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Keywords:

  • prostate cancer;
  • bladder cancer;
  • direct costs;
  • indirect costs;
  • total costs;
  • research fund allocation

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

OBJECTIVE

To compare the costs of managing prostate and bladder cancer and relate them to current expenditure on research, as the increasing prevalence of both necessitates the adequate direction of resources.

METHODS

All new prostate and bladder cancers diagnosed in 2001–2002 were identified from British Association of Urological Surgeons Section of Oncology database (national and local). The total cost of diagnosing, treating and following patients for 5 years was estimated as the sum of direct costs (National Health Service) and indirect costs (loss of earnings). Annual research fund allocation (RFA) for each cancer were obtained from the National Cancer Research Institute UK.

RESULTS

There were 15 099 and 7703 patients with newly diagnosed prostate (mean age 72.3 years) and bladder cancers (mean age 71.3 years). The total cost for prostate cancer was estimated at £92.74 million, with hormonal therapy alone costing £63.1 million. The total cost for bladder cancer was £55.39 million, of which superficial disease cost £35.25 million. The mean cost per patient was more for bladder than for prostate cancer (£8349 vs. £7294). The RFA allocation during this period was £20.56 million and £4.62 million for prostate and bladder cancer, respectively, and the respective RFA allotment per pound spent on the mean cost of disease management per patient was £2818 and £553.

CONCLUSION

Individual patient management is more costly for bladder cancer but less is invested in research than for prostate cancer. This study suggests a need to re-evaluate future strategies.


Abbreviations
RP

radical prostatectomy

NHS

National Health Service

TC

total costs

IC

indirect costs

DC

direct costs

RFA

research fund allocation

NCRI

National Cancer Research Institute

TURBT

transurethral resection of bladder tumour.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Prostate and bladder cancer account for 85% of all genitourinary malignancies, with prostate cancer ranking first among all cancers and bladder cancer fifth [1]. In the UK during 1999, the incidence was 20 842 and 10 524 for prostate and bladder cancer, respectively [1]. The evidence suggests an increasing trend in the incidence of both malignancies in recent years, with the incidence of these cancers being 18 201 and 10 287 in 1997 [2]. Nonetheless, better treatment methods and earlier detection has resulted in a decrease in cancer-related mortality [3], as shown by the age-standardized death rate per million population for prostate cancer, at 302 and 274 in 1991 and 2001, respectively. The corresponding values for male bladder cancer were 121 and 93 deaths per million.

Treatment for both diseases is well established but varies depending on the stage and grade. For localized prostate cancer the treatment options include active monitoring or watchful waiting, radical prostatectomy (RP), radical radiotherapy, and more recently brachytherapy. In advanced disease the options include hormone manipulation, with most patients receiving LHRH analogues. In addition, a few patients may undergo orchidectomy or may receive antiandrogen therapy. In those with hormone-refractory disease second-line hormone therapy is used and includes the addition of antiandrogens or oestrogens. Chemotherapy for advanced prostate cancer is used in a few patients. In those with known bone involvement who complain of pain, analgesia is the primary treatment, followed by local radiotherapy. However bisphosphonates may be recommended in a selected few, to prevent bone disease-related complications.

For superficial bladder cancer the treatment involves endoscopic surveillance, tumour resection and intravesical chemo- or immunotherapy. Those with locally advanced bladder cancer may have radical surgery or radiotherapy, whilst metastatic disease is treated essentially with chemotherapy.

Once treated, all patients require some form of follow-up, as there is a significant risk of recurrence. The progression rate for prostate cancer varies with the grade of the disease, at 15–52%[4]. More than 60% of superficial bladder cancers will recur despite treatment, whilst the risk increases with the grade of the disease [5,6]. Furthermore, the cited mortality rates show that significantly many patients survive, thus resulting in an accumulation of patients requiring continuing care.

There is no doubt that the diagnosis, treatment and follow-up of these two malignancies results in a significant burden on National Health Service (NHS) resources. However, there are limited data available on the economic impacts of prostate and bladder cancer. Chamberlain et al.[7] suggested that the cost of prostate cancer was at least £45 million annually. However, this value was based on incidence and prevalence data from the early 1990s, and only accounted for primary-care costs and the cost of in-patient days. At that time there were no national statistics available for the cost of radiotherapy, surgery, hormone therapy and chemotherapy, and hence the estimates were grossly underestimated.

It is paramount that accurate data are available with which to plan future resource allocation and to highlight areas where more cost-effective management is required. The aims of the present study were to assess the impact of prostate and bladder cancer on the UK healthcare and social economy. We present the direct (DC) and indirect costs (IC) of diagnosis, treatment and 5-year follow-up of all patients diagnosed with prostate and bladder cancer in the UK during 2001–2002, and total costs (TC) and cost per patient, with comparisons between the cancers and correlations with current research expenditure.

METHOD

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

All new prostate and bladder cancers diagnosed between January 2001 and 2002 were identified from the BAUS Section of Oncology database [8]. For comparison, patients with the same diagnosis at our Institute in an equivalent period were also identified from the local BAUS database.

The DC were defined as the expenditure related to the diagnosis, treatment and 5-year follow-up of the patients identified. This included outpatient visits, haematological, biochemical, pathological, microbiological and radiological investigations required during diagnosis and follow-up, as well as the costs of various treatments (surgery, radiotherapy, chemotherapy, hormone therapy and immunotherapy). The protocols for the investigation of patients during diagnosis and follow-up were based on European Association of Urology guidelines [9,10]. The individual costs of these investigations were obtained from the local NHS Trust Finance Directorate and are thought to be typical of most Trusts across the UK. The patients were divided into various subgroups according to the stage of disease and treatment. The DC were calculated for each subgroup of patients and summed.

The IC were defined as loss of earnings based on the average weekly wage in relation to age and sex for the year 2000 (Table 1), the data for which were obtained from the UK Economics Database [11]. Loss of earnings was defined as any activity related to diagnosis, treatment and follow-up that required time off from normal employment.

Table 1.  The mean weekly earnings in 2000 (UK Economics Database 2002)
Age group,yearsMean weekly earnings, £
MenWomen
<18151.3152.6
18–20217.2193.3
21–24314.7270.2
25–29390.1334.2
30–39479.8381.6
40–49520.7364.8
50–59491.8334.9
60–64407.4289.4

The details available from BAUS database were insufficient to calculate the IC, as there were no details of the age and sex distribution in the individual subgroups. Hence, for the purpose of calculating IC, the cohort of patients who were diagnosed with prostate and bladder cancer at our institute during the same period were used and costs extrapolated to the national data (Table 2). The treatments received by individuals dictate the follow-up, which in turn affects costs, and hence local and national data were compared for the number of patients receiving particular treatments (Table 3).

Table 2.  Comparison of the incidence between Local Trust and UK (BAUS) of the two cancers
PopulationProstateBladder
Preston:
Incidence   140  75
Mean age, years    73.1  72.3
UK
Incidence15 0997703 (5688 men, 1983 women)
Mean age, years    72.4  71.3
Table 3.  Comparison of the local and national data for treatments for prostate and bladder cancer; the UK data are available in only 83.9% and 85.8% of patients, respectively
CategoryLocal (%)UK (%)TC (£M)
  • *

    In the national data for prostate cancer, 1328 patients had TURP and 18 had chemotherapy.

  • †With costs of mitomycin and BCG instillation.

Prostate cancer
Hormones42.147.263.1
Watchful waiting10 8.7 1.8
RP14.2 9.912.5
Radical radiotherapy26.218.112.4
with hormones 7.1 
(TURP*) (1.9)
(Chemotherapy*) (0.02)
Bladder cancer
TURBT (low-grade)5660.335.25
TURBT (high-grade)1610.2 6.1
Cystectomy/related surgery17.33 5.2 3.6
Radiotherapy 6.6 9.02 8.1
Systemic chemotherapy 2.6 1.1 1.5

The TC of diagnosing, treating and following patients for 5 years were estimated as the sum of DC (NHS) and IC. The cost per patient was calculated as TC for each cancer divided by the incidence for each cancer. All calculations were based on the assumption that there would be no mortality or disease recurrence in any of these patients over the 5-year follow-up. The annual research fund allocation (RFA) for each cancer were obtained from National Cancer Research Institute (NCRI) [12].

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

In the period assessed there were 15 099 newly diagnosed prostate cancers (mean age 72.3 years; Table 2). The treatments for these patients were RP (1506), radical radiotherapy (2735), hormone therapy (7127) and chemotherapy (18). There were 1320 patients for whom no treatment was available from the database, so they were assumed to be on active monitoring. A further group of patients were identified in whom it was not clear, for cost calculations, what kind of treatment they received. These 1065 patients were entirely excluded from the calculation (organ-conserving surgery 12, other surgery 637, other treatments 396, immunotherapy three, and intravesical chemotherapy 17). There were 1328 patients who had a TURP and had a diagnosis of prostate cancer. For these patients the cost of diagnosis was calculated and included in the TC. However, the treatments for these patients were not available and therefore this value was excluded from the cost calculation.

During the period assessed there were 7703 newly diagnosed bladder cancers (mean age 71.3 years), with the disease being almost three times more common in men than women. Superficial disease was almost three times more common than invasive disease. Amongst these patients the treatment was not stated in 732, whilst in 337 the treatment was not clear enough calculate cost (other surgery 157, systemic immunotherapy 40, hormones 26, other treatment 114). All these patients were excluded. Hence the cost calculation was based on 6634 patients, comprising transurethral resection of bladder tumour (TURBT) low-grade 4645, high-grade 794; radical radiotherapy, 695; radical cystectomy, 408; systemic chemotherapy, 92.

The TC for the diagnosis, treatment and 5-year follow-up of patients with prostate cancer diagnosed during 2001–2 was estimated at £92.74 million. Hormonal therapy was estimated to cost £63.1 million, thereby accounting for over two-thirds of the TC. The TC of radical radiotherapy and RP were similar, but almost 1.5 times more patients were treated with radical radiotherapy than with RP.

The TC for the diagnosis, treatment and 5-year follow-up of patients with bladder cancer diagnosed during 2001–2 was £55.39 million; the TC of superficial disease was £35.25 million, whilst the corresponding TC for invasive disease was £20.2 million. The TC for patients undergoing radical radiotherapy was over twice that for cystectomy (£8.1 vs £3.6 million). However, more patients were treated with radiotherapy than cystectomy (695 vs 408).

The percentage of patients receiving each treatment locally compared reasonably with national values (Table 2). In some instances more patients received radical treatment locally than nationally. However, local data were used for calculating IC in the proportion of patients in the pre-retirement age group only, and this accounts for a small proportion of TC. The DC form the greater proportion of the TC (90–98%) for both cancers (Table 4); DC implies that the burden is directly borne by the NHS.

Table 4.  Distribution of DC and IC for prostate and bladder cancers diagnosed in 2001–2 for the subsequent 5 years
CostsProstateBladder
low-gradehigh-grade
% of TC
DC97.694.589.9
IC 2.4 5.510.1
£ million:
TC92.7435.9519.44
Estimated DC for NHS90.533.9717.47
IC 2.23 1.98 1.97

Prostate cancer has a greater impact on the UK health economy than bladder cancer (£92.74 vs £55.39 million) (Table 5), because the incidence of the former is almost twice that of the latter (15099 vs 7703). However, the mean cost of treatment of each patient with bladder cancer is more than that for each patient with prostate cancer (£8349.2 vs £7294.2)

Table 5.  National expenditure for patients with prostate and bladder cancer diagnosed in 2001–2, and the RFA (based on NCRI values) as the total and against the cost of disease management per patient
CostsProstateBladder
TC (£ million)  92.74  55.39
Cost of management/patient (£)7294.28349.2
RFA
2001–02 (£ million)  20.56   4.62
disease management (£)2818 553.34

The annual RFA during 2001–2 as reported by the NCRI was £20.56 and £4.62 million for prostate and bladder cancer, respectively (Table 5) [12]. To compare these values according to the economic impact of each disease we calculated the RFA per pound spent on the mean cost of disease management per patient. This showed that ≈ £2818 is spent on the research of prostate cancer per pound spent on the cost of management per patient, whilst the corresponding value for bladder cancer was £553 (Table 5). This shows that investment in research for prostate cancer is five times greater than that for bladder cancer.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Prostate and bladder cancer are the commonest malignancies treated by urologists. The strategies involved in the diagnosis, treatment and follow-up of both are well investigated, but the cause and prevention are to some degree relatively less well explained. Healthcare systems should ideally function to provide the optimum care regardless of cost. However, the definition of optimum care is debatable and unfortunately the cost of treatment is a real issue in medicine worldwide. In the UK there are few data on the cost of treatments for prostate and bladder cancer, and this is likely to be related to the difficulty in calculating such values, which involve many variables. However, these data are most important in planning future urological healthcare investment strategies. The present study is one of the first to assess the economic burden of prostate and bladder cancer in the UK.

Presently, the estimated TC, over a 5-year period, of managing patients with prostate cancer diagnosed in one calendar year (2001–2) is £92.8 million, whilst that for bladder cancer in the same period is £55.39 million, thus showing that both diseases are relatively costly to the UK health economy.

The present study only estimated the economic impact of these two cancers; we consider that the calculations are underestimates of the true expenditure for several reasons. First, there is the inadequacy of recording the incidence of both tumours, and their various treatments, in the BAUS database. This resulted in the exclusion of some patients and therefore an underestimate of the costs. Second, the IC were calculated only for those patients who were in the employment age group. The drawback of this is that patients who were designated as having retired realistically still contribute to the economy, and furthermore many still may be in some form of employment. A more accurate assessment of IC could have been obtained by using values for ‘present value of lifetime earnings’, which considers that those retired still have a value to the economy, regardless of whether they are employed. However, such figures are not available for the UK. Third, it was assumed that there was no disease recurrence or mortality during the 5-year follow-up. This assumption was made for ease of calculations, but including this would undoubtedly increase the costs further. In addition, no weight was given in our calculations to the expenditure related to palliative care, nursing homes or social services, whilst there can be no possible estimate of the cost for the amount of mental and physical suffering that patients and their relatives undergo. Last, the values stated represent the cost of managing a group of patients diagnosed in one calendar year, over a period of 5 years. Realistically there would be a gradual accumulation of patients over time, which would increase costs further.

In the treatment of prostate cancer the expenditure on hormone manipulation contributes ≈ 68% of the TC, almost entirely from the use of LHRH agonists, which currently are the mainstay of hormone therapy. Orchidectomy is comparable with LHRH agonist therapy both in terms of treatment efficacy and in maintaining the quality of life of patients [13–16], and is undoubtedly the least expensive. This would suggest that offering patients orchidectomy should be considered for all those treated with hormone manipulation.

The overall costs of RP and radiotherapy for prostate cancer are comparable, although more patients were treated with radiotherapy. The number of patients opting for specific treatments is variable, as in most cases it will be dictated by patient preference and the availability of local skills and resources. The cost per patient treated by radiotherapy was considerably cheaper than by RP for early prostate cancer in the present assessment, and comparable with previous assessments [17].

Some patients in the present study were diagnosed with prostate cancer from the histology of specimens taken at TURP for BOO. The cost of TURP was included as part of the cost of diagnosis. Specific data on the treatment offered to these patients was not available and therefore could not be calculated. The present study aimed to provide as realistic a view as possible and therefore included the available data in the TC for prostate cancer; excluding TURP gave an overall cost reduced by £1.95 million, to a TC of £92.73 million.

In comparison to the study by Chamberlain et al.[7] on the cost of prostate cancer, the current values may initially seem to be an underestimate. There are several reasons for this; Chamberlain et al. based their values on incidence and prevalence data from the early 1990s, obtained from primary care and cancer registry sources which may not have been accurate. In addition, they concentrated on inpatient stay, primary care and community care costs. At that time there were no data available on the costs of treatments such as radiotherapy. The current study estimated costs of secondary care, main therapies and loss of earnings over a 5-year period in a cohort of patients diagnosed in one calendar year. Hence the values differed, as they measure different variables in different populations.

The TC of bladder cancer is less than for prostate cancer, reflecting that the incidence of the former is half that of the latter. However, the cost of management per patient is greater than for prostate cancer (Table 5), probably because patients with bladder cancer are followed using a protocol that involves regular cystoscopy, which is more expensive than the PSA test used for following prostate cancer.

Superficial bladder cancer costs ≈ £35 million, which is considerably more than the cost of invasive disease (£20 million). Both stages of disease require intensive follow-up with cystoscopy, which accounts for the major cost burden. However, superficial disease is more common and hence has a greater economic impact.

There is a notable difference in the IC between bladder and prostate cancer, and between low- and high-grade bladder cancer. IC represent the loss of earnings related to absence from work during diagnosis and treatment. These IC were calculated with the available local data and were extrapolated to the national data (as explained above), and are based only on those patients of pre-retirement age. Most of the patients were aged >65 years and therefore were not included in the calculation of IC. The differences between various groups could be explained by the following. The follow-up of bladder cancer involving greater loss of time from work because of various forms of cystoscopy (flexible and rigid) that require at least a day of absence. In comparison, follow-up for prostate cancer mainly involves an outpatient visit for a PSA check, which may require a day off work, but less frequently. In addition, more days are lost for high-grade bladder cancer, as a result of more frequent cystoscopies and general anaesthetics.

The costs of bladder cancer management could be reduced in several ways, e.g. allowing less frequent check cystoscopies in superficial low-grade disease, which is a relatively benign condition, and considering outpatient rather than inpatient general anaesthetic cystoscopy [18]. Considering cheaper and less-invasive surveillance is, as yet, not an option, but new urinary tumour markers, once available, may increase the accuracy of predicting tumour recurrence, and if widespread use ensues this may relate to a cost saving. In addition, the search for better intravesical therapies may eventually lead to far less recurrence and progression of the disease.

The treatment of high-grade and invasive disease is variable, and includes endoscopic resections, radical cystectomy and radiotherapy, with the judicious use of intravesical chemo- and immunotherapy. In the current estimates, radical radiotherapy was more expensive than cystectomy, possibly because more patients were treated by this method, but that such patients still need to undergo regular cystoscopic review is also important.

In the UK, ≈ £450 million is spent on research every year, of which most is provided by 15 major bodies (≈ £335 million) [12]. The NCRI incorporates the data from these major funding organizations, and being the major funding network it is assumed that the data should reflect the research spending by the nation as a whole. The annual RFA for various cancers obtained from NCRI database shows that investment in prostate cancer research was over £20 million, whilst for bladder cancer it was <£5 million. Comparing these values to the cost of disease, prostate cancer had an investment of £2818 for every pound spent on disease management per patient, compared to £533 for bladder cancer. This vast difference undoubtedly and rightly relates to the incidence and mortality of each disease. However, the present study highlights that on an economic basis there are certain areas in both cancers where more investment might lead to more efficient management and reduced cost. The NCRI data cannot be used to identify the specific areas of research in which investment is made; it is likely that most is directed towards diagnosis and treatment, despite that in the longer term the only realistic gains may lie in understanding the cause of the disease and in producing prevention strategies.

In the future the costs of managing these two diseases are likely to increase as a result of several factors, e.g. increasing incidence, increasing public awareness, the widespread use of PSA testing, the possible introduction of PSA screening, the availability of newer possibly more expensive treatments, the ageing population and more referrals on the ‘2-week cancer referral’ rules, which may result in more investigations and increased incidence.

In conclusion, this study highlights the economic impact of prostate and bladder cancer in the UK, and may prove helpful in planning future strategies in healthcare and research funding allocation.

ACKNOWLEDGEMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Authors’ contributions: V.K. Sangar conceived the study, assessed the validity of calculations and jointly prepared the text with N. Ragavan, who collected the data, made the financial calculations and prepared the text. (Both VKS and NR contributed significantly in the development of the project calculations and preparation of the text). S.S. Matanhelia advised on the design of the study and contributed to the text. M.E. Watson advised on the design of the study and contributed to the text. R.A. Blades provided overall supervision of the project with periodic assessment on progress and preparation of text.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES
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