The Clinical and Economic Impacts of Skeletal-Related Events Among Medicare Enrollees With Prostate Cancer Metastatic to Bone

Abstract

Background. Approximately 40% of men diagnosed with metastatic prostate cancer experience one or more skeletalrelated events (SREs), defined as a pathological fracture, spinal cord compression, or surgery or radiotherapy to the bone. Accurate assessment of their effect on survival, health care resource utilization (HCRU), and cost may elucidate the value of interventions to prevent SREs. Materials and Methods. Men older than age 65 years with prostate cancer and bone metastasis diagnosed between 2004 and 2009 were identified from linked Surveillance Epidemiology and End Results-Medicare records. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk for death associated with SREs were calculated by using Cox regression. HCRU and costs (in 2013 U.S. dollars) were evaluated in a propensity score-matched cohort by using Poisson regression and Kaplan-Meier sample average estimators, respectively.Results. Among 3,297 men with prostate cancer metastatic to bone, 40% experienced $1 SRE (median follow-up, 19 months). Compared with men who remained SRE-free, men with $1 SRE had a twofold higher risk for death (HR, 2.29; 95% CI, 2.09-2.51). Pathological fracture was associated with the highest risk for death (HR, 2.77; 95% CI, 2.38-3.23). Among men with $1 SRE, emergency department visits were twice as frequent (95% CI, 1.77-2.28) and hospitalizations were nearly four times as Conclusion. Among men with prostate cancer metastatic to bone, experiencing $1 SRE is associated with poorer survival, increased HCRU, and increased costs. These negative effects emphasize the importance of SRE prevention in this population. The Oncologist 2016;21:320-326Implications for Practice: This study confirms the substantial adverse clinical and economic effects of skeletal-related events (SREs) in men with prostate cancer. Compared with men who have prostate cancer metastatic to the bones and no SREs, men with prostate cancer metastatic to the bones experiencing $1 SRE had a twofold increase in the risk for death, a twofold increase in the number of emergency department visits, and a fourfold increase in the number of hospitalizations; they also incurred an additional $21,000 in direct medical costs attributed to SREs. Strategies to prevent SREs are potentially of high value in this patient population.

Do skeletal-related events predict overall survival in men with metastatic castration-resistant prostate cancer?

“…A more recent study using almost 3,297 men from SEER-medicare found that among men with metastatic prostate cancer, those with >1 SRE had greater than twofold risk of death versus those with no SREs. 13 Although the reference group was men with bone metastases but no SREs, the study did not restrict to those with CRPC. Finally, another study used nearly 7,000 men diagnosed with metastatic PC between 2000–2007 from SEER-Medicare.…”

“…7–9 Meanwhile, a number of population-based studies found an association between SREs and worse OS. 10–13 Although these population-based studies benefited from large sample sizes, they could only capture information on metastases, SREs and disease characteristics from ICD-9 codes. Specifically, these prior observational studies were unable to adjust for bone pain, number of bone metastases, and PSA doubling time (PSADT).…”

Diagnostic expansion in clinical trials: myocardial infarction, stroke, cancer recurrence, and metastases may not be the hard endpoints you thought they were

“…And while there is clear evidence that skeletal related events do confer a poor prognosis,22 there is not comparable evidence for each of the other events included in the composite.…”

Radium-223 in a Community Setting for Castration Resistant Prostate Cancer

“…Risk factors for the subsequent development of bone metastasis include higher Gleason score, higher serum prostate specific antigen (PSA), and shorter PSA doubling time (Moriera et al, 2016). Roughly 40% of men with metastatic prostate cancer develop skeletal related events (SREs) such as a pathologic fracture, spinal cord compression, and the need for surgery or radiotherapy to the involved bone (McDougall et al, 2016). These SREs carry with them substantial economic costs (Perrault et al, 2015), patient discomfort, and reduced cancer specific survival (Koo et al, 2015).…”