Low risk, high cost

The old joke in healthcare research is that nearly every study concludes that more studies are needed. But two new studies on the high cost of low-benefit prostate cancer treatments support that humorous observation.

In one study, published in the Journal of the American Medical Association, researchers found that men with prostate cancer who were at low risk for dying from that condition or were at high risk of dying from other causes received an increasing number of advanced-treatment technologies such as intensity-modulated radiotherapy and robotic prostatectomies.

In a study published in the Annals of Internal Medicine, researchers found that keeping close watch on low-risk prostate cancers in men aged 65 and older rather than initiating radiation or surgical treatment prolonged life expectancy by two months longer than the more advanced treatments and was $10,900 to $24,200 cheaper.

“Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced-treatment technologies,” the JAMA report stated. The authors also noted that the increased use of intensity-modulated radiotherapy, or IMRT, and robotic prostatectomy could largely be explained because they were replacements for other therapies such as external beam radiation treatment, or EBRT, and open radical prostatectomy. The authors noted that startup costs for IMRT and robotic surgery facilities are close to $2 million.

Dr. Ralph Weichselbaum, chairman of radiation and cellular oncology for University of Chicago Medicine, said the authors may be understating the issue. “Doctors are doing a lot of expensive, unnecessary stuff—that seems to be the take-home message,” he said.

The Annals of Internal Medicine study offered a similar message. “Mounting evidence suggests that many men with localized, low-risk prostate cancer are treated unnecessarily at substantial personal and societal cost,” the report stated. Its authors estimated that if the number of men with newly diagnosed low-risk prostate cancer who selected a “watchful waiting” observation strategy increased to 50% from 10%, it would result in cost savings of $1 billion.

The increases in procedures using advanced-treatment technologies cited in the JAMA study were recorded between 2004 and 2009. Weichselbaum said he thought the data were still relevant and doubted whether more recent figures would be significantly different. But Dr. R. Jeffrey Karnes, an associate professor of urology with the Mayo Clinic's Graduate School of Medicine in Rochester, Minn., thought otherwise.

Karnes said fewer prostatectomies were being done at Mayo. But he also noted that most prostatectomies are done robotically now, so it's not surprising that the number of these operations among men with low risk of prostate cancer death is increasing because the numbers are increasing in general. Statistics aside, Karnes said he thought economics were responsible for part of the increase.

“Hospitals have an underlying pressure to use the technology,” he said.

While the term “watchful waiting” may seem benign, the perceived passivity of this approach can cause many men to experience great anxiety and lead them to undergo procedures whose benefits may be dubious just because they feel the need to take action. Because of this, patient choice—perhaps driven by hospital marketing—is a factor in the increase of expensive treatments. Karnes said some patients are averse to radiation while others avoid surgery. Many seek to avoid unpleasant prostate cancer-related conditions they saw a friend or relative experience.

The JAMA report said some experts have suggested that, to ease this anxiety, low-risk tumors be called something besides “cancer.”

Karnes said he's heard the term “premalignancy” suggested, but he said more than a change of terminology is needed.

“We have to do a better job of allaying that fear,” Karnes said, adding that psychological help to deal with anxiety could be one method. Better diagnostic and prognostic tools also are needed, as current biopsy tests can only go so far in determining the aggressiveness of a tumor. He said better imaging and genetic tests could go a long way to meet this challenge.

Dr. Charles Cutler, chairman of the American College of Physicians Board of Regents, said the treatment decisions examined in these studies often begin with discussion in the primary-care physician's office.

“This is something that I deal with all the time—conversations with men who have been diagnosed with low-risk prostate cancer. The word 'cancer' dominates the conversations,” Cutler said. “It's part of our culture that people don't like the idea of actually waiting with cancer. Certainly the literature supports that watchful waiting is the right thing to do. But the psychology of the situation makes watchful waiting hard to do.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks