Characterizing the real-world economic burden of metastatic castration-sensitive prostate cancer in the United States

Figures & data

Figure 1. Study design scheme. ADT: androgen deprivation therapy; HRU: healthcare resource utilization; LOT: line of therapy; mCSPC: metastatic castration-sensitive prostate cancer.

Figure 2. Identification of the study population. ADT: androgen deprivation therapy; ARSIs: androgen receptor signaling inhibitors; EMR: electronic medical records; LOT: line of therapy; mCRPC: metastatic castration-resistant prostate cancer; mCSPC: metastatic castration-sensitive prostate cancer; PARP: poly ADP-ribose polymerase; PC: prostate cancer.

^aMedications considered as advanced treatment for mCSPC therapy were: ARSIs (i.e., apalutamide, darolutamide, enzalutamide, abiraterone acetate), chemotherapy (i.e., cabazitaxel, carboplatin, cisplatin, docetaxel, etoposide, mitoxantrone), PARP inhibitors (i.e., niraparib, olaparib, rucaparib, talazoparib), immunotherapy (i.e., sipuleucel-T, pembrolizumab), estrogens (i.e., estramustine phosphate, diethystilbestrol, polyestradiol phosphate), radiopharmaceuticals (i.e., radium-223, lutetium-177-PSMA-617).

^bRecords for medications used as advanced treatment for mCSPC were evaluated in the Flatiron oncologist-defined LOT tables, as well as medication orders, administrations, and oral tables.

^cPatients with clinical trial medication were excluded.

Table 1. Baseline demographic and clinical characteristics.

	Overall cohort	Advanced therapy subgroup
	N = 871	n = 418
Age at index date, years, mean ± SD [median]	70.6 ± 9.3 [71.0]	67.6 ± 9.0 [67.0]
Race, n (%)
White	489 (56.1)	234 (56.0)
Black	114 (13.1)	60 (14.4)
Other	170 (19.5)	80 (19.1)
Unknown	98 (11.3)	44 (10.5)
Practice type, n (%)
Community	781 (89.7)	376 (90.0)
Academic	85 (9.8)	40 (9.6)
Both	5 (0.6)	2 (0.5)
Insurance plan type, n (%)
Commercial	370 (42.5)	222 (53.1)
Medicare	418 (48.0)	155 (37.1)
Medicaid	83 (9.5)	40 (9.6)
VA	0 (0.0)	1 (0.2)
Stage at initial PC diagnosis, n (%)
Localized PC	357 (41.0)	129 (30.9)
mCSPC	514 (59.0)	289 (69.1)
Year of index date, n (%)
2017	258 (29.6)	59 (14.1)
2018	175 (20.1)	83 (19.9)
2019	158 (18.1)	94 (22.5)
2020	158 (18.1)	102 (24.4)
2021	121 (13.9)	79 (18.9)
Time from PC diagnosis to mCSPC, months, mean ± SD [median]	37.5 ± 67.7 [0.0]	24.3 ± 53.7 [0.0]
Time between mCSPC and index date, months, mean ± SD [median]	6.1 ± 10.7 [1.7]	4.5 ± 8.9 [1.7]
Most recent ECOG performance score,^a n (%)	495 (56.8)	274 (65.6)
0	242 (48.9)	149 (54.4)
1	173 (34.9)	91 (33.2)
2	63 (12.7)	26 (9.5)
3	14 (2.8)	7 (2.6)
4	3 (0.6)	1 (0.4)
Gleason score at initial PC diagnosis, n (%)
≤6	50 (5.7)	10 (2.4)
7	137 (15.7)	48 (11.5)
8	132 (15.2)	68 (16.3)
9	237 (27.2)	140 (33.5)
10	51 (5.9)	37 (8.9)
Not available	264 (30.3)	115 (27.5)
Patients progressing to castration resistance, n (%)	299 (34.3)	111 (26.6)
Time between mCSPC and castration resistance, months, mean ± SD [median]	16.6 ± 13.3 [12.6]	15.0 ± 9.3 [13.1]
≤1 month, n (%)	4 (1.3)	0 (0.0)
>1 to ≤3 months, n (%)	10 (3.3)	4 (3.6)
>3 to ≤6 months, n (%)	28 (9.4)	9 (8.1)
>6 to ≤12 months, n (%)	101 (33.8)	35 (31.5)
>12 months, n (%)	156 (52.2)	63 (56.8)
Evidence of prior ADT use,^b n (%)	567 (65.1)	311 (74.4)

Abbreviations: ADT: androgen deprivation therapy; ECOG: Eastern Cooperative Oncology Group; mCSPC: metastatic castration-sensitive prostate cancer; PC: prostate cancer; SD: standard deviation; VA: Veterans Affairs.

^a ECOG scores were considered at any time prior to and including the index date.

^b Evidence of prior ADT use was defined as any ADT at any time prior to (and excluding) the index date.

Table 2. Baseline and follow-up HRU PPPM.

	Overall cohort			Advanced therapy subgroup
	Baseline		Follow-up^b	Baseline		Follow-up^b
	Overall	mCSPC pre-treatment period^a	Overall	Overall	mCSPC pre-treatment period^a	Overall
Mean ± SD [median] or n (%)	N = 871	n = 863	N = 871	n = 418	n = 415	n = 418
Length of period, months	12.0 ± 0.0 [12.0]	3.7 ± 4.2 [1.7]	14.9 ± 12.6 [11.2]	12.0 ± 0.0 [12.0]	3.0 ± 3.4 [1.7]	14.5 ± 11.2 [12.0]
All-cause
Inpatient admissions
≥1 inpatient admission	394 (45.2)	211 (24.4)	394 (45.2)	195 (46.7)	104 (25.1)	193 (46.2)
No. of admissions	0.10 ± 0.22 [0.00]	0.21 ± 0.59 [0.00]	0.18 ± 0.81 [0.00]	0.08 ± 0.15 [0.00]	0.22 ± 0.60 [0.00]	0.13 ± 0.31 [0.00]
No. of days	1.06 ± 3.14 [0.00]	2.83 ± 7.00 [0.00]	1.95 ± 5.01 [0.00]	0.79 ± 2.18 [0.00]	2.84 ± 6.66 [0.00]	1.73 ± 4.41 [0.00]
No. of days per admission	9.50 ± 11.92 [6.00]	10.79 ± 17.22 [6.00]	13.92 ± 25.41 [7.00]	8.72 ± 11.07 [5.00]	10.44 ± 19.68 [5.38]	14.31 ± 25.96 [8.00]
Emergency room visits
≥1 emergency room visit	318 (36.5)	118 (13.7)	307 (35.2)	160 (38.3)	59 (14.2)	143 (34.2)
No. of days with visits	0.06 ± 0.13 [0.00]	0.09 ± 0.38 [0.00]	0.06 ± 0.18 [0.00]	0.07 ± 0.15 [0.00]	0.10 ± 0.38 [0.00]	0.06 ± 0.17 [0.00]
Outpatient visits
≥1 outpatient visit	865 (99.3)	819 (94.9)	859 (98.6)	416 (99.5)	396 (95.4)	413 (98.8)
No. of days with visits	1.97 ± 1.49 [1.59]	4.81 ± 4.89 [3.95]	2.92 ± 2.60 [2.40]	1.93 ± 1.48 [1.50]	4.77 ± 3.79 [4.13]	3.17 ± 2.87 [2.59]
Pharmacy claims
≥1 pharmacy claim	804 (92.3)	721 (83.5)	806 (92.5)	400 (95.7)	366 (88.2)	404 (96.7)
No. of pharmacy claims	2.36 ± 2.43 [1.75]	4.14 ± 5.71 [2.83]	3.24 ± 3.09 [2.62]	2.45 ± 2.51 [1.80]	4.53 ± 4.77 [3.30]	3.96 ± 3.19 [3.37]
Other services^c
≥1 other service	47 (5.4)	22 (2.5)	53 (6.1)	23 (5.5)	8 (1.9)	25 (6.0)
No. of days with other services	0.05 ± 0.67 [0.00]	0.06 ± 0.78 [0.00]	0.05 ± 0.47 [0.00]	0.08 ± 0.95 [0.00]	0.10 ± 1.11 [0.00]	0.05 ± 0.43 [0.00]
PC-related^d
Inpatient admissions
≥1 inpatient admission	272 (31.2)	166 (19.2)	330 (37.9)	135 (32.3)	81 (19.5)	169 (40.4)
No. of admissions	0.05 ± 0.10 [0.00]	0.16 ± 0.52 [0.00]	0.14 ± 0.78 [0.00]	0.05 ± 0.09 [0.00]	0.17 ± 0.52 [0.00]	0.11 ± 0.29 [0.00]
No. of days	0.62 ± 1.99 [0.00]	2.42 ± 6.58 [0.00]	1.76 ± 4.70 [0.00]	0.57 ± 1.90 [0.00]	2.56 ± 6.45 [0.00]	1.62 ± 4.27 [0.00]
No. of days per admission	13.31 ± 21.45 [7.00]	12.76 ± 19.57 [7.00]	17.08 ± 28.59 [9.00]	11.66 ± 15.52 [6.00]	11.94 ± 21.89 [6.00]	16.50 ± 27.78 [9.00]
Emergency room visits
≥1 emergency room visit	56 (6.4)	41 (4.8)	113 (13.0)	32 (7.7)	22 (5.3)	59 (14.1)
No. of days with visits	0.01 ± 0.04 [0.00]	0.03 ± 0.24 [0.00]	0.02 ± 0.11 [0.00]	0.01 ± 0.05 [0.00]	0.04 ± 0.28 [0.00]	0.03 ± 0.13 [0.00]
Outpatient visits
≥1 outpatient visit	815 (93.6)	780 (90.4)	850 (97.6)	393 (94.0)	381 (91.8)	408 (97.6)
No. of days with visits	0.73 ± 0.78 [0.50]	3.14 ± 3.91 [2.31]	1.79 ± 1.98 [1.40]	0.76 ± 0.78 [0.58]	3.39 ± 3.26 [2.90]	2.08 ± 2.06 [1.66]
Pharmacy claims
≥1 pharmacy claim	439 (50.4)	393 (45.5)	501 (57.5)	231 (55.3)	209 (50.4)	319 (76.3)
No. of pharmacy claims	0.10 ± 0.19 [0.08]	0.51 ± 1.37 [0.00]	0.46 ± 0.66 [0.17]	0.09 ± 0.17 [0.08]	0.56 ± 1.70 [0.08]	0.71 ± 0.79 [0.73]
Other services
≥1 other service	2 (0.2)	1 (0.1)	2 (0.2)	2 (0.5)	1 (0.2)	2 (0.5)
No. of days with other services	0.00 ± 0.01 [0.00]	0.00 ± 0.01 [0.00]	0.00 ± 0.00 [0.00]	0.00 ± 0.01 [0.00]	0.00 ± 0.00 [0.00]	0.00 ± 0.00 [0.00]

Abbreviations: ARSI: androgen receptor signaling inhibitors; HRU: healthcare resource utilization; ICD-10-CM: International Classification of Diseases 10th Revision Clinical Modification; LHRH: luteinizing hormone-releasing hormone; mCSPC: metastatic castration-sensitive prostate cancer; No.: number; PARP: poly ADP-ribose polymerase; PC: prostate cancer; PPPM: per-patient per-month; SD: standard deviation.

^a The mCSPC pre-treatment period was defined as the portion of the 12-month baseline period that occurred on and after evidence of metastasis but prior to the initiation of therapy.

^b The overall follow-up period was defined as the time from the index date until the earliest of i) evidence of castration resistance, ii) end of continuous insurance eligibility, iii) end of data availability, or iv) death (if available).

^c Other services include medical claims for dental/vision care, durable medical equipment, mass immunization center, birthing centering center, and claims at an "other place of service".

^d PC-related HRU and costs were identified with the ICD-10-CM code C61 and procedure codes for LHRH or of the following guideline-recommended therapies for mCSPC: ARSIs, chemotherapy, PARP inhibitors, immunotherapy, estrogens, and radiopharmaceuticals. .

Figure 3. Baseline and follow-up costs PPPM. ARSI: androgen receptor signaling inhibitor; ER: emergency room; HRU: healthcare resource utilization; ICD-10-CM: International Classification of Diseases 10th Revision Clinical Modification; IP: inpatient; LHRH: luteinizing hormone-releasing hormone; OP: outpatient; mCSPC: metastatic castration-sensitive prostate cancer; PARP: poly ADP-ribose polymerase; PC: prostate cancer; PPPM: per-patient-per-month; US: United States.

Notes:

^aPC-related HRU and costs were identified with the ICD-10-CM code C61 and procedure codes for LHRH or of the following guideline-recommended therapies for mCSPC: ARSIs, chemotherapy, PARP inhibitors, immunotherapy, estrogens, and radiopharmaceuticals.

^bThe mCSPC pre-treatment period was defined as the portion of the 12-month baseline period that occurred on and after evidence of metastasis but prior to the initiation of therapy.

^cThe follow-up period was defined as the time from the index date until the earliest of i) evidence of castration resistance, ii) end of continuous insurance eligibility, iii) end of data availability, or iv) death (if available).

Table 3. Baseline and index treatment patterns.

	Overall cohort		Advanced therapy subgroup
	N = 871		n = 418
n (%)	Baseline^a	Index treatment^b	Baseline^a	Index treatment^b
ADT	223 (25.6)	453 (52.0)	126 (30.1)	0 (0.0)
Leuprolide	196 (22.5)	381 (43.7)	113 (27.0)	0 (0.0)
Degarelix	22 (2.5)	49 (5.6)	10 (2.4)	0 (0.0)
Other ADT	15 (1.7)	23 (2.6)	7 (1.6)	0 (0.0)
ARSI	154 (17.7)	263 (30.2)	154 (36.8)	263 (62.9)
Abiraterone acetate	106 (12.2)	176 (20.2)	106 (25.4)	176 (42.1)
Enzalutamide	38 (4.4)	62 (7.1)	38 (9.1)	62 (14.8)
Apalutamide	14 (1.6)	25 (2.9)	14 (3.3)	25 (6.0)
Darolutamide	1 (0.1)	0 (0.0)	1 (0.2)	0 (0.0)
First-generation antiandrogens	413 (47.4)	0 (0.0)	216 (51.7)	0 (0.0)
Bicalutamide	412 (47.3)	0 (0.0)	216 (51.7)	0 (0.0)
Chemotherapy	3 (0.3)	134 (15.4)	3 (0.7)	134 (32.1)
Docetaxel	2 (0.2)	133 (15.3)	2 (0.5)	133 (31.8)
Etoposide	1 (0.1)	0 (0.0)	1 (0.2)	0 (0.0)
Cisplatin	0 (0.0)	1 (0.1)	0 (0.0)	1 (0.2)
Immunotherapy	0 (0.0)	5 (0.6)	0 (0.0)	5 (1.2)
Sipuleucel-T	0 (0.0)	4 (0.5)	0 (0.0)	4 (1.0)
Pembrolizumab	0 (0.0)	1 (0.1)	0 (0.0)	1 (0.2)
Combination therapy^c	–	16 (1.8)	–	16 (3.8)

Abbreviations: ADT: androgen deprivation therapy; ARSI: androgen receptor signaling inhibitor.

^a Treatments during the baseline period are not mutually exclusive.

^b Treatments used on the index date are mutually exclusive and were used as monotherapy unless specified otherwise.

^c Combination therapy includes ARSI + chemotherapy, ARSI + other, and chemotherapy + chemotherapy.

 Data availability statement

Data that support the findings of this study were used under license from Flatiron Health, Inc. and Komodo Health Solutions. Restrictions apply to the availability of these data, which are not publicly available and cannot be shared. The data are available through request made directly to the data vendor, subject to the data vendor’s requirements for data access.