Is It Time to 'Regulate' Prostate Cancer Care?
Is It Time to 'Regulate' Prostate Cancer Care?
Hello. I am Dr. Gerald Chodak for Medscape. In January, in the Annual Reviews of Medicine, an article was published by Vickers and associates about a modified approach to the treatment of prostate cancer. Controversy has been increasing about the pros and cons of screening, overdiagnosis, overtreatment, and differences in outcomes between doctors who have great experience and those who have less experience. Maybe it's time for us to do something different in the interest of better care for our patients.
Many men are getting screened who have a near zero chance of getting benefit from treatment. It makes no sense to continue to treat men who are older, less healthy, and who have shorter life expectancies. Certainly, if these patients want treatment, it can be done, but it shouldn't be done until they are fully aware of the much greater likelihood of harm over benefit.
For other men, making sure that they understand the risks and benefits is critical before the screening process begins. Once a man starts on the pathway and receives a diagnosis, it will be increasingly difficult for him to back out and get off that train without going down to the end of the line and receiving a treatment that he may not need.
In addition, we need to take a different approach to active surveillance. It is unlikely that physicians will say to patients, "We think your tumor isn't very risky" and hope that they will follow with active surveillance. There is too much of a business process here, a big industry with all kinds of newer therapies, such as CyberKnife (Accuray; Sunnyvale, California), high-intensity focused ultrasound, and proton therapy. To cover the expenses of offering these treatments, payments are needed, so something different has to be done. Perhaps a review committee should investigate how men are treated or counseled before their treatment begins. This would serve a real benefit, because currently for this disease there is tremendous bias, resulting in men getting treatments that are expensive and not necessarily in their best interest.
We need better studies that help us figure out the long-term effects of some of these newer therapies. Until we have long-term studies, should there be more restriction on these treatments? Or should we simply continue to do business as usual and say, "Well, we will pay for it even though we really don't know the long-term results"?
Finally, an even more controversial concept has to do with outcome analysis and whether it's time to say to some doctors, "You don't do enough of it" or "Your results are not good enough for you to continue to do this type of therapy." Maybe we need to take the European paradigm, which sends patients to high-volume centers where the outcomes ultimately may be better. The average urologist is doing fewer than 10 prostatectomies a year, which results in a higher complication rate compared with higher-volume surgeons. The same may be true for radiotherapists and seed specialists. Is it time for us to say, "Unless you can prove that you get good results, you shouldn't be able to do it, and we're certainly not going to pay you for it"?
I realize that these are unconventional approaches. However, this disease is affecting hundreds of thousands of men each year, costing a lot of money, and leaving a lot of men with a quality of life that is certainly compromised and, ultimately, not in their best interest. For most of these men who get treated, it's not going to help them live longer or better.
These are ideas for thought and discussion. Further evaluation is needed, along with different strategies for the management of prostate cancer. I look forward to your comments. Thank you.
Hello. I am Dr. Gerald Chodak for Medscape. In January, in the Annual Reviews of Medicine, an article was published by Vickers and associates about a modified approach to the treatment of prostate cancer. Controversy has been increasing about the pros and cons of screening, overdiagnosis, overtreatment, and differences in outcomes between doctors who have great experience and those who have less experience. Maybe it's time for us to do something different in the interest of better care for our patients.
Many men are getting screened who have a near zero chance of getting benefit from treatment. It makes no sense to continue to treat men who are older, less healthy, and who have shorter life expectancies. Certainly, if these patients want treatment, it can be done, but it shouldn't be done until they are fully aware of the much greater likelihood of harm over benefit.
For other men, making sure that they understand the risks and benefits is critical before the screening process begins. Once a man starts on the pathway and receives a diagnosis, it will be increasingly difficult for him to back out and get off that train without going down to the end of the line and receiving a treatment that he may not need.
In addition, we need to take a different approach to active surveillance. It is unlikely that physicians will say to patients, "We think your tumor isn't very risky" and hope that they will follow with active surveillance. There is too much of a business process here, a big industry with all kinds of newer therapies, such as CyberKnife (Accuray; Sunnyvale, California), high-intensity focused ultrasound, and proton therapy. To cover the expenses of offering these treatments, payments are needed, so something different has to be done. Perhaps a review committee should investigate how men are treated or counseled before their treatment begins. This would serve a real benefit, because currently for this disease there is tremendous bias, resulting in men getting treatments that are expensive and not necessarily in their best interest.
We need better studies that help us figure out the long-term effects of some of these newer therapies. Until we have long-term studies, should there be more restriction on these treatments? Or should we simply continue to do business as usual and say, "Well, we will pay for it even though we really don't know the long-term results"?
Finally, an even more controversial concept has to do with outcome analysis and whether it's time to say to some doctors, "You don't do enough of it" or "Your results are not good enough for you to continue to do this type of therapy." Maybe we need to take the European paradigm, which sends patients to high-volume centers where the outcomes ultimately may be better. The average urologist is doing fewer than 10 prostatectomies a year, which results in a higher complication rate compared with higher-volume surgeons. The same may be true for radiotherapists and seed specialists. Is it time for us to say, "Unless you can prove that you get good results, you shouldn't be able to do it, and we're certainly not going to pay you for it"?
I realize that these are unconventional approaches. However, this disease is affecting hundreds of thousands of men each year, costing a lot of money, and leaving a lot of men with a quality of life that is certainly compromised and, ultimately, not in their best interest. For most of these men who get treated, it's not going to help them live longer or better.
These are ideas for thought and discussion. Further evaluation is needed, along with different strategies for the management of prostate cancer. I look forward to your comments. Thank you.
