The Prostate Cancer Treatment Bazaar, complete with lack of trial data & conflicts of interest

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Not to be missed in this week’s Archives of Internal Medicine is an invited commentary, “The Prostate Cancer Treatment Bazaar,” by Dr. Michael Barry. After describing about a dozen different treatment options for prostate cancer, Barry writes:


“Complicating the decision, there is an embarrassing lack of comparative clinical trials among these therapies. In fact, for the majority of men who are 65 years and older when newly diagnosed as having prostate cancer, the only randomized trial suggests that arguably the most aggressive of the treatments, radical prostatectomy, and the least aggressive, watchful waiting, have similar prostate cancer-specific mortality over 12 years of follow-up.

Given this knowledge vacuum, the type of a physician a man consults may unduly influence his choice. Since many men with prostate cancer discovered through screening have an excellent outcome for years, even without attempted curative therapy, specialists may then naturally assume, based on personal experience, that their treatment works. But increasingly, there are complex financial motives that may lead to bias as well. Large capital investments in equipment for robotic surgery or proton beam therapy, for example, create an intense need to recoup investments by increasing patient throughput. A recent paradox has been the investment by urology groups in roughly $3 million worth of equipment for intensity-modulated radiotherapy, given very favorable reimbursement for this treatment and despite evidence that its marginal benefit over 3-dimensional conformal therapy is meager relative to its cost.

Fully informing men about their prostate cancer treatment options involves honestly telling men what we do not know as well as the little we do. It requires a shared decision-making process, in which patient preferences, not physician specialty and certainly not physician investment, determine the treatment course. It is time to make a real shared decision-making process for prostate cancer and other major health problems a “major appliance” in the patient-centered medical home.”

Read the entire commentary.

(Disclosure: Dr. Barry is president of the Foundation for Informed Medical Decision Making, which is the sole supporter of the project.)

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