Prostates and health policy

With all of those aging prostates on Capitol Hill, one wonders how much money Washington, DC urologists make off of legislators’ walnut-sized glands.

Here are two examples of the kind of public discussion through journalism that we need more often – and both focus on prostates.

David Leonhardt discusses prostate cancer as a litmus test for health care reform. Why prostate cancer? He explains:

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.

“No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.” When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, “Watchful waiting.”

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.

Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified — and the bill is rising rapidly.

You may never see this bill, but you’re paying it. It has raised your health insurance premiums and left your employer with less money to give you a decent raise. The cost of prostate cancer care is one small reason that some companies have stopped offering health insurance. It is also one reason that medical costs are on a pace to make the federal government insolvent.

Meantime on MinnPost.com, Susan Perry writes about more doubts about prostate cancer screening:

On Father’s Day last month, Sen. John Kerry, D-Mass., and radio shock jock Don Imus co-authored an op-ed for the Boston Globe in which they argued that men needed to be sure they received regular preventive screening check-ups for prostate cancer. Both men are prostate cancer survivors.

“Screening for prostate cancer is the only option,” they wrote.

But therein lies a big, big problem — and yet another medical controversy. Just a few days after that op-ed ran, a review article in the medical journal CA: A Cancer Journal for Clinicians reported that the PSA blood test, routinely used to screen for prostate cancer, saves few lives, wastes money and often leads to risky and unnecessary treatments.

An editorial that accompanied the review noted that not a single well-designed clinical trial has yet to show that PSA screening reduces the death risk from prostate cancer.

However, if you don’t want to be discouraged about engaging the public in a discussion of the role of evidence in health care refom, don’t read the comments attached to either piece.