Low risk, high cost

Ad­vanced prostate treat­ment not al­ways ben­e­fi­cial

Modern Healthcare - - THE WEEK IN HEALTHCARE - Andis Robeznieks

The old joke in health­care re­search is that nearly ev­ery study con­cludes that more stud­ies are needed. But two new stud­ies on the high cost of low-ben­e­fit prostate can­cer treat­ments sup­port that hu­mor­ous ob­ser­va­tion.

In one study, pub­lished in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion, re­searchers found that men with prostate can­cer who were at low risk for dy­ing from that con­di­tion or were at high risk of dy­ing from other causes re­ceived an in­creas­ing num­ber of ad­vanced-treat­ment tech­nolo­gies such as in­ten­sity-mod­u­lated ra­dio­ther­apy and robotic prosta­te­c­tomies.

In a study pub­lished in the An­nals of In­ter­nal Medicine, re­searchers found that keep­ing close watch on low-risk prostate can­cers in men aged 65 and older rather than ini­ti­at­ing ra­di­a­tion or sur­gi­cal treat­ment pro­longed life ex­pectancy by two months longer than the more ad­vanced treat­ments and was $10,900 to $24,200 cheaper.

“Ag­gres­sive di­rect-to-con­sumer mar­ket­ing and in­cen­tives as­so­ci­ated with fee-for-ser­vice pay­ment may pro­mote the use of th­ese ad­vanced-treat­ment tech­nolo­gies,” the JAMA re­port stated. The au­thors also noted that the in­creased use of in­ten­sity-mod­u­lated ra­dio­ther­apy, or IMRT, and robotic prosta­te­c­tomy could largely be ex­plained be­cause they were re­place­ments for other ther­a­pies such as ex­ter­nal beam ra­di­a­tion treat­ment, or EBRT, and open rad­i­cal prosta­te­c­tomy. The au­thors noted that startup costs for IMRT and robotic surgery fa­cil­i­ties are close to $2 mil­lion.

Dr. Ralph Weichselbaum, chair­man of ra­di­a­tion and cel­lu­lar on­col­ogy for Univer­sity of Chicago Medicine, said the au­thors may be un­der­stat­ing the is­sue. “Doc­tors are do­ing a lot of ex­pen­sive, un­nec­es­sary stuff—that seems to be the take-home mes­sage,” he said.

The An­nals of In­ter­nal Medicine study of­fered a sim­i­lar mes­sage. “Mount­ing ev­i­dence sug­gests that many men with lo­cal­ized, low-risk prostate can­cer are treated un­nec­es­sar­ily at sub­stan­tial per­sonal and so­ci­etal cost,” the re­port stated. Its au­thors es­ti­mated that if the num­ber of men with newly di­ag­nosed low-risk prostate can­cer who se­lected a “watch­ful wait­ing” ob­ser­va­tion strat­egy in­creased to 50% from 10%, it would re­sult in cost sav­ings of $1 bil­lion.

The in­creases in pro­ce­dures us­ing ad­vanced-treat­ment tech­nolo­gies cited in the JAMA study were recorded be­tween 2004 and 2009. Weichselbaum said he thought the data were still rel­e­vant and doubted whether more re­cent fig­ures would be sig­nif­i­cantly dif­fer­ent. But Dr. R. Jef­frey Karnes, an as­so­ciate pro­fes­sor of urology with the Mayo Clinic’s Grad­u­ate School of Medicine in Rochester, Minn., thought oth­er­wise.

Karnes said fewer prosta­te­c­tomies were be­ing done at Mayo. But he also noted that most prosta­te­c­tomies are done robot­i­cally now, so it’s not sur­pris­ing that the num­ber of th­ese op­er­a­tions among men with low risk of prostate can­cer death is in­creas­ing be­cause the num­bers are in­creas­ing in gen­eral. Statis­tics aside, Karnes said he thought economics were re­spon­si­ble for part of the in­crease.

“Hos­pi­tals have an un­der­ly­ing pres­sure to use the tech­nol­ogy,” he said.

While the term “watch­ful wait­ing” may seem be­nign, the per­ceived pas­siv­ity of this ap­proach can cause many men to ex­pe­ri­ence great anx­i­ety and lead them to un­dergo pro­ce­dures whose ben­e­fits may be du­bi­ous just be­cause they feel the need to take ac­tion. Be­cause of this, pa­tient choice—per­haps driven by hos­pi­tal mar­ket­ing—is a fac­tor in the in­crease of ex­pen­sive treat­ments. Karnes said some pa­tients are averse to ra­di­a­tion while oth­ers avoid surgery. Many seek to avoid un­pleas­ant prostate can­cer-re­lated con­di­tions they saw a friend or rel­a­tive ex­pe­ri­ence.

The JAMA re­port said some ex­perts have sug­gested that, to ease this anx­i­ety, low-risk tu­mors be called some­thing be­sides “can­cer.”

Karnes said he’s heard the term “pre­ma­lig­nancy” sug­gested, but he said more than a change of ter­mi­nol­ogy is needed.

“We have to do a bet­ter job of al­lay­ing that fear,” Karnes said, adding that psy­cho­log­i­cal help to deal with anx­i­ety could be one method. Bet­ter di­ag­nos­tic and prog­nos­tic tools also are needed, as cur­rent biopsy tests can only go so far in de­ter­min­ing the ag­gres­sive­ness of a tu­mor. He said bet­ter imag­ing and ge­netic tests could go a long way to meet this chal­lenge.

Dr. Charles Cut­ler, chair­man of the Amer­i­can Col­lege of Physi­cians Board of Re­gents, said the treat­ment de­ci­sions ex­am­ined in th­ese stud­ies of­ten be­gin with dis­cus­sion in the pri­mary-care physi­cian’s of­fice.

“This is some­thing that I deal with all the time—con­ver­sa­tions with men who have been di­ag­nosed with low-risk prostate can­cer. The word ‘can­cer’ dom­i­nates the con­ver­sa­tions,” Cut­ler said. “It’s part of our cul­ture that peo­ple don’t like the idea of ac­tu­ally wait­ing with can­cer. Cer­tainly the lit­er­a­ture sup­ports that watch­ful wait­ing is the right thing to do. But the psy­chol­ogy of the sit­u­a­tion makes watch­ful wait­ing hard to do.”

Re­searchers say a grow­ing num­ber of men are get­ting robotic surgery for prostate can­cer even when the can­cer is low risk or they’re more likely to die from an­other cause.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.