The coming realities in the management of prostate cancer

There’s an interesting interview with Dr. Anthony Zeitman — the president of the American Society of Radiation Oncology (ASTRO) — in the most recent issue of The ASCO Post — a news magazine distributed to members of ASCO. In this article, Dr. Zeitman is quoted as follows:

Everyone knows that significant change in our health-care system is coming. We feel the rumbling of an earthquake but none of us know exactly what our world will look like after the quake hits. One thing, however, is clear — overutilization of fee-for-service resources is a huge problem in American health care and is a major target for health-care reformers. Put simply, overutilization means too much care, and that is as bad for our patients as too little care. We are going to have to kick the tires of what we do and ask what value do our treatments really bring to patients.

Now it would be easy to react to this statement by saying that advances in technology and their application are critical to improving health-care outcomes over time. However, the problem that we are really faced with is that we aren’t sufficiently selective about the application of the technologies we develop. Our marketing-oriented culture drives us to “sell” the benefits of every new technology long before we really know just how valuable they really are.

There has been a lot of furore recently about the use of bevacizumab (Avastin) in the treatment of progressive breast cancer. It is certainly the case that some women with progressive forms of breast cancer respond very well to bevacizumab in combination with chemotherapy — but the majority do not. And there is no evidence that bevacizumab extends the overall survival of women with breast cancer. Unless we are able to show, with clarity, which women really do benefit from treatment with bevacizumab, it makes perfect sense to us that the U.S. Food & Drug Administration (FDA) and the European Medicines Agency (EMEA) have both decided to withdraw the approval of bevacizumab for the treatment of breast cancer — especially since the drug is still available for off-label prescription.

The interview with Dr. Zeitman is a follow-up to his Presidential Address at the ASTRO annual meeting last year — “Conscience-based Medicine in the Age of Temptation.” In that address, Zeitman argued that the radiation oncology community needed to refocus its approach to clinical practice so that it thought not only about how to bring new and better treatments into day-to-day use but also about how to eliminate the use of redundant treatments of limited value. And yes … he did use prostate cancer as an exemplar for his premise.

Several types of treatment available today for the first-line management of localized, low-risk prostate cancer can offer a 90+ percent progression-free survival rate at 10 years. If we are to use newer (or indeed older) forms of technology, then it seems to us that those new technologies had better be able to demonstrate, clearly, that they do one at least of three possible things:

  • Offer the same progression-free and overall survival benefit as is currently available with a major reduction in risk for complications and side effects compared to current technologies
  • Offer the same progression-free and overall survival benefits at a major reduction in cost by comparison with current technologies
  • Offer a very clear improvement in the certainty of progression-free and overall survival at 10 years (which will be very hard to do indeed)

In an ideal world, any new technology that could offer the first two benefits ought to be able to eliminate the need for many (if not quite all) of the current, commonly used forms of treatment for low-risk, localized prostate cancer. Some of those therapies, of course, might retain a value as second-line therapies.

The arguments about the relative merits of different treatments for prostate cancer are all too frequently based on individual training (of physicians) and individual experiences (of patients). There are close to no data whatsoever that provide clear guidance for anyone (although I do know that some surgeons have been incr4easingly shocked at the long term outcomes and quality of life of patients who underwent brachytherapy up to 15 years ago now).

The “New” Prostate Cancer InfoLink commends Dr. Zeitman for his forthright focus on the need for some more common sense in the development and application of new technology. He isn’t just talking about its application in radiation oncology and prostate cancer. Those are simply subjects that are his recognized area of very considerable expertise. He is, in fact, talking about the application of technology in the entire American health care system. It really is time for a more rational approach. We cannot afford to give a new Lamborghini to everyone with a driving license every single year. Even Oprah limits herself to the studio audience when she indulges in that sort of generosity.

2 Responses

  1. There seems to be a new trend to discuss the efficiency of medical treatments in general and of cancer in particular. This takes place in the context of the national discussion on the rising cost of health care and focuses on new and costly treatments and on the merits of treatment of advanced stage cancer: treatments that are extremely costly, are usually associated with great discomfort for the patient and can only extend life by a few months.

    This discussion has serious ethical implications and I think all of us would be well served if it could be taken in a thoughtful manner. I am afraid, however that it will quickly descend to the level of “death panels” arguments.

  2. To follow up on the previous I will quote from an article by Dr. Kolodziej published in Oncology in February.

    “In fact, cancer patients make up less than 1% of the commercially insured population, yet they account for over 10% of costs, with a significant portion of these costs involving patients receiving chemotherapy. The combination of high-cost chemotherapy drugs and extreme variation in the use of these drugs, outpatient costs, and unexpected emergency room visits for complications or unmanaged side effects results in average annual costs of $111,000 per patient, approximately four times the costs incurred by cancer patients who do not receive chemotherapy.”

    “Roughly 32% of total Medicare spending goes to care for patients with chronic illnesses in their last two years of life, with many of these costs associated with repeated hospitalizations.”

    I wonder where this discussion goes to. Would the result be a more stringent approval process for new drugs and for Medicare to agree to pick up the costs? Would it be a requirement for more personalized medicine and tailoring treatments to specific patients?

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