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Impact of the National Health Fund Policy on Hormone Treatment for Prostate Cancer in Jamaica

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Impact of the National Health Fund Policy on Hormone Treatment for Prostate Cancer in Jamaica Investigación original / Original research Impact of the National Health Fund policy on hormone treatment for prostate cancer in Jamaica Belinda F. Morrison,1 William D. Aiken,1 and Marvin E. Reid 2 Suggested citation Morrison BF, Aiken WD, Reid ME. Impact of the National Health Fund policy on hormone treatment for prostate cancer in Jamaica. Rev Panam Salud Publica. 2011;29(6):404–8. ABSTRACT Objective. To compare the proportion of patients choosing surgical versus medical castra- tion to treat prostate cancer, before and after the National Health Fund (NHF) of Jamaica began to subsidize hormone therapy. Methods. A retrospective review was performed at the University Hospital of the West In- dies (UHWI), Jamaica. The pathology database at UHWI was searched to identify patients who had prostate biopsies between January 2000 and December 2007. These were combined with records of biopsies at external institutions. Medical records of all patients with positive prostate biopsies were reviewed to determine if they had received androgen deprivation ther- apy (ADT). Patients were classified as having had surgical castration (bilateral orchiectomy) or medical castration. Chi-square statistics were used to determine the difference in propor- tions between those choosing medical versus surgical castration before and after March 2005, when the NHF began offering subsidies for ADT drugs. Results. Of the 1 529 prostate biopsies performed during the study period, 680 (44.0%) cases of prostate cancer were diagnosed. Of these, 458 patients underwent ADT and had com- plete records available for analysis. The mean patient age was 72 years. During the entire study period, surgical castration was performed in 265 patients (58.0%) and medical castra- tion in 193 (42.0%). A greater proportion of orchiectomies were performed before March 2005, rather than after (P < 0.001). Estrogens were the most common method of medical castration used before the NHF subsidy became available (62.0%); while luteinizing hormone-releasing hormone analogues (38.0%) and antiandrogens (36.5%) were most often chosen afterwards. Conclusions. Surgical castration was more common than medical castration before March 2005. After the NHF began to subsidize the cost of drugs for hormone therapy, medical cas- tration was chosen more often. Increased access to drugs for hormone therapy has changed treatment patterns in Jamaica. Key words Prostatic neoplasms; orchiectomy; androgen antagonists, therapeutic use; prescrip- tion fees; Jamaica. Androgen deprivation therapy (ADT) metastatic prostate cancer were first de- ADT may be achieved via surgical or remains the treatment of choice for ad- scribed (2), this type of treatment has be- medical means (1). The decision about vanced and metastatic prostate cancer come widespread. ADT improves sur- the type of ADT chosen depends on a (1). Since 1941, when the palliative ef- vival for patients with locally advanced number of variables, including treat- fects of castration and estrogens on disease previously treated with external ment costs, adverse effects, patient age, beam radiation (3). A practice variation and availability of therapeutic options. 1 Department of Surgery, University of the West In- that has gained acceptance is the use In the United States of America, where dies, Kingston, Jamaica. Send correspondence to of ADT in patients with rising prostate prostate cancer screening is becoming Belinda Morrison, [email protected] 2 Sickle Cell Unit, University of the West Indies, specific antigen (PSA) after curative routine, there has been a stage migra- Kingston, Jamaica. therapy (4). tion, with most patients presenting with 404 Rev Panam Salud Publica 29(6), 2011 Morrison et al. • Changes in hormone treatment for prostate cancer in Jamaica Original research localized prostate cancer (1). Despite initiation of therapy and the specific type Among the 458 study subjects, the this, the use of ADT has increased due to of ADT were recorded. March 2005 mean age was 72.0 years. There was failure of local therapy, which can be marked the point at which the NHF no difference in age between patients identified by rising PSA in patients (1). began to subsidize drugs for medical choosing medical versus surgical castra- In Jamaica, widespread screening has ADT. Ethical approval was obtained tion or between the two study periods not been adopted yet, and therefore, from the Ethics Department, Faculty of (before/after March 2005) (Table 1). most cases of prostate cancer are locally Medical Sciences, University of the West Over the course of the entire study pe- advanced or metastatic at presentation. Indies, Kingston, Jamaica. riod (January 2000–December 2007), 265 As a result, ADT use is still the norm in (58.0%) of the 458 subjects were treated Jamaica. Statistical analyses with surgical castration and 193 (42.0%) Surgical castration (bilateral orchiec- with medical castration. A greater pro- tomy) was the first method of ADT de- Values are expressed as counts or pro- portion of orchiectomies (60.0%) were scribed (2); however, this procedure is portions. Associations between categori- performed prior to March 2005 and the permanent, has deleterious effects on cal variables were performed with χ2 sta- introduction of the NHF subsidy of med- sexual function, and affects patient qual- tistics using Stata statistical software, ical ADT, rather than after (42.0%; P < ity of life (5, 6). Conversely, medical version 10 (StataCorp LP, College Sta- 0.001) (Table 2). Estrogens (62.0%) were castration is reversible, but treatment tion, Texas, United States). For continu- the most common method of medical cas- is expensive. In the United States, there ous outcome variables, t-test was used tration prior to NHF subsidy; while after- has been a decline in surgical ADT for to determine differences in means. Eco- wards, luteinizing hormone-releasing prostate cancer (7). nomic costs of health interventions were hormone (LHRH) analogues (38.0%) and In 2003, the National Health Fund expressed in US$ as of February 2011, antiandrogens (36.5%) were most fre- (NHF) was established in Jamaica to pro- using the Bank of Jamaica monthly ex- quent. During both periods, cyproterone vide substantial discounts (around 60%) change rate (8). acetate was the most frequent antian- on specific medications used to treat cer- drogen used. In addition, several patients tain medical conditions. In 2005, the RESULTS used multiple forms of ADT, including NHF added to its approved list five multiple drugs and/or both medical and ADT drugs used to treat prostate cancer: During the January 2000–December surgical treatment, due to either PSA pro- bicalutamide, oral conjugated estrogens, 2007 period, a total of 680 cases of pro- gression or adverse effects (Table 3). goserelin, leuprolide, and flutamide. state cancer were diagnosed from 1 529 Later, cyproterone acetate, and the taxol prostate biopsies (44.0%) performed at DISCUSSION group of compounds were added. In the UHWI. When combined with the March 2005, the NHF began providing positive biopsies from the other institu- In Jamaica, prostate cancer is the lead- significant subsidies for these medica- tions, a total of 458 patients underwent ing cancer in men, with an annual age- tions, facilitating greater access to a vari- ADT for prostate cancer and had records specific incidence rate of 65.5 per 100 000 ety of newer treatments. available for study. (9). It is also the most common cause of The present study sought to compare the proportion of patients choosing sur- gical versus medical castration before TABLE 1. Age distribution of patients treated with androgen deprivation at the University Hospital of the West Indies, Jamaica, before and after the National and after the introduction of the NHF’s Health Fund began to subsidize drugs for hormone therapy, 2000–2007 subsidy for ADT drugs in Jamaica. Period MATERIALS AND METHODS Before subsidy After subsidy (January 2000–February 2005) (March 2005–December 2007) The Pathology Database at the Univer- Castration type Mean age in years (SDa) Mean age in years (SD) sity Hospital of the West Indies (UHWI), Mona, Jamaica, was reviewed to identify Medical 70.7 (9.3) 73.5 (8.3) Surgical 73.4 (9.2) 74.4 (8.7) all patients with prostate biopsies during the January 2000–December 2007 period. a Standard deviation. All patients whose local biopsies were positive were combined with those of TABLE 2. Methods of castration chosen by 458 patients being treated for prostate cancer at Uni- other patients from external institutions, versity Hospital of the West Indies, Jamaica, before and after the National Health Fund began to including a private pathology laboratory subsidize drugs for hormone therapy, 2000–2007 and the National Public Health Labora- tory in Kingston, Jamaica. The relevant Period records of patients with positive prostate Before subsidy After subsidy (January 2000–February 2005) (March 2005–December 2007) Total biopsies were reviewed, and those who Method of underwent ADT during the study period castration No. % No. % No. % were included. Patients were classified as having had Medical 79 39.4 114 57.6 193 42.1 Surgical 181 60.6 84 42.4 265 57.9 surgical castration (bilateral orchiec- Total 260 100.0 198 100.0 458 100.0 tomy) or medical castration. The date of Rev Panam Salud Publica 29(6), 2011 405 Original research Morrison et al. • Changes in hormone treatment for prostate cancer in Jamaica TABLE 3. Methods of medical castration at the University Hospital of the West Indies, Jamaica, gories of ADT drugs are available in Ja- before and after the National Health Fund began to subsidize drugs for androgen deprivation maica and have similar adverse effects therapy, 2000–2007 due to hypogonadism. Diethylstilboestrol was the original es- Period trogen used for prostate cancer treat- Before subsidy After subsidy (January 2000–February 2005) (March 2005–December 2007) ment. The mechanisms of action include Method of inhibiting LHRH release by the hypo- castration No.
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