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Prostate cancer – Is it overtreated?
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Balance needed between definitive treatment and active surveillance
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For men with less aggressive prostate cancers, the balance between the risks and benefits of immediate treatment with surgery or radiation may not be sufficiently well defined. Uncertainty regarding their disease natural history then leads many to proceed along what is often regarded as the safest route — definitive treatment.
At the same time, many patients with prostate cancer may have an unfounded fear of harm arising from their low-risk prostate cancer. Lastly, the concept of active surveillance to many patients defies logic when they are constantly bombarded by media examples of celebrities who have succumbed to cancer.
For providers, the dissemination of research evidence into clinical practice is hampered by implementation barriers such as explaining the pros and cons of different treatments within a time constraint imposed by limited reimbursements.
There is also a prevalent concern among providers that he/she would be legally liable if a patient progresses and dies from prostate cancer under an active surveillance approach. In reality, patients should be as informed and accepting of this risk as they are about the possibility of death due to complications arising from surgery. The final possibility that I will raise regarding potential over-treatment is the fact that our current reimbursement paradigm incentivizes more treatment rather than less treatment.
Over the years, technological advances including the PSA test and incorporation of extended pattern biopsies have incrementally improved our ability to detect prostate cancer; however, they have not allowed us to better identify who is likely to have fatal prostate cancer. Consequently, prostate cancer screening results in the over-detection of tumors that are not likely to ever become clinically significant. Moreover, treatment of such cancers may, in and of itself, may lead to deterioration of health status due to complications of therapy.
An alternative option is active surveillance or expectant management of low risk prostate cancers when they are identified. Observational data have established that older men who choose active surveillance for well- or moderately-differentiated (eg Gleason score of 6 or lower) cancers will most likely die from competing causes. There is also mounting evidence supporting the safety of the active surveillance approach in so far as definitive treatment is still expected to provide a cure in most cases that progress from low risk to high risk.
Looking at this issue from a national perspective, we found that more than half of men with this lower-risk prostate cancer received definitive treatment when active surveillance would have been reasonable options (Miller, JNCI 2007). One may reflect upon why this phenomenon occurs from both the patients’ and providers’ perspective.
For men with less aggressive prostate cancers, the balance between the risks and benefits of immediate treatment with surgery or radiation may not be sufficiently well-defined. Uncertainty regarding their disease natural history then leads many to proceed along what is often regarded as the safest route – definitive treatment. There is clearly a desperate need for medical information to be translated into lay language as was done by the Michigan Department of Community Health under the auspices of the Michigan Cancer Consortium. In that effort, prostate cancer treatment options and descriptions of side effects were framed in an easily readable format at a 6th grade reading level (www.prostatecancerdecision.org). At the same time, many prostate cancer patients may have an unfounded fear of harm arising from their low risk prostate cancer. Lastly, the concept of active surveillance to many patients defies logic when they are constantly bombarded by media examples of celebrities who have succumbed to cancer.
For providers, the dissemination of research evidence into clinical practice is hampered by implementation barriers such as explaining the pros and cons of different treatments within a time constraint imposed by limited reimbursements. There is also a prevalent concern among providers that he would be legally liable if a patient progresses and dies from prostate cancer under an active surveillance approach. In reality, patients should be as informed and accepting of this risk as they are about the possibility of death due to complications arising from surgery. The final possibility that I will raise regarding potential over-treatment is the fact that our current reimbursement paradigm incentivizes more treatment rather than less treatment. In conclusion, over-treatment of low risk prostate cancer is not likely to be in the patient or society’s best interest.
John T. Wei, MD, MS, is Associate Professor of Urology and Associate Chair for Clinical Research in the Department of Urology at the University of Michigan, Ann Arbor.
Both definitive treatment and active surveillance have risks
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In order to support this argument, one would need to demonstrate that prostate cancer screening finds clinically insignificant cancers. In contrast to this belief, there are available data from a number of studies that demonstrate that PSA screening (1) identifies clinically significant prostate cancer, (2) detects prostate cancer with more favorable clinical and pathologic features, and (3) has led to stage migration and fewer cases of metastatic disease at initial diagnosis (which is incurable).
Although watchful waiting and deferred management are available options, recent clinical data show that these options are not without risk, including, but not limited to, the development of erectile dysfunction. Furthermore, the belief that current reimbursement paradigms favor more treatment rather than less treatment is unproven, particularly give the current atmosphere of declining reimbursements.
A urologist would likely generate more revenue with less risk if he/she were to stay in the office seeing patients rather than performing a radical prostatectomy — especially when one considers the current Medicare reimbursement, the 90-day global period, and the in-patient and out-patient postoperative care that is required even when there are no complications.
Most, if not all, clinicians would agree that elderly patients and patients with significant comorbidities are not likely to benefit from prostate cancer diagnosis and treatment. Until further data are available, physicians should have in-depth discussions with their patient prior to proceeding with prostate cancer screening and treatment. In the absence of definitive data, each patient needs to determine the best course of management for himself with input from his physician.
Howard L. Adler, MD, is Director of the Prostate Care Program and Clinical Assistant Professor of Urology at Stony Brook University Medical Center, Stony Brook, N.Y.