Competition and patient demand have some hospitals eyeing investments in a controversial field of medicine called cryosurgery.
Since the 1960s, physicians have used supercooled nitrogen to destroy cancer cells by freezing them. Recent technological advances, however, have turned cryosurgery into a safer and less invasive procedure. Now, with ultrasound as a guide, physicians can perform cryosurgical procedures through small incisions in a patient's skin instead of open surgery.
Its use as a treatment for prostate cancer, in particular, is sparking a vicious debate.
Some physicians charge that a number of hospitals and the news media have been too quick to trumpet cryosurgery as a first-line treatment before its effectiveness over time is documented.
"I'm very concerned about the way it's getting sold," said Donald Skinner, M.D., chairman of the department of urology at the University of Southern California School of Medicine. "It's fine if you have a patient with metastatic cancer. I have real reservations about its use in patients with potentially curable cancer."
Meanwhile, a national patient-advocacy group accuses medical professionals of ignoring data that support the use of cryosurgery as a primary treatment. They are delaying its spread because of money and ego, not legitimate clinical concerns, said Lloyd Ney, founder of Patient Advocates for Advanced Cancer Treatment, Grand Rapids, Mich.
The controversy has grazed one of the leading makers of cryosurgical equipment. Cryomedical Sciences modified its marketing material after the Food and Drug Administration last month warned the company not to promote its AccuProbe system as a treatment for prostate cancer. Physicians may use the $209,000 system as they see fit because it's cleared for general use in oncology, urology and other fields, but the company can't market it for specific diseases.
Rockville, Md.-based Cryomedical blames hospitals, patients and the media for any excessive hype. New treatments for high-profile diseases simply draw a lot of attention, said J.J. Finkelstein, its president and chief executive officer. "We've been very conservative," he said.
Prostate cancer, like breast cancer, is becoming a political topic. About 200,000 men will be diagnosed with prostate cancer this year; one in four will die from it.
PAACT, a 10-year-old group, is a vigorous proponent of cryosurgery. Its newsletter reaches thousands of patients, and Mr. Ney has touted cryosurgery on television talk shows.
Radical prostatectomy and radiation therapy often leave men impotent and incontinent. Physicians agree that fewer men suffer impotence after cryosurgery, but they debate its accompanying rate of incontinence and its long-term effectiveness.
Because the procedure is minimally invasive, patients lose less blood and have shorter hospital stays. And, cryosurgery can be repeated, although some physicians argue it'll be too late to help patients by the time tests show cryosurgery has failed. Other urologists prefer "watchful waiting" to immediate treatment because the disease has a long course.
"We've been called on by hospitals to examine (cryosurgery)," said Melanie Swan, a senior associate at ECRI, a Plymouth Meeting, Pa.-based technology assessment group. "Our advice is, until there's better outcome data and while it's considered investigational, wait."
Yet, some hospitals report discussing investments in cryosurgical equipment, and others have bought it.
Cryomedical sold its first system in June of last year. It's now sold systems to 69 U.S. hospitals and one abroad.
Physicians at 153-bed Princeton Hospital in Orlando, Fla., bought the equipment in May 1993. Through April 1994, the hospital recorded 50 inpatient cryosurgery procedures at an average cost of $12,400 and an average length of stay of 1.7 days, said Brenda de Treville, its chief marketing officer.
During that time, Princeton recorded one radical prostatectomy, at a cost of $50,000 and a 7.5-day hospital stay, Ms. de Treville said. In the previous 12 months, it performed about eight radical prostatectomies, she said.
Most patients undergoing cryosurgery didn't receive radical prostatectomies or radiation first, said Nabil Hilwa, M.D., a urologist at Princeton.
"To any patient, we offer all modalities," Dr. Hilwa said. "I tell them, `Radical has been there many, many years. We only have records for cryo for three to four years. The early statistics are very encouraging. It's your choice.'*"
Princeton's marketing of the procedure raised patient interest in the area, said Byron Hodge, M.D., a urologic oncologist at the Walt Disney Memorial Cancer Center at Florida University Hospital Medical Center in Orlando. The 1,245-bed hospital began offering cryosurgery two months ago.
"We felt this would be important for our program because there seems to be a need," Dr. Hodge said. "The cancer help line received several phone calls from patients wanting to know if it's available. I think it offers some definite advantages, (but) we have to be very careful about recommending it for primary care until we have follow-up. I think it's my responsibility to sober up a few people about cryosurgery."