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Utilization of Secondary Cancer Treatments Following Radical Prostatectomy
Stephen B. Williams, M.D., Xiangmei Gu, M.S., Stuart R. Lipsitz, Ph.D., Jim C. Hu, M.D., MPH.
Brigham and Women's Hospital, Boston, MA, USA.

BACKGROUND: Biochemical recurrence occurs after radical prostatectomy in a substantial number of men, and many will receive secondary therapies such as radiation and/or hormonal therapy. We sought to identify factors associated with receipt of secondary therapies and estimated associated healthcare expenditures.
METHODS: We used SEER-Medicare linked data from 2004-2006 to identify 4,247 men who underwent radical prostatectomy and 600 men who subsequently received secondary therapies. We used Cox regression to identify factors associated with receipt of secondary therapies. Moreover, we compared 12-month healthcare expenditures of men who underwent radical prostatectomy and secondary therapies vs. radical prostatectomy alone.
RESULTS: Prostate biopsy Gleason score, PSA, D’Amico risk assessment and SEER region were significantly associated with receipt of secondary treatments (all p<0.001). Higher surgeon volume was associated with lower odds of receiving secondary therapies (hazard ratio [HR], 0.64; 95% CI, 0.49-0.84 [p<0.001]). Men with positive surgical margins were three times as likely to receive additional cancer treatments than men with negative margins (HR, 3.2; 95% CI, 2.71-3.78 [p<0.001]). High D’Amico risk stratification was the strongest predictor of receiving additional treatments (HR, 8.3; 95% CI, 6.13-11.22 [p<0.001]) after prostatectomy. Age, race, comorbidity status, regional variation, and surgical approach were not associated with use of secondary therapies. The median expenditures of additional post-prostatectomy hormonal therapy, radiation therapy, radiation and hormonal therapy vs. prostatectomy alone were $6,408, $19,460, and $31,374 vs. $15,052 (p<0.001).
CONCLUSION: High-risk disease characteristics and positive surgical margins were strongly associated with receipt of secondary therapies. Men treated by high volume surgeons were less likely to receive secondary therapies, suggesting that more experienced surgeons preferred
expectant management rather than adjuvant therapies independent of disease characteristics. Surprisingly, patient age and co-morbidity did not influence the use of secondary therapies, which increased health expenditures 2-3 fold.
Cost Analysis of Secondary Cancer Treatments

Radical ProstatectomyRadical Prostatectomy and Hormonal TherapyRadical Prostatectomy and RadiationRadical Prostatectomy and Radiation with Hormonal Therapyp-value
Baseline healthcare expenditures in the year prior to prostate cancer diagnosis, median$2,559$1,797$2,003$2,2630.699
One year post-prostatectomy health care expenditures*, median (IQR)$15,052$6,408
$19,460 (12606,34079)$31,374 (19298,43252)<0.001
Prostate cancer healthcare expenditures$12,493$4,611$17,457$29,111na

*We excluded men who underwent radical prostatectomy and secondary therapies more than 8 months after prostate cancer diagnosis to ensure that we fully captured the expense associated with primary and secondary therapy.
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