Prostate cancer has been described as the litmus test for healthcare spending reform. The disease, which strikes 240,000 men in the U.S. every year, is at the core of contentious clinical, economic and policy debates. As researchers, policymakers, physicians and payers attempt to revise the script for prostate cancer management, the process may offer lessons that can be applied across the healthcare continuum.
The U.S. Preventive Services Task Force (USPSTF) issued the most recent strike in the debate on May 21 when it delivered a Grade D rating for prostate-specific antigen (PSA)-based screening for prostate cancer. There is "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits,” according to USPSTF. The demotion incited a flurry of activity among many urologists and radiation oncologists, who defended the test as the only widely available screening test for the disease, and referred to the 40 percent drop in mortality from prostate cancer in the last 20 years with the availability of PSA-based screening. At the same time, the American Urological Association acknowledged not all prostate cancers are life-threatening.
Active surveillance: A tough sell
There’s the rub. “Prostate cancer is different. It is one of the rare conditions where there are credible data which suggest certain patient groups are unlikely to benefit from screening or treatment,” says Cary P. Gross, MD, of Yale University School of Medicine in New Haven, Conn. Data suggest the value of prostate cancer screening and treatment decreases with age. Many men older than 65 years, and certainly older than 75 years, should not be screened, says Gross, who adds that some older men with less aggressive tumors are unlikely to benefit from treatment.
National Comprehensive Cancer Network guidelines recommend active surveillance as one option for men with low-risk of prostate cancer, i.e. a Gleason score of 6 on biopsy and a PSA of less than 10. However, research suggests active surveillance is not being used as often as it could be, according to Ronald C. Chen, MD, MPH, of the department of radiation oncology at University of North Carolina in Chapel Hill.
In fact, data, guidelines and clinical practice appear to be misaligned. In a research letter published Feb. 27 in Archives of Internal Medicine, Gross and colleagues reported “increasingly aggressive treatment of patients with a low likelihood of clinical benefit, without a commensurate increase in the treatment of patients with a high likelihood of clinical benefit.” They found the use of curative treatment (radical prostatectomy or radiation therapy) increased from 38 percent of men with moderate-risk disease and a life expectancy of less than five years in 1998 to 1999 to 52.1 percent in 2006 to 2007. Use of curative therapy also trended up for men with low-risk tumors and life expectancies less than five years and five to 10 years. But curative therapy dipped among men with moderate-risk tumors and a life expectancy of more than 10 years.
|The View from Above: Effective Therapies Rise to the Top|
Most men with prostate cancer want to know if treatment will cure the disease and if they will be cancer-free.
The Prostate Cancer Results Study group has surveyed the evidence and compiled it in a format to share with patients and physicians.
The chart on the right shows results of studies which included at least 100 men with low-risk disease (stage T1 or T2a or b, Gleason score </= 6, PSA </= 10 ng/ml).
According to the chart, the brachytherapy cluster indicates more studies showing longer, progression-free survival.
|Source: Prostate Cancer Center of Seattle,BJU Int, 2012, Vol. 109 (Supp. 1), 8/29/12|
It’s likely that several forces are at play. Reimbursement for treatment is higher than for surveillance, which may incentivize physicians to treat some patients with lower-risk disease. Urologists who own a linear accelerator can earn $4,000 to $10,000 for referring a patient to their equipment and therefore may be incentivized to treat with only that modality, says Peter D. Grimm, DO, of the Prostate Cancer Treatment Center in Seattle.
Joseph C. Hodges, MD, MBA, of University of Texas Southwestern Medical Center in Dallas, agrees. “Overtreatment is a direct result of poorly designed healthcare policy. The [Stark Law] loophole that allows a urologist to own pathology labs, surgical centers, imaging equipment and radiation treatment facilities directly fuels the