CLINICAL AND ECONOMIC-CONSIDERATIONS IN THE TREATMENT OF PROSTATE-CANCER

Prostate cancer is a growing health problem with considerable economic consequences. Despite progress in the management of this disease, few areas in medicine generate greater disagreement. The larger part of h ealthcare resources are allocated to 'halfway technologies' aimed at p alliative intervention to prolong life, while a relatively small part goes to measures aimed at preventing or curing the disease. The aetiol ogy of this cancer is multifactorial and no practical measures for pri mary prevention are known. The number of patients diagnosed with prost ate cancer is increasing steadily. The age-adjusted mortality, however , has increased only slightly. In its early stages, prostate cancer is often asymptomatic and is usually not diagnosed until it has advanced . Programmes for the early detection of prostate cancer (screening) cl aimed to reduce morbidity and mortality are a matter of controversy. F urthermore, there has been much debate regarding optimal treatment in the early stages of the disease. Economic considerations have not as y et been integrated into studies concerning localised prostate cancer. The routine first-line treatment of advanced prostate cancer usually i nvolves some type of endocrine treatment. The most straightforward tec hnique is surgical castration. Oral estrogens are as effective as cast ration, but have significant cardiovascular adverse effects. These may possibly be prevented if estrogens are given parenterally. A third pr incipal endocrine treatment is the administration of antiandrogens. Me dical castration can be attained by the administration of recently dev eloped synthetic peptides, gonadotrophin-releasing hormone [luteinisin g hormone-releasing hormone (LHRH)] (GnRH) analogue agonists which are given parenterally. The advantage of this type of medical castration is that the trauma of surgical castration and the adverse effects of o ral estrogens are avoided. In an attempt to improve the results obtain ed with endocrine treatment, the concept of combining surgical or medi cal castration with antiandrogens was introduced. This combination cou ld offer improved response rates and survival in a significant number of patients. However, this advantage must be weighed against the toler ability profiles and the high costs of antiandrogens and GnRH analogue s. When using expensive drugs, the duration of treatment is a crucial factor in the total cost. As the length of treatment varies greatly be tween patients it is difficult to decide the most cost-effective alter native for a single individual. The patient's preference is an importa nt factor when selecting treatment. When there is little or no differe nce in the effect of different regimens the total lifetime cost is imp ortant. Few economic evaluations have been carried out in the area of prostate cancer. In view of the substantial financial burden of prosta te cancer, more systematic use of health economic methods should be ma de, and economic considerations integrated into ongoing or planned cli nical studies.