One of four articles published yesterday in the journal Health Affairs is causing another major furor in the urology community. The article reports that urology practices that carry out their own pathological analysis of biopsy samples in house order more biopsy samples than practices that send samples to independent laboratories.
As regular readers will be aware, there has been a prior furor over the fact that some large urology practices have been developing or acquiring their own radiation therapy centers and referring patients to these centers for radiation treatment. The article in Health Affairs analogously suggests that when urology practices develop and implement their own in-house pathology services, there is an associated for-profit motive which then drives the excessive use of the service.
Those readers who subscribe to The Wall Street Journal, will find a commentary about this issue on line on the Journal’s web site today. The abstract of the article by Mitchell in Health Affairs explicitly states the following:
- That urology practices that “self-referred” biopsy specimens (cores) billed Medicare for 4.3 more specimens per prostate biopsy than the adjusted mean of six specimens per biopsy sent out for assessment by non-self-referring urology practices to independent pathology providers.
- That, in 2007, the adjusted prostate cancer detection rate was 12 percent higher among men being evaluated by urologists who did not self-refer uropathology services than among men being evaluated by urologists that did self-refer.
- That financial incentives prompt self-referring urology practices to carry out biopsies on men who may be at minimal risk for prostate cancer.
The American Urological Association was up in arms about this article yesterday — before they had even seen the full text, probably because the article also suggests that self-referral of biopsy specimens to in-house uropathology laboratories should simply be banned.
Whatever one may believe about the rights and wrongs of self-referral of patients and test specimens within a clinical practice, one does have to wonder, as a patient, whether the ability to make money by taking more biopsy cores that are not clearly associated with any increase in the likelihood of diagnosis of prostate cancer is a good thing.
One can certainly debate whether having a PSA test is a benign event. But a prostate biopsy most certainly is not. It comes with significant risks, most particularly the risk for infection and even death as a consequence of an infection that leads to sepsis. Excessive use of prostate biopsy is therefore excessively risky — unless there is very clear evidence that conduct of such biopsies is associated with an increase in diagnosis of clinically significant prostate cancer.
The same issue of Health Affairs includes articles on three other issues that are (arguably) associated with the risk for inappropriate or excessive use of forms of diagnostic and therapeutic methods related to the management of prostate cancer:
- Mirkin et al. write about the accuracy and appropriateness of advertising of robot-assisted laparoscopic prostatectomy (RALP) over the Internet.
- Makarov et al. address the regional rates of “appropriate and inappropriate imaging rates,” which they suggest are a consequence of poor regional policies that fail to encourage only appropriate imaging.
- Jacobs et al. provide an article entitled “Growth of high-cost intensity-modulated radiotherapy for prostate cancer raises concerns about overuse;” the topic of this article is self-evident.
It would be easy to write all this off as a storm in a teacup, or to get the idea that some people simply want to eliminate what they see as excessive spending on the diagnosis and management of prostate cancer. The “New” Prostate Cancer InfoLink takes a somewhat different view, which is that ever since the development of nerve-sparing surgery and the PSA test in the 1980s, the diagnosis and management of prostate cancer has become an industry … and an industry that offers major revenue streams and profits to those who serve it.
Whether we like it or not, as patients, we need to be aware that, just as we can be “scammed” by Nigerians who send us e-mails about the $30 million they need to move to a bank in America, we can also be “scammed” by clinicians who encourage us to undergo tests of extremely limited value. When the doctor says to you, “I don’t think we are going to find anything but I’d like you to have a CT scan and a bone scan just in case,” it is worth saying to yourself (and to the doctor), “Just how likely is it that you think we might find something? One in a hundred or one in a hundred thousand?”
If it’s one in a hundred, maybe the scan is worth it to you. If it’s one in a hundred thousand, it almost certainly isn’t! But it may be worth a lot to that doctor. The same may apply to whether you really need that biopsy and just how many cores the physician is taking.
Even though no money immediately comes out of your pocket (in America) when you go for that test, because it is covered by Medicare or your insurance provider, that money is coming out of your pocket in the end — in taxes, in your insurance premiums, in your annual contributions to Social Security, you name it.