Editorials cite “crazy medicine, unsustainable public policy” with new radiation treatments

We should not overlook the Journal of Clinical Oncology editorial (opens as pdf file) that accompanied the robotic prostatectomy side effects paper about which we’ve already blogged.

That editorial – by 3 authors from the University of California San Francisco cancer center – reminds readers that the costs of robotic prostatectomy (on average, they say, robotic surgery adds approximately $2,200 or 20% to the cost of a prostatectomy), should be compared with those of other high tech treatment alternatives.  Namely, intensity modulated radiation therapy (IMRT) or proton-beam therapy, “whose costs,” they write, “both capital and marginal – are far greater.”

The editorialists conclude:

“The ready availability of technology should not be a reason to apply it, particularly for those whom it may not benefit. Indeed, a higher-order priority on the Institute of Medicine’s priority list for comparative effectiveness research is comparing all treatments for localized prostate cancer. The concerns and issues raised by Barry et al (in the robotic vs. open surgery comparison) are hardly unique to surgery, given that IMRT and proton-beam therapy also entail morbidity and greater cost. Indeed, the question at the end of the article regarding whether Medicare should cover (robotic prostatectomy) is, if anything, more relevant to novel radiation techniques, given that although additional costs of robot-assisted surgery are mostly absorbed by hospitals with small increases in reimbursement compared with open surgery, IMRT and proton-beam therapy are reimbursed at much higher rates by Medicare and other payers than either conventional radiation or surgery by any approach.

Treatment decisions should be driven by cancer risk and patient preferences for outcomes rather than by financial incentives or availability of technology, be it a robot or a proton accelerator. If clinicians aim to improve the quality, effectiveness, and efficiency of prostate cancer care in the United States and to retain control of disease management in an era of increasingly concerned regulators, we must begin collecting and disclosing patient-reported, risk-adjusted outcomes prospectively across multiple treatment modalities, facilities, and individual providers, and we should advocate for a health care system that rewards quality and efficiency rather than volume and technology alone.”

Meantime, Ezekiel Emanuel (oncologist and former White House adviser) and Steven Pearson (internist with Mass General’s Institute for Technology Assessment) write an opinion piece in the New York Times, entitled, “It Costs More, but Is It Worth More?” They write:

“If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. There has not been a single randomized trial, only small, short-term studies. Such trials cannot evaluate the therapy’s long-term outcomes, nor resolve the concerns that some experts have raised regarding a potentially increased risk of hip fractures, bowel problems or other delayed effects associated with the therapy’s treatment for prostate cancer.

So why is the venerable Mayo Clinic building two proton beam facilities? Because it’s competing against Massachusetts General Hospital, M. D. Anderson in Texas, the University of Pennsylvania, Loma Linda in California — all of which have one. With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy.”


Mayo Clinic’s CEO reacted to the New York Times piece.

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Malcolm Vye

January 11, 2012 at 1:16 pm

How can you do randomized trials of conventional radiation vs proton beam unless there are enough machines to treat a sufficient number of patients for statistically valid comparisons.