LAUSR

In an era when the controversy over prostate cancer screening and overtreatment of localized disease continues to unfold, it is easy to overlook the burden associated with advanced-stage prostate cancer. In 2016, there were still an estimated 26,120 deaths due to prostate cancer, which remains the sixth leading cause of cancer-related death in the United States. Clinical progression to metastatic disease poses a significant burden for the patients whom it affects. The vast majority of prostate cancer metastases are to the bone, and roughly half of the patients with bony metastases experience a fracture or spinal cord compression or require radiation or surgery for palliation. Quality of life significantly deteriorates for patients with metastases because of both the disease process itself and the morbidity associated with additional treatments. Metastasis also results in increased utilization of health care resources as patients undergo diagnostic workups and subsequent medical care. Although the duration of survival with metastatic disease has improved, patients with metastatic disease often require multiple therapies to delay prostate-specific death and to manage the morbidity of metastasis; this results in lasting increases in medical resource use. Recent randomized controlled trial data provide quality evidence showing that early definitive treatment of localized prostate cancer reduces the rate of metastatic disease by more than 50%. This demonstrates the effectiveness of early definitive interventions for combatting progression to metastatic disease. However, there is a concern that rates of advanced-stage and metastatic disease may rise in coming years. Prostate cancer screening rates have declined broadly since the US Preventive Services Task Force issued recommendations against prostate-specific antigen screening in 2012. Although the rates of advanced-stage prostate cancer have remained constant over the decade preceding 2013, data suggest that there may already be an evolving shift toward tumors being identified at later stages. The US Preventive Services Task Force recommendation against prostate cancer screening was heavily influenced by an emphasis on mortality as an outcome; the impact of reducing the morbidity and cost burden associated with metastatic disease was minimally addressed. This was partly due to a lack of quality data available at the time of guideline development on the epidemiology of metastasis and the benefit of treatment for reducing metastatic development. Two key data elements required for the equitable evaluation of the benefit of avoiding or delaying metastatic prostate cancer are the epidemiology of metastasis and the modern health care cost and resource utilization patterns associated with the development of metastasis. In this issue of Cancer, Li et al present a study of longitudinal medical cost and resource utilization patterns in the year before and after the development of metastatic prostate cancer in men initially diagnosed with localized disease between 2000 and 2011. The authors compare data from matched controls who did not develop metastases with the National Cancer Institute’s Surveillance, Epidemiology, and End Results cancer registry data linked to medical insurance claims from Medicare. Li et al report that overall, 7.1% of men initially diagnosed with localized prostate cancer in the Surveillance, Epidemiology, and End Results registry developed subsequent metastases over the 12-year follow-up period. On average, during the month of the diagnosis of metastatic disease, medical costs increased 5-fold over the premetastatic baseline cost and remained roughly twice the cost of prediagnosis care through 1 and 2 years of followup. Although medical resource use was equivalent in the 2 groups before the diagnosis of metastasis, during the month of the diagnosis of metastatic disease, there was a significant rise in medical resource utilization, with nearly half (48.6%) requiring inpatient admission, and the metastatic group remained twice as likely to be hospitalized as the controls for the duration of follow-up. For the group diagnosed with metastatic disease, the utilization of outpatient resources, including home health aides, skilled nursing facilities, and hospice, increased from roughly 19% of patients using 1 of these services