In the May 15 issue, The ASCO Post reported on the relative cost-effectiveness of approaches to treating localized prostate cancer (“Advances in Prostate Cancer Accompanied by Ongoing Debates,” page 1). The article analyzed an important scientific paper presented at both urology and radiation oncology meetings, and a physician interviewed for the article described a “medical arms race” in the treatment of prostate cancer, with more side effects associated with the more expensive treatments that have not shown improved results.
Yet the latest buzz on prostate cancer, including national TV and print coverage, is “Not to Screen” for the disease. To an extent, this approach eliminates the issue of overtreatment or treatment of early (indolent) prostate cancer. It saves the already expensive and underfunded health-care system (specifically, Medicare) millions of dollars, and saves tens of thousands of patients the risks of major side effects from sometimes unnecessary yet aggressive treatment.
It will be a sad commentary when, a decade from now, today’s smart minds in urology and radiation oncology will be critiqued for our collective failure to identify and appropriately treat biologically active prostate cancer. Future critics will outline how early 21st century physicians took great pride in developing sophisticated, expensive surgical (robotic) techniques and radiation therapies (brachytherapy, tomotherapy, RapidArc, adaptive radiotherapy, and proton-beam therapy) to treat and cure patients with indolent prostate cancer. Clearly, they will point out, reimbursement for prostate cancer therapy rewards expensive technology and is another example of insurance and advertising driving the use of the most costly treatments for all patients at all times. Others will point to how regional business arrangements markedly changed patterns of care for localized prostate cancer.
The controversy in prostate cancer is not about whether to screen or the cheapest approach to treating localized disease. The controversy is and has always been over what groups of patients warrant treatment. The answer to this question will automatically address the issue of optimum treatments for patient subsets. Patients with low-risk cancer do just as well with no treatment, since most of these cancers are inactive before treatment. Thus, for them, no treatment is the best treatment, and any treatment, including sophisticated technology, will achieve good results.
Our current knowledge identifies whom to screen and when to biopsy the prostate. Pathologists have developed biologic criteria with the Gleason scoring system and other pathological findings. It is primarily the clinicians (urologists and radiation oncologists) who have failed to adhere to actively and appropriately treating only intermediate-risk and high-risk prostate cancer, and selecting active surveillance for low-risk disease.
Rather, we have collectively chosen to increase our workload (as well as our academic prestige and bank balance), pad the published data, and improve our results by actively treating low-risk disease. However, several studies have shown the outcome for low-risk prostate cancer (which is 50% of newly diagnosed prostate cancers) is just as good with surveillance and delayed treatment for the 20% to 30% patients who show biochemical or pathological progression to a higher risk category.
It is time that leaders in our respective fields, trial designers, and journal editors show some leadership. If it takes disincentives (for patients, doctors, and institutions) to dissuade us from undertaking unnecessary treatment, many of us will consider that a blessing in the long run. This will be better than an ostrich-like approach of being reticent about screening and detecting early-stage intermediate- and high-risk prostate cancer. The last thing we want to do is practice medicine dictated by trial lawyers, epidemiologists, or health-care economists. Yet if that happens, we will have only ourselves to blame. ■
—Gilbert A. Lawrence, MD, DMRT, FRCR
Radiation Oncology, Faxton Hospital
Utica, New York