Prostate cancer treatment could be a marker for health reform

For men with prostate cancer, even those with the early-stage type, the urge to treat is undeniable and understandable. The same apparently holds true for their doctors. But sometimes no treatment, at least for a while, is better -- both for men with cancer and for the healthcare system as a whole.

More men -- and, again, their doctors (who are paid by procedure, not by performance) -- need to ask themselves whether less might ultimately provide more. That's the suggestion posed by a smart, making-the-big-picture-personal piece in today's New York Times.

For writer David Leonhardt, the true test of health reform can be summed up with our medical and insurance systems' approach to prostate cancer, specifically the common, slow-growing kind. It's the kind that can often be monitored with what is known as watchful waiting without the risk of side effects that comes with radiation and surgery.

He writes:

But if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

And in our current fee-for-service medical system — in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients — you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

If you doubt that similar-benefits contention and want an in-depth look at how the treatments compare, there's this report: "Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer" from the Agency for Healthcare Research and Quality.

The report, released last year, concludes:

Published evidence indicates that no one therapy can be considered preferred for localized
prostate cancer due to limitations in quality of the body of comparative effectiveness evidence. All treatment options result in adverse effects (primarily urinary, bowel, and sexual) though the severity and frequency may vary between treatments and according to the provider/hospital. Even if differences in therapeutic efficacy exist, differences in AEs [adverse effects], convenience, and costs are likely to be important factors in individual patient decision making. Despite this uncertainty, patient-reported satisfaction with any individual therapy received is high.

Leonhardt is right. This one example highlights the seemingly large and intractable problems of rising healthcare costs (proton radiation therapy isn't cheap) and getting the most effective healthcare for our national dollars.

And, come decision-making time, if less-expensive treatments are as effective as more high-tech ones,  perhaps it's time to question some of the recommendations for expensive treatment and screenings.

-- Tami Dennis

Illustration: Wes Bausmith / Los Angeles Times

Comments

[E. Michael D. Scott]

There are undoubted problems with the entire way we approach the risk for and management of prostate cancer. But let no one be under any illusions -- the problem starts with the fact that we lack an effective and simple test to differentiate the men who have clinically significant prostate cancer that may kill them from the men who have indolent disease that is highly unlikely to have clinically significant impact in that man's lifetime.

Until we solve that problem, and afterwards, every man has (and deserves) the right to understand his risk for clinically significant prostate cancer that may lead to his early death, and be managed accordingly.

If we had such a test, we could save billions of dollars in excessive costs for unneeded biopsies and treatment. Without that test, what is a man supposed to do today? Pretend there is no risk?

Mike Scott
Co-Founder, The "New" Prostate Cancer InfoLink

[Mark Perman, MD]

I treat prostate cancer patients in Florida with radiation. Your blog post, and today’s article from the New York Times, In Health Reform, a Cancer Offers an Acid Test, are of great interest to me.

Both left out an important treatment option that should have been considered. This treatment is effective, less invasive, has fewer and milder side effects and is less time consuming for the patient. Additionally, it’s far less expensive than IMRT or Protons.

Stereotactic robotic radiosurgery (I use the CyberKnife Radiosurgery System) delivers high-dose radiation with pinpoint precision. CyberKnife treatment for prostate cancer is routinely completed within five working days, compared to IMRT or Proton Therapy which both usually requires 40 - 45 treatments.

The ability to offer my patients a treatment they can do before or after work , or even during their lunch break , allows them the chance to continue productive work uninterrupted.

I agree with other opinions expressed by Radiation Oncologists on the NYT article that newer technology usually implies greater costs and as a corollary, are more financially rewarding to the physician. It will probably come as a surprise to your readers that doctors who perform robotic radiosurgery make considerably less money treating patients with CyberKnife than with IMRT. If we were in it for the money, CyberKnife treatment would be a rarity, but over 3,000 men have now been treated since 1994.

Despite the financial dis-incentive for its use, I offer this option, as my priority is to offer, what I believe to be the best treatment for my patients.

It should be noted that this treatment saves Medicare money, but ironically, two Medicare regions, including Florida, are currently proposing to withdraw payment for this important treatment option. Given the scarcity of evidence for many other treatments correctly cited in your article, let’s hope that they will reconsider. Otherwise patients, physicians and taxpayers will all suffer.

Mark Perman, MD

[Mark Brenner]

I too am a radiation oncologist, and my father, a physician himself, was treated with external beam irradiation in his early 60’s and was cured—he died at age 88 of natural causes—and for years I said that when the day comes that I have prostate cancer I would choose external beam irradiation. It is an excellent mode of treatment, and in the nearly 30 years since my father was diagnosed the field has come light-years in its ability to better distinguish between the treatment target and the surrounding normal tissue, and to better spare the latter while pushing the doses to the cancer ever higher, resulting in increasingly improved cure rates and lower rates of complications. But it comes at a substantial cost—whereas my father’s daily treatment from the front, the back, and both sides (“2-Dimensional” in Radiation-speak) took just over 7 weeks and was relatively inexpensive even by that day’s standards, today’s treatments span 8-9 weeks, and the charges and reimbursement rates for “IMRT with IGRT localization” [ultra-high tech localization and treatment] typically run $50,000 or so.

But as prostate cancer is getting diagnosed much earlier, many patients don’t require 40-45 daily treatments—and many refuse surgery—and I make sure that all my patients know that they have other, equally good options. Many choose radioactive seed implants, and in fact beginning 8-10 years ago I decided that I would likely go that route.

But over the past 4-5 years, a new and even more precise mode of treatment, CyberKnife Stereotactic Radiosurgery (CK SRS) has emerged. Pioneered in Naples, Florida by the late Dr. Jay Friedland, it requires only 5 treatments, and the 70-80 patients I have treated thus far have tolerated it so amazingly well that one of my referring urologists has occasionally asked me I am remembering to turn on the machine! Moreover, recently published data from Dr. Chris King at Stanford, while still early, is outstanding—no treatment failures and no complications in 41 patients at a minimum of nearly 3 years follow-up (and Dr. King tells me that those numbers are still holding up with over 4 years minimum follow-up, and many more patients). CyberKnife is certainly at least as good as any other form of treatment (and my own bias is that ultimately the data will show it to be superior), and best of all, it costs FAR less than external beam irradiation—simply because it only takes 5 treatments as opposed to 40-plus [I often joke with my patients who are deciding how they want to be treated that if they want to help out my checking account they should choose the external beam], and it costs FAR, FAR less than proton beam.

Mr. Scott is correct in stating that a major factor in the cost of prostate treatment is that we are treating many patients who don’t really need it—we simply aren’t yet able to tell which patient absolutely needs to be treated and which guy is going to live another 35 years and never have a problem, and in that sense the PSA is both a blessing and a curse. But Dr. Perman is also correct in pointing out that in a day when health care cost containment is one of the most pressing issues our nation faces, it is absolutely beyond comprehension that some Medicare programs are considering not covering the costs of CK treatment, yet continuing to pay for the much more costly IMRT, and contemplating paying for proton treatments! If that isn’t insanity, what is?

Mark J. Brenner, M.D., FACR

Chairman, Department of Radiation Oncology

Sinai Hospital of Baltimore

[viperfred]

I was 63 when diagnosed with prostate cancer (PCa).

My father had advanced PCa diagnosed (1980) when he was 69. His treatment was barbaric when compared with to today’s options.

His experience motivated me to understand as much as possible about PCa prevention, detection and treatment.

When my PSA increased (.75 ng/ml 2006 to 2007) I had a biopsy which confirmed early stage (Gleason 3-3) PCa

I thought I knew all the options Surgery, Brachytherapy, Cyro, ADT/Chemo, HIFU, Proton RT, EB RT by IMRT.

I feel very fortunate to have consulted with doctors at Stanford who offered several surgical options, (nerve sparing, robotic, etc.) and radiation options included IMRT and SBRT/CyberKnife. The radiation oncologist (Dr. Christopher King) answered all questions about every option. Dr. King commented that a clinical trial using the CyberKnife was a possible option.

After a few days of research, it was clear that the CyberKnife offered the best chance of cure and lowest rate of side effects. The only down side was limited treatment history (3 1/2 years at the time). However, the physics and science has been well documented so the lack of actual long-term data was not a major concern compared with the benefit of cure and low risk of side effects. All treatment options are a compromise of risk and unknown long term outcome.

In my opinion the CyberKnife is the ultimate treatment for localized PCa. It has the lowest biological failure rate to date for of all options treating early stage localized PCa. And the toxicity rate is the lowest as measured by the side effects.

As it turned out the hardest part of this treatment option was dealing with the denial of treatment by my insurance company. I appealed the insurance company for 7 months. The appeal denial was covered by CBS/SF here is a link to that story. http://cbs5.com/investigates/CyberKnife.blue.shield.2.716740.html

My appeal with the state of CA (IMR) overturned the 7 month denial of my insurer. July 23, 2008 (approximately 2 months after the CBS story ) the insurer added the CyberKnife to their policy for treating prostate cancer.

The CyberKnife has treated over 2500(as of Jan.19, 2009) patients with few biological failures reported for treatment of localized PCa. The longest treatment history (starting Dec. 2003) is from Stanford by Dr. Christopher King, 2008 study update.

I was treated by Dr. King, and fourteen days post CK treatment there were minimal side effects. I am amazed by the improvements is radiation delivery and their impact on biological failure rate and reduction in side effects. CyberKnife treatment was completed May 7, 2008, I have had zero side effects for the last year.

Advances in PCa awareness, prevention, early detection and treatment are marching along at a pretty slow pace.

Awareness (Doctors and Patients) is the first step to mitigating PCa’s impact on ones quality of life. Patients must understand all treatment options to make an informed choice for treatment.

Prevention is the ultimate goal wills all cancer. A lot of work is focused on vaccines and biological therapies to boost our immune system, etc. Progress is slow, federal funding and private funding are low relative to the magnitude of prostate cancer. We need to increase research for imaging to better define prostate cancer for early detection. Better markers are needed to determine if a treatment was successful.

Better PCa awareness has increased early detection along with advances better understanding of the role in family history of prostate cancer, PSA vs age, PSA velocity vs age, and meaning fPSA and EPSA.

For the PCa patient early detection increases the chance of cure for all treatment options but the risk and side effects from many have not changed.

In my opinion, the CyberKnife/SBRT treats early stage PCa better than other option while maximizing the patient’s quality of life and ease of treatment.

Fred

[Windfall]

It's not just prostate cancer treatment options/recommendations that have been corrupted by entrenched interests. Check out what one honest doc has to say about Varian versus CyberKnife for lung cancer...

"I wouldn't want to calculate the professional revenue I've lost by treating 60 lung pts with CK rather than with 7 weeks of RT, not even taking into account that the CK treatments are more time consuming for me. It may be small consolation, but the CK pts have had an 85-90% complete response rate (by PET/CT scan) compared to 15-20% with standard RT. Go figure - the treatment which takes less work with poorer results pays the rad onc more! On a certain business level, you do have to give Varian credit (assuming you are not a lung cancer patient)."

http://messages.finance.yahoo.com/Stocks_(A_to_Z)/Stocks_A/threadview?rt=1&bn=51532&tid=14437&mid=14475&tof=1&m=tm&so=L&o=lpr&num=50&off=1