Prostate cancer as a poster child for health care reform

Some (maybe many) readers of this column are not going to like an article on the front page of the New York Times today.

The author of this piece, David Leonhardt, looks at prostate cancer management as an economist, not as a patient, and focuses on something we all understand but tend not to want to deal with, which is the sheer cost of treating all the men who probably don’t need treatment with whatever the latest form of gizmo is today (surgical robots, proton beam therapy, other forms of high-tech radiotherapy, etc.).

Neither Mr. Leonhardt nor the current writer are in any way suggesting that these forms of treatment may not be effective and appropriate for carefully selected patients. What Leonhardt is trying to point out (correctly in our opinion) is that so long as the economics of the American health care system favor the delivery of more care as opposed to the most apporpriate care, everyone associated with the health care system is to some extent driven to increase the amount of “care” they provide instead of making sure that the patient understands what the best care is liley to be for the individual patient. Prostate cancer happens to be the example he has focused on to make his point.

The “New” Prostate Cancer InfoLink is aware that there are already a number of initiatives afoot to ensure that prostate cancer therapies are one of the items that are looked at carefully as part of the proposed “comparative effectivesness research” initiatives associated with health care reform (see this article on Medscape). Frankly, in principle, we think this is a good idea. It may force us to really conduct the comparative studies needed to evaluate the relative merits of different types of treatment that have been avoided for so long.

However, what is not so clear is whether such studies will really help doctors to advise individual patients of their best options — because no amount of comparative effectiveness research is going to answer the more fundamental question of whether you do or don’t actually treat an individual 55-year-old man with (say) a PSA of 3.7, a Gleason score of 3 + 7, a clinical stage of T1c, and a small amount of cancer in 2/12 biopsy cores. It is this question that is at the heart of the real debate about prostate cancer, and we won’t resolve this until we have tests that can differentiate much more accurately and as early as possible between men who can clearly be shown to be at high risk for aggressive disease and those who are not.

It seems reasonable to this writer that physicians be paid a fixed sum for the management of a patients with a well-defined condition such as prostate cancer. In other words, whether the doctor carries out radiotherapy or a RALP or active surveillance over a period of time, (s)he would be paid the same amount of money. Then the doctor is not driven by technology to optimize his/her revenue. Rather, (s)he knows up front what (s)he will get paid and can focus entirely on helping the patient to get the most appropriate form of treatment.

Of course that is an idea that will have limited appeal to large sectors of the professional health care community.

6 Responses

  1. Since the medical, advocate, or patient communities have not reached any degree of consensus on how to treat prostate cancer (and consensus is decreasing), and it is only killing 3% of men who get a diagnosis, we should only be surprised that this has not happened sooner. To fund universal health care, the country will have to spend its health care dollars more efficiently — and may do so over the strong objections of a prostate cancer medical community that cannot even produce data that supports prostate cancer screening.

    It would be interesting to know how much of the funding for prostate cancer detection and treatment comes from the government. Why haven’t Medicare and other government medical programs (like my retired military Tricare) required more prostate cancer information as a requirement for reimbursement, and used the data for long-term treatment effectiveness studies. It would seem that, using a sample size as large as that would likely be, randomization would not be much of an issue.

  2. Steve: The costs of doing prospective economic analyses of the type you are suggesting are very, very high, the structural quibbling between the different interest groups over the details becomes mind-bogglingly complicated, and by the time one gets the results (for a disease like prostate cancer) the data are barely relevant to current practice. By comparison it is just SO much easier to do the sort of retrospective cost analysis that was reported by Ekwueme et al. on the cost of prostate cancer testing with PSA and DRE a couple of years ago.

  3. Sitemaster,

    The report you reference didn’t even go so far as treatment and concluded:

    “Finally, identifying and measuring all the resources used in screening for, diagnosing, and clinically staging prostate cancer is a time-consuming and expensive process. In many situations, such detailed evaluations may not be practical. Therefore, the resource cost estimates reported will invariably diverge from the microcosting approach recommended by the U.S. Panel on Cost-Effectiveness in Health and Medicine (17).”

    The U.S. Panel was talking about: “Cost-effectiveness analysis probability data can be collected as part of a research protocol (primary data), or can be abstracted or extrapolated from existing published research (secondary data).”

    What I’m proposing is to build a system of data collection and analysis into the government insurance claims system. Look for events like screening, biopsy treatment, retreatment, follow-up meds, continuing claims (saying that the claimant is still alive) or the report of death that terminates coverage, and go from there.

  4. Steve: I understand what you are suggesting. The fact that something like this can theoretically be done does not, however, necessarily correlate with the likelihood of it happening and being done well. This is why the PLCO trial ended up providing bad data — we allowed people to be included in the analysis who were randomized to no screening but actually were getting screened.

    Collecting all of the data you are talking about — and making sure those data are accurate — is an immensely time-consuming and expensive task. On top of which, there would be intense academic argument over what needed to be collected and how. I just can’t see it happening for purely economic reasons because it would have to be done for at least a decade. The CaPSURE project has already been doing something like this for nearly a decade now but on a much smaller scale.

  5. I think you missed the point of the article. As I read it, the point is that Americans resist the concept of evidence-based medicine. If surgery is as effective as IMRT but costs 75% less, then on a cost basis it should be the favored primary treatment, barring extenuating circumstances such as cardiovascular disease or other health impediments. I think the author’s point is correct: there is too much self-serving bias in medical care that is pushing the system over the brink. But there is also too much consumer (i.e. patient) bias too.

  6. ‘ “No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.” When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, “Watchful waiting.” ‘

    Back to PSA/DRE testing then … This is just getting silly now!

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