Elsevier

European Urology

Volume 49, Issue 6, June 2006, Pages 1028-1034
European Urology

Prostate Cancer
Diffusion and Economic Consequences of Health Technologies in Prostate Cancer Care in Sweden, 1991–2002

https://doi.org/10.1016/j.eururo.2005.12.018Get rights and content

Abstract

Objective

To describe the diffusion of six main health technologies used for management of prostate cancer, to estimate the economic consequences of technological changes, and to explore factors behind the diffusion.

Methods

Data describing the diffusion 1991–2002 were obtained from population-based databases. Costs were obtained from Linköping University Hospital and Apoteket AB. Factors affecting the diffusion of the technologies were explored.

Results

Utilization of technologies with a curative and/or palliative aim has increased over time, except for surgical castration. PSA-tests are used increasingly. The total cost of the study technologies has increased from 20 million euros in 1991 to 65 million euros in 2002. Classification of radical prostatectomy revealed a profile associated with a slow/limited diffusion, while classification of PSA-tests revealed a profile associated with a rapid/extensive diffusion.

Conclusions

Several technological changes in the management of prostate cancer have occurred without proven benefits and have contributed to increased costs. There are other factors, besides scientific evidence, that have an impact on the diffusion. Consequently, activities aimed at facilitating an appropriate diffusion of new technologies are needed. The analytical framework used here may be helpful in identifying technologies that are likely to experience inappropriate diffusion and therefore need particular attention.

Introduction

Prostate cancer is the most common malignancy in Sweden and constitutes over 30 percent of all male cancers [1]. In 1991 5,294 men (124/100,000) were diagnosed with prostate cancer in Sweden and in 2002 there were 9,035 cases (204/100,000) [1]. Prostate cancer is also the leading cause of death among men with 2,164 deaths recorded in 1991 (51/100,000) and 2,460 in 2001 (56/100,000) [2].

In the past two decades, management of the disease has undergone considerable change. With the introduction of PSA-tests, early diagnosis of the disease became possible. Treatment of early disease using surgical (radical prostatectomy) and radiological techniques (external radiotherapy and brachytherapy) was improved and utilized rather than watchful waiting, which was the predominate strategy for managing early prostate cancer in Sweden up until that time. For advanced disease, new forms of treatment such as depot-injection of GnRH-analogues and oral non-steroidal antiandrogens were introduced, and they nearly replaced surgical castration, which had been the standard treatment for six decades. The changes in disease management have incurred considerable cost increases [3] despite poor evidence regarding important health benefits [4], [5], [6], [7], [8]. However, a recent study showed that radical prostatectomy reduces mortality compared to watchful waiting in early prostate cancer [9].

To ensure an optimal use of resources for health care it is essential to be able to adequately guide and control the rate and extent of diffusion of new health technologies. Without regulating activities, technologies with favourable characteristics may experience too slow or too limited a diffusion and technologies with no health or cost advantages may be widely used. Initiating activities aimed at facilitating an optimal diffusion of new technologies is therefore an important task for policy makers. So far, there has been very limited research on diffusion of health technologies.

In the process of seeking increased knowledge about diffusion and technological changes several attributes of the technologies have been suggested to be of particular interest [10]; relative advantage (the degree to which a technology is perceived as superior to the relevant existing and competing technology), compatibility (the degree to which a technology is perceived as being consistent with existing values and past experiences), complexity (the degree to which a technology is perceived as difficult to understand and to use), trialability (the degree to which a new technology may be experimented with by the potential adopters before adoption) and observability (the degree to which the outcomes of a technology are visible). A product based technology is available for purchase on the healthcare market, e.g. a pharmaceutical, and method based technologies are mainly developed by health care professionals, e.g. a program for prostate cancer screening [11].

The objective of this study was to describe the diffusion of six main health technologies (PSA tests, radical prostatectomy, radiation therapy, orchiectomy, GnRH-analogues and antiandrogenes) used in the management of prostate cancer, to calculate the costs in Sweden from 1991 to 2002, and to explore factors behind and related to the diffusion.

Section snippets

Population

The total male population in Sweden was approximately 4.5 million in 2002 [12]. Of these, 35 percent were 50 years of age or older and the majority were white males. In Sweden, all inhabitants have a unique registration number enabling registration of diagnostic and therapeutic measures for diseases. All cases of tumour disease are registered in the National Cancer Register. In addition, all cases of prostate cancer are registered in the National Prostate Cancer Register (NPCR) with respect to

PSA-tests

The use of PSA-tests has increased approximately seven-fold during the period 1991–2002, and in 2002 approximately 430,000 tests were performed in Sweden (Fig. 1).

Curative treatment

The number of radical prostatectomies in Sweden has increased from 178 in 1991 to 1,174 in 2002 (Fig. 2). The corresponding increase during the last three years has been approximately 60 percent, from 726 in 1999 to 1,174 in 2002. Radiation therapies with a curative aim have also been utilized to an increasing extent during the period

Sources of data

For completion and optimal correction we obtained and compared data from several population based sources. Data on surgical and radiation procedures were obtained from the NPCR. Since 1998, all health care regions in Sweden register new cases of prostate cancer in the NPCR. The register is updated annually and no variables have been removed; however variables have been added and adapted according to changing views on management of prostate cancer. To ensure high coverage, the NPCR is checked

Conclusions

The utilization patterns of six main health technologies used in the management of prostate cancer illustrates the dynamic development of health care, with old technologies being used less and new technologies coming into use. Major changes include replacement of orchiectomy by chemical castration, and the increasing use of radical prostatectomy, radiation therapy and PSA-tests. These changes in technology have resulted in a great cost increase for prostate cancer care in Sweden without proven

References (26)

  • Carlsson P. Spridning och ekonomiska effekter av medicinsk teknologi: Institutionen för TEMA. Linköping, Linköping...
  • Statistics Sweden.(Accessed at www.scb.se...
  • G. Sandblom et al.

    Validity of a population-based cancer register in Sweden an assessment of data reproducibility in the South-East region prostate cancer register

    Scand J Urol Nephrol

    (2003)
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