30k over ten years if you stay status quo. Again I wish you the best of luck on this plan. I will continue to state that I think the lowest age for AS for a healthy man is 64, but I understand your thoughts and willingness to go with it.

In any case, AS is big business. I don't think that institutions or doctors, private or otherwise, will shy away from an AS patient.

Tony

Franchot
Regular Member


Date Joined Jun 2009
Total Posts : 130
   Posted 9/11/2010 12:57 PM (GMT -6)   
TC-LasVegas said...
I will continue to state that I think the lowest age for AS for a healthy man is 64, but I understand your thoughts and willingness to go with it.

Tony


When I first looked into AS I thought I would be deemed too young, but I feel that I'm being closely monitored that if something suddenly spikes up, I can appropriately deal with it. My thinking is that in years past before the more advanced testing came into place many men probably had small amounts of prostate cancer at my age and it went undetected and these men still lived out their lives to reasonable ages. I am also hoping that less intrusive ways of dealing with the cancer will emerge in the near future which may benefit me.

But as I've written before, Doing Active Surveillance does not mean sitting back and not doing much of anything. You have to be ACTIVE in watching the disease and also changing your diet, exercise level, and stress level if needed and then being prepared to step to other treatment options if the numbers do not play out in your favor.

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 9/15/2010 8:46 AM (GMT -6)   
There’s been lots of discussion here recently on the “business of prostate cancer.” This thread (started just last week by Tony), in particular, was a discussion on the cost of Active Surveillance (AS), with some discussion about how the cost of AS compares to the cost of other primary treatment modes.

Well, Tony has his “fingers on the pulse” of what the latest researchers are thinking and studying. In a report published last month in the journal “Cancer”, Johns Hopkins researchers compared initial treatment costs and total costs of PC treatments.

The purpose of the study was to inform patients and clinicians considering treatment options, and policy makers interested in “patterns of cost.” The report emphasized that “patterns of cost” vary widely based on initial treatment.

In summary,
  •  AS has the lowest initial treatment and lowest total costs
  •  Hormonal (HT) + radiation has the highest initial treatment cost
  •  HT + Radiation and the HT-alone treatments ended up being about the same, and were the highest total cost

URL: http://www.ncbi.nlm.nih.gov/pubmed/20734396?s_cid=pubmed

Post Edited (Casey59) : 9/15/2010 8:52:40 AM (GMT-6)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/15/2010 9:59 AM (GMT -6)   
Here is Casey's thread activated:
www.ncbi.nlm.nih.gov/pubmed/20734396?s_cid=pubmed

Thanks for the post. It is well known that AS will likely end up in treatment. In such cases AS has the potential of increasing the inital costs of all of the other options by that amount shown in the study.

I noticed how the costs represented in the study are lower than most of our patient experiences for treatment. Such being the case the initial cost of AS is 4,270.00 and the 5 year cost is 9130.00 according to this study. Seeing that the cost of surgery is about half in this study than what most of our guys are seeing their invoices (17k in the study), it would seem that the cost of AS is also under represented. So the question arises, are these the cost to JHU and not to the patient?

If such is the case, then I nailed the costs for AS in the JHU model above.

Very interesting.

Tony
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