Health Affairs asks tough questions about cost, value, and medical care of men at risk for prostate cancer

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.

8 Responses

  1. Is there any consensus on the accuracy of prostate cancer diagnosis and the number of biopsy cores that should be taken? Is there any correlation between the number of biopsy cores and the risk of infection, incontinence, or other complications from biopsy?

  2. Real consensus? No.

    Here is the USA there is now (as of 2012) a general tendency, unless there are strong indicators to do otherwise, to take 12 biopsy cores under transrectal untrasound (TRUS) guidance based on the need to take cores from specific areas of the prostate. However, there is no consensus about the “right” number of cores and the precision with which they should be taken from specific areas of the prostate. However, many studies have shown that the probability of an initial diagnosis appears not to depend on the number of cores that are actually taken so long as it is six or more.

    A biopsy is never more than a small sampling of the entire prostate.

    I am also not aware of any data that provides reliable information about risk for infection and other possible side effects of biopsy correlated to the number of biopsy cores taken. However, risk for infection is probably dominated by factors that are unrelated to the number of biopsy cores and have more to do with the sterility of the equipment and the surgical field and whether the patient was given appropriate antibiotic prophylaxis prior to his biopsy.

  3. It’s a sad state of affairs when we patients must practice “defensive patientry” to avoid being “scammed” by the professional we have hired to diagnose and treat us. It’s hard enough to sufficiently educate oneself to effectively question, in good faith and with the goal of establishing a truly collaberative relationship, the proposed advice and treatment recommended by your doctor. Having to consider whether the doctor’s recommendations are also motivated solely by profit instead of the proper care of the patient fosters an adverse, not collaberative relationship. This is all Adam Smith’s fault. Perhaps, in a world with perfect knowledge, the doctors who are motivated by profit at the expense of their patients’ welfare will go out of business. Thanks are due to Sitemaster for spreading the word.


  4. Richard,

    I should be clear that few physicians are motivated solely by profit. Most doctors who write and speak like this believe all too sincerely in the messages they are delivering. They have been brainwashed by their training and their self-belief and are actually convinced (a) that they are correct in their beliefs and (b) that the revenue stream associated with their behavior is in some way entirely justified by the time they have put into their training and their work. But patients do need to watch for signals of this type of self-delusion.

    I can only speak for myself when I say that I want the doctors who help me to manage my health over time to be able to hear, first and foremost, not what they want to do but what I want to be able to achieve, so that there is a completely honest conversation about the possible and the risks associated with attempts to achieve the possible.

  5. I agree with the Sitemaster, it is al about patient centered care. It is about the goals of the patient and what they want to achieve. The healthcare system is there to help them achieve those goals.

  6. Richard:

    I don’t think that such practices are “all” Adam Smith’s fault. He was well aware of the dangers of unbridled free enterprise, and stated them in print. (I don’t have the texts handy.) He described and theorised about what he saw happening in the UK, approved of capitalism as it developed at the start of the Industrial Revolution, and disliked some “side effects” (my pun) of it.

    In much of Europe, and for a time in the USA, there was a consensus — social democracy and state intervention — about how to keep these (and periodic economic crises) under control. It was set up under the influence of Keynes and others by agreements made before 1939. The consensus collapsed between 1979 and 1981, not as a result of any financial crisis, but because of the decisions of Reagan, Thatcher (UK), and Lubbers (the Netherlands). Adam Smith might well not have approved; his name and the phrase, “the invisible hand” were hijacked and misleadingly used to lend scientific legitimacy to what has been going on since 1979. He wrote before the start of the labour movement (around 1840) and couldn’t have predicted that the three politicians I mentioned would use union issues as the means to destroy the consensus in their countries.

  7. It is standard practice among contemporary urologists to obtain 12 cores. I live in a large city and don’t know of anyone except one 67-year-old urologist who takes 6 cores. In my experience our positive biopsy rate has not altered since we went from 6 to 12 biopsies.

    Prostate cancer is an ever-evolving disease where every few years recommendations change. On one hand there is politics and public policy; on the other hand these are individual patients making decisions.

    Articles like these only strengthen the role for IPAB recommended in the new healthcare reform bill. Going down this path will make PSA testing, mammograms, and prostate biopsies unwarranted and save the insurance companies and Medicare lots of money. When this happens, the patients are the ones who will suffer.

  8. Dear GSR:

    Please pardon my apparent naivety, but if your “positive biopsy rate has not altered since we went from 6 to 12 biopsies,” then what is the benefit of taking 12 biopsy cores as compared to 6, 8, or 10?

    You appear to be stating that you identified the same number of prostate cancer patients using the older sextant biopsy as you identify today using the 12-core biopsy. Or perhaps what you are trying to say is that you identify the same number of patients with prostate cancer but that the accuracy of the diagnostic information (in terms of stage and grade and distribution of the cancer within the prostate) is improved.

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