Prostate cancer treatment: The wrong acid test for health care reform

On the front page of today’s New York Times, just below a photo of Vladimir Putin, David Leonhardt writes about his “personal litmus test” for health care reform (In Health Reform, a Cancer Offers an Acid Test). His litmus test is different than the typical ideological one, which focuses on whether or not a public plan is included. For him, it’s how well the solution deals with the cost of prostrate cancer treatments. In particular, he’d like to see the various prostate cancer treatments –the costs of which range from a few thousand dollars for watchful waiting to $100,000+ for proton radiation therapy– subjected to comparative effectiveness research and have incentives aligned to encourage cost effective treatment. Right now, the problem is that there is an incentive to perform more costly treatments and little information on what’s best.

Yet there is a more fundamental issue, which could be addressed by scientific innovation rather than health policy wonkery. And that issue is the diagnosis and management of prostate cancer. Now, men undergo PSA tests followed by biopsies when the number looks bad. Those biopsies can be traumatic and are often inconclusive, leading to more tests, lots of worrying, along with treatments that are often unneeded, expensive and harmful (impotence and incontinence anyone?)

A big problem is that some men thought to have “slow-growing early stage prostate cancer” as described in the article can end up dying from the disease. And that’s the main reason why such aggressive, costly treatments are pursued.

A better emphasis for health care reform would be to focus on providing incentives for the development and deployment of sensitive, specific diagnostic tests that can help determine whether treatment is needed and if so, which treatment is right for the particular individual. What we want to avoid are tests that just add to the uncertainty –driving up costs for testing, consultation and treatment while producing more worry.

We should be able to finance even the most expensive treatments when needed –if we can determine when they really are needed.

July 8, 2009

3 thoughts on “Prostate cancer treatment: The wrong acid test for health care reform”

  1. Agree David. A great clinical and health policy challenge is that prostate cancer (like cancer overall) is not one disease – and one patient is unlike another. A slow growing/not highly aggressive prostate tumor in an elderly man is very different than a highly aggressive tumor in a younger man. It would be tragic for people to derive sweeping generalizations about prostate cancer, i.e. watching and waiting is right for everyone. For example, I have a young colleague, (i.e. within 10 years of my age), who was diagnosed with aggressive prostate cancer, had aggressive treatment and follow-up and is doing very well. Conversely, I know of an elderly medically informed individual who doesn’t get PSA testing because he feels “why bother.” He feels it’s not going to change any treatment decisions since for him it’s going to be watching and waiting anyhow….

  2. The American Urological Association submitted the following letter to the NY Times this morning–

    To the Editor:
    We read with great interest the column, “In Health Reform, a Cancer Offers an Acid Test” (Leonhardt, Economic Scene, July 8, 2009). Mr. Leonhardt’s column raises important issues about U.S. healthcare policy, including physician payment, standards of care and the importance and necessity of comparative effectiveness research (CER), using prostate cancer treatment as his “litmus test” for healthcare reform.
    However, the column may also leave readers with very real misconceptions about prostate cancer treatment that we feel warrant clarification.
    Prostate cancer is a complex disease. Treatment inherently involves patient discretion and in-depth consultation between a man and his physician. The variation in tumor aggressiveness and the complex balance of benefits and risks of treatment add to prostate cancer’s complexity. To assert that watchful waiting is equally effective for the majority of patients and therefore the best option primarily because it is the least costly is inaccurate at best and irresponsible at worst. Watchful waiting is not for everyone. It is important that patients and physicians work together to select the best treatment for the disease, taking into account not only affordability, but also the patient’s risk factors, underlying conditions, personal preferences, family situation, and tolerance for different risks and side effects. While watchful waiting may be a viable treatment for one man, another could benefit significantly from surgery or an advanced radiation therapy. It is up to the urologist, urologic oncologist or other treating professional to discuss treatment options and risk factors as they pertain to individual patients. That said, the American Urological Association (AUA) strongly concurs that research comparing the relative effectiveness of different prostate cancer treatments is urgently needed, and indeed has publicly testified in support of such research. Therefore, we were particularly gratified to find that the Institute of Medicine (IOM) included prostate cancer in the first quartile of its recently issued disease priorities for CER. The AUA and those member urologists who conduct prostate cancer research look forward to collaborating with a variety of research partners to perform the comparative investigation of prostate cancer treatments.
    Finally, Mr. Leonhardt fails to mention that clinical practice guidelines exist to provide care standards and assessment of treatment options for prostate cancer. The AUA’s evidence-based clinical practice guidelines are the result of a scientifically rigorous process that includes a systematic literature review, meta-analysis of the data extracted and multidisciplinary expert panel review to support key recommendations about established treatments for which clinical data is available. These guidelines acknowledge new technologies while taking into account the available literature or the lack thereof. Until sorely needed CER investigations are conducted to address the very legitimate concerns Mr. Leonhardt outlined in his article, these documents are a widely respected, invaluable source of guidance to the broader clinical community that works in concert with patients to help them choose the most effective and appropriate treatment for prostate cancer.
    Anton Bueschen, MD
    American Urological Association
    Baltimore, MD

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