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The other prostate cancer controversy — and what it says about Congress’ willingness to legislate true health-care reform

The PSA test (which I posted about on Tuesday) isn’t the only prostate cancer controversy.

Just as contentious is the debate over what is the appropriate treatment for this disease, which kills 27,000 American men each year.

In Wednesday’s New York Times, reporter David Leonhardt does a great job of explaining the treatment controversy.

He writes:

Right now, men with the most common form – slow-growing, early-stage prostate cancer – can choose from at least five different courses of treatment. The simplest is known as watchful waiting, which means doing nothing unless later tests show the cancer is worsening. More aggressive options include removing the prostate gland or receiving one of several forms of radiation. The latest treatment – proton radiation therapy – involves a proton accelerator that can be as big as a football field.
Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.

Yet, as Leonhardt points out, the cost differences for these treatments is huge, ranging from a few thousand dollars (in follow-up medical visits and tests) for watchful waiting to more than $100,000 for proton radiation therapy.

“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,” says Leonhardt.

“The country is paying at least several billion more dollars for prostate treatment than is medically justified – and the bill is rising rapidly,” he adds.

This issue is Leonhardt’s “personal litmus test” for the success (or failure) of the health-care-reform legislation now being debated in Congress. It will determine, he says, if Congress is truly serious about fixing “the fundamental problem with our medical system: the combination of soaring costs and mediocre results. If they don’t, the medical system will remain deeply troubled, no matter what other improvements they make.”

A footnote:
Given the high false-positive rates of PSA testing (results that indicate disease when there isn’t any), watchful waiting may often be the best treatment option for prostate cancer. But it’s not without its hidden costs. According to the editorial in CA: A Cancer Journal for Clinicians (which I referenced in my Tuesday post), even “the strategy of watchful waiting is associated with side effects. It is known that a large number of men with a history of prostate cancer suffer from depression and mental anguish leading to an increased risk of suicide, and these men are at risk of losing health insurance.”

Comments (3)

  1. Submitted by Lee Smith on 07/09/2009 - 09:06 pm.

    Watchful waiting has been replaced by active surveillance and yes I can imagine it would raise anxiety to know that there is a cancer growing in one’s body and getting worse but not deciding to get rid of it. I imagine that’s why most men I know who found they had fairly agressive prostate cancer, faculty members with PhDs at my University and in local engineering firms, chose surgery. This gold standard seems to many to be the best way to eliminate the cancer. Most of us don’t particularly worry about the side effects and fortunately we value our lives more than our erections. I’m happy to report I know many of us who seem to go on and on. I guess we are an atypical island here in new york state where prostate cancer is found by PSA testing and cured by surgery. No one committs suicide, no one has depression, we are all happy to grow up with our grand children and not be in the hospital. Thank God for PSA testing. I hope Mr. Leonard never suffers the anguish of having prostate cancer but if he did perhaps he would learn something about what he is talking about.

    PS: we are fortunate to have good options for treatment — as far as proton radiation treatment — given the quoted cost and the many viable, successful other options I would question its appropriateness and don’t know that it is even available in most parts of the country.

  2. Submitted by Stephen Lehman on 07/10/2009 - 11:40 am.

    This makes no sense. No one would treat prostate cancer with the diagnosis based only on a PSA test. A prostate biopsy, while uncomfortable, is neither debilitating nor hugely expensive, and it is extremely reliable. If the PSA tests are suspicious, why not biopsy and know for sure? Only then do you know what’s really going on and what course of action is most sensible.

    And Lee Smith is correct: surgery usually makes the most sense, particularly for middle-aged men, especially since new surgical techniques and rehab programs can spare most men any long-term compromises of normal functioning.

  3. Submitted by John E. Holliday on 07/12/2009 - 12:52 am.

    Dear Ms. Perry and ALL,

    Neither I nor anyone else, in my opinion, should tell another man what PCa treatment he should select. It is a very personal decision that every patient should make for himself. What we SHOULD be doing, however, is to educate men and their loved ones in an unbiased manner, so that they can make INFORMED decisions as to their treatment choices.

    The truth is that ALL forms of treatment have POTENTIAL morbidity (side effects)and they are very much AGE and STAGE of disease related (among others), with greater involvement as these two factors increase. Seventy to 80% of men diagnosed with Prostate Cancer (PCa) are over 65 years of age, which is an important factor in reducing the mortality rates in relation to incidence.

    More and more patients are being diagnosed at younger ages as the use of the PSA blood tests grows and these are the very men who are at greatest risk of directly dying from the disease. Because their extended life expectancy provides ample time for PCa to progress to a life threatening stage.

    Although, PCa is most often called a slow growing Cancer, in relation to other malignancies, it is not always so and a limited minority can be quite aggressive. Although the statistical likelihood (the odds) can be established for GROUPS of patients with similar disease factors, the FACT is that there is no reliable way to identify which INDIVIDUAL patient will experience which form of aggressiveness.

    Men with potentially curable, early stage disease presenting today represent 75 to 80% of newly diagnosed PCa patients. Prior to the introduction of the PSA blood test, for use in screening in 1991, when Digital Rectal Exam(DRE) and/or clinical symptoms were the only diagnostic signals, that same 75 to 80% figure represented the percentage of men in the pre-PSA era that were diagnosed with ADVANCED PCa and in whom 50% already had metastases from incurable systemic disease.

    Logically, this direct reversal of PCa statistical severity is, most likely, the reason for the DRAMATIC REDUCTION of over 37% in mortality from PCa, since hitting its peak in 1993. This is a greater reduction in deaths than experienced at any other Cancer site during this time period and even more significant is the fact that it has occurred as the at-risk age group continues to grow significantly.

    The poor language semantics in the use of the term “false positives” in PSA results, which you mis-characterized earlier as “indicating disease when no disease is present”, is certainly a misunderstanding by laymen, including uninformed journalists, of medical language. Any knowledgable and COMPETENT Physician (or layman for that matter) is well aware that the PSA test is NOT Prostate Cancer specific and is not represented to be. It is a test that shows the amount of PSA in the blood at any given time. PSA is a protein, mainly produced by the Prostate, that that eminates from both benign and malignant (cancerous) Prostate cells, but malignant cells, normally, (but not always), introduce more PSA into the blood stream than do benign (non-cancerous) cells. Thus ONE of the possible reasons for an elevated PSA is PCa.

    There can be a variety of reasons for a TEMPORARY rise in a single PSA reading, but persistant elevations are usually due to one of three common causes. These are (1) Prostatitis (inflammation) often caused by infection, (2) Benign Prostate Hyperplasia (BPH) the natural growth in the size of the Prostate, often seen in varying degrees in many men after the age of 40, and of course, (3) Prostate Cancer. A persistently elevated or steady rise in sequential PSA readings indicates need for determining the likely cause. There is causal disease present, but it is not necessarily PCa. In fact, in follow-up Biopsies done because of elevated PSA, approximately 1 in 4, or 25-30% are found to have PCa present. So the odds are at least 3 to 1 that an elevated PSA, alone, will NOT subsequently result in a Prostate Cancer diagnosis.

    Is PSA a perfect diagnostic test? No, but is the best presently available and the cited statistical results since its introduction give every indication that it has made a substantial contribution to a dramatic reduction in PCa mortality. Under the present approach, positively screened men have a choice as to whether they wish treatment and, if so, what form of treatment they prefer. What choices are available to unscreened men?

    Who in their right mind would want to return to those pre-PSA days of forlorn prognosis, dismal treatment results and patient helplessness? –

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