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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Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data.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.

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Comments

Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Keith Paterson

July 8, 2009 at 3:49 pm

In July 2008 my PSA reached 9.5. A second test confirmed this result, so my Dr. performed a biopsy in September. This confirmed cancer was present in at least 5 of the 12 sectors of the prostate. I explored the various treatment options open to me, and finally decided on Radiation Therapy -IMRT/IGRT, mainly because I was advised that my cancer was “Early Stage”. I underwent 42 sessions of radiation starting in mid January 2009, and had a PSA check in June. The result was 1.27, so it seems that my treatment was successful – but time will tell!
Two points I would dispute from the articles above.
1. My total IMRT treatment cost was around $15,000 – a long way from the $50,000 quoted. (The treatment was carried out in central California).
2. I fail to see how money is lost through “suspect PSA” results. A consistantly high result should surely lead only to a biopsy, without which treatment would not, or at least should not, be performed.

W Robert Lee

July 9, 2009 at 1:33 pm

I enjoy this blog because it emphasizes the importance on data so I feel compelled to respond. The statement that no trial has found that PSA decreases death due to prostate cancer is INCORRECT. In fact, the largest study reported to date (Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009; 360(13):1320-1328.) demonstrates that PSA-based screening reduced the rate of death from prostate cancer by 20% (3). One can argue that the number of men screened and treated is too high to justify screening, but it is absolutely true that the European study supports the hypothesis that screening reduces prostate cancer mortality.

Brian Hildebrandt

July 18, 2009 at 3:50 pm

Although a 20% reduced death rate is great, one also has to factor in quality of life being effected by some of these more invasive treatments. That’s one of the positives of watchful waiting.

FFxi Gil

August 7, 2009 at 4:24 am

“Two points I would dispute from the articles above.
1. My total IMRT treatment cost was around $15,000 – a long way from the $50,000 quoted. (The treatment was carried out in central California).
2. I fail to see how money is lost through “suspect PSA” results. A consistantly high result should surely lead only to a biopsy, without which treatment would not, or at least should not, be performed.”
Agree statement.