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Alison M Pearce, Fay Ryan, Audrey Alforque Thomas, Aileen Timmons,
Frances J Drummond, Linda Sharp
Comparing the costs of prostate cancer
follow-up in primary and secondary care
WITH AN ESTIMATED 25,000 prostate cancer survivors in Ireland,
there are more men living with prostate cancer than any other
form of cancer.1 Like other cancers, follow-up care after active
treatment for prostate cancer is important to detect disease recur-
rence or side-effects such as incontinence, sexual dysfunction or
depression.2,3,4
Follow-up after prostate cancer
Traditionally, prostate cancer follow-up care has been within the
hospital setting, and included regular visits to a specialist clinician
for several years; indeed some patients are never discharged from
follow-up.2 With growing numbers of survivors, it is argued that
this model of care is economically unsustainable,3 and alternative
approaches, such as greater involvement of primary care, have
been suggested.
Evidence suggests that these alternative approaches do not
result in significantly different rates of recurrence, survival,
adverse events, patient wellbeing or patient satisfaction up to five
years following diagnosis.3,4,5,6 However, there is little known about
the economic implications of these different approaches, particu-
larly in prostate cancer.
The aim of this study was to compare the costs of three
approaches for prostate cancer follow-up in Ireland: the European
Association of Urology (EAU) guidelines,7 the NICE guidelines8 and
current practice.
Methods
Economic modelling is a strategy for representing complex real-
world situations in simpler form, and is often used as a framework
to compare alternative models of care. This study developed an
economic model of 10-year follow-up with three arms:
• The European Association of Urology (EAU) guidelines,7 which
are commonly followed in Ireland and imply ongoing, indefi-
nite follow-up, including PSA tests, with a clinician in a hospital
setting
• The National Institute for Health and Care Excellence (NICE)
guidelines, which are more reflective of the recent literature and
suggest initial follow-up and PSA tests with a clinician in hospital
and discharge to primary care after two years8
• Current practice in Ireland, taken from a recent survey of prostate
cancer clinicians in Ireland, conducted by the National Cancer
Registry.
Table 1 shows a summary of the follow-up protocol assumed for
each arm of the model.
The economic model performed a cost minimisation analysis,
which assumes the outcomes of each model arm are not signifi-
cantly different. This assumption for prostate cancer follow-up
is supported by a number of studies comparing survival, rates
of recurrence, quality of life and patient satisfaction with cancer
follow-up in primary versus secondary care setting.3,4,5
Two large surveys of prostate cancer survivors, undertaken at
the National Cancer Registry, were used to identify the probability
of individuals having a physichal or psychosocial problem each
year after diagnosis.9,10 Annual relapse rates were obtained from
the literature,11 and Irish life tables were used to capture the risk
of death from background mortality.12 The model considers costs
from the HSE perspective, however as there is no comprehensive
set of reference costs for the Irish health service, most costs were
sourced from the UK reference costs published by the Personal and
Social Services Research Unit13 (see Table 2).
Results
Table 3 shows the cost of follow-up per survivor and the costs for
each guideline arm as a percentage of the cost of the current prac-
tice arm. Current practice was the least cost efficient arm of the
model; the NICE guidelines were most cost efficient (74% of cur-
rent practice costs) and the EAU guidelines intermediate (92% of
current practice costs). As a cost minimisation analysis the model
assumes the outcomes (such as detection of recurrence, survival
and quality of life) are equivalent across model arms.
For the new cases of prostate cancer diagnosed in 2009, the Irish
healthcare system could have saved more than €230,000 over a
10 year period if the EAU guidelines were adopted and followed.
If the NICE guidelines were adopted and followed in Ireland these
potential savings could be more than €760,000 for the same time
period.
Discussion
The higher cost of current practice was due to the involvement
of GPs to obtain PSA tests throughout follow-up, even when care
was hospital based. The NICE guidelines were the most cost effi-
cient, largely because of the greater involvement of primary care;
appointments in primary care typically cost the health service
substantially less than clinician appointments in hospital.
Comparison of results to previous work
These results are consistent with previous cost analyses. An
economic model from the Netherlands, compared breast cancer
follow-up in hospital with shifting care to either the National
Screening programme or to GPs and found substantial cost
savings.15 Similarly, economic evaluations of colorectal cancer
follow-up by surgeons or GPs in Norway16 and breast cancer
follow-up by physicians or nurses in Sweden17 found that moving
follow-up into primary care was cost saving.
Implications for follow-up in Ireland
While it is recognised that modelling is a simplification of the
real world, these results indicate that involvement of primary care
in prostate cancer follow-up could be increased in Ireland. There
are some specific issues within the Irish healthcare system, such
as the relatively high proportion of sole-GP practices in Ireland,19
which would need to be considered. However, the economic
20 cancerprofessional Spring 2016
recession following the financial crisis in 2008 instigated a tight-
ening of the Irish healthcare budget, with the 2015 budget being
the first in seven years to provide an increase in resources.18
Given the high volume of cases, identifying a more cost-effective
protocol for prostate cancer follow-up than current practice has
the potential to help reduce the growing strain on the healthcare
budget.
Areas for further research
The cost, or cost effectiveness, of an intervention is only one
element in rational decision making about implementation, albeit
an increasingly important one. Factors such as the preferences,
acceptability and adherence by patients, as well as the accept-
ability, willingness and training of health professionals are also
important. These issues are currently being investigated in Ireland
in other phases of the Follow-up After Cancer Treatment (FACT)
study, and will be reported in due course.
Conclusion
This is the first study of the costs of prostate cancer follow-up
in the Irish setting, and also the first comparison of the costs
associated with alternative models of follow-up care in prostate
cancer. Current practice was the least cost-efficient option for
prostate cancer follow-up care, thus demonstrating the potential
for significant savings within the Irish healthcare system associ-
ated with implementation of alternative models of care.
Alison M Pearce* is a post-doctoral research fellow at the National
Cancer Registry Ireland (NCRI); Fay Ryan* is a masters of health
economics student at the University of Sheffield, UK; Audrey
Alforque Thomas is a post-doctoral research fellow, NUI, Galway;
Aileen Timmons is a post-doctoral research fellow, NCRI; Frances
J Drummond is project manager, NCRI; and Prof Linda Sharp is
professor of cancer epidemiology, Newcastle University, UK
(*Joint first authors; correspondence – Alison Pearce, a.pearce@ncri.ie)
References
1. Sharp L, Deady S, Gallagher P et al. The magnitude and characteristics of the popu-
lation of cancer survivors: using population-based estimates of cancer prevalence to
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reviewsection
Spring 2016 cancerprofessional 21
Table 1: Summary of follow-up protocol in each arm of a 10-year cost minimisation model
(comparing three different follow-up care strategies with a cohort of 1,000 men aged 66 treated curatively for prostate cancer)
Model Arm PSA testing Setting Other
European Association
of Urology7
Year 1: 3, 6 and 12 months
Years 2: every 6 months
Year 3: every 6 months
After year 3: annually
Hospital-based clinician DRE and imaging
techniques are not used
in routine follow-up
National Institute
for Health and Care
Excellence8
Year 1: every 6 months
Year 2: every 6 months
Year 3: annually
After year 3: annually
Hospital-based clinician initially. If patient has
stable PSA level and no complications after two
years, offer follow-up in a primary care setting
(such as GP, nurse-led or via secure electronic
communication)
DRE and imaging
techniques are not used
in routine follow-up
Current practice* Year 1: every 4 months
Year 2: every 6 months
Year 3: annually
After year 3: annually
Hospital-based clinician initially, with PSA
performed by GP. If patient has stable PSA level after
five years, discharge to GP
DRE, blood tests and
imaging are not used in
routine follow-up
Table 2: Model input costs for a 10-year cost minimisation model
(comparing three different follow-up care strategies with a cohort of 1,000 men aged 66 treated curatively for prostate cancer)
Basic cost Cost to healthcare systemcNotes
Aged 60-69 years Aged 70+
Medical consultanta
(per hour of contact)
€124.74
(£99)
n/a n/a n/a
PSA testb€7.22
(£5.70)
n/a n/a n/a
General practitioner
Patient contact 11.7
minutesa
€42.84
(£34)
€16.71
(£13.26)
€40.70
(£32.30)
An 11.7 minute appointment is needed for the
GP to carry out a PSA test
General practitioner 17.2
minutesa
€61.74
(£49)
€24.08
(£19.11)
€58.65
(£46.55)
A 17.2 minute appointment is needed for the
GP to carry out full follow-up care
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COST OF PROSTATE CANCER FOLLOW-UP
22 cancerprofessional Spring 2016
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Table 3: Cost of prostate cancer follow-up care per survivor
(results of a discounted base case 10-year cost minimisation model comparing three different follow-up care strategies with a
cohort of 1,000 men aged 66 treated curatively for prostate cancer)
Cost of prostate cancer
follow-up care per survivor
Percentage of
current practice cost
Savings compared to current practice over a 10-year period
Per survivor For a year’s cohort of survivors
EAU Guidelines €1,057.32 92% €92.49 €236,959
NICE Guidelines €852.73 74% €297.08 €761,119
Current Practice €1,149.81 – – –
