ICER/Families USA “Proven Best Choices” for treatment of low-risk prostate cancer

According to a report from Kaiser Health News, the consumer organization Families USA is collaborating with the Institute for Clinical and Economic Review (ICER) to provide a series of “Proven Best Choices” guides for patients about screening and treatments for selected disorders.

One of the first of these “Proven Best Choices” guides addressed “Treatment options for men with low-risk prostate cancer” and we have to say that we are less than enthused by how the document discusses the three recommended “Proven Best Choices” which are listed as:

  • Active surveillance (monitoring)
  • [Radical] prostatectomy (surgery)
  • Brachytherapy (radiation)

Here are just some of the examples of the problems with this particular guide:

  • Most importantly, it does not mention loss of sexual/erectile function as a very common side effect at all under the “Prostatectomy” heading. But this problem occurs in  about 80 percent of all men with serviceable erectile function prior to surgery. (Reference to this fact is actually under the “Brachytherapy” heading, where it states blandly that “After surgery, you may have trouble having an erection.” Clearly this was a layout error in the document.)
  • In addition, with regard to radical prostatectomy and risk for incontinence, it states only that “After surgery, you may have trouble controlling your bladder”. In fact, almost all radical prostatectomy patients will have “trouble” controlling their bladders for several weeks or months (if not years).
  • It states that you will have a “1-4 week recovery time” after a radical prostatectomy. This is at best “misleading” since most men will take longer than that to recover good continence, let alone good erectile function (if they recover this at all).
  • There is no mention whatsoever of “watchful waiting” as an entirely appropriate and extremely cost-effective option for older men and others with life expectancies of < 10 years. (“Watchful waiting” and “active surveillance” are not the same thing at all.)

The document lists intensity-modulated radiation therapy (IMRT) and proton beam radiation therapy (PBRT) as being “lower value options” for the treatment of low-risk prostate cancer. That is not an unreasonable evaluation (although arguable in the case of some older patients and in the case of men for whom retention of a high level of erectile function is a key issue).

The document doesn’t even mention stereotactic body radiation therapy (SBRT) as a treatment option for low-risk disease. In fact this is highly effective in the treatment of low-risk prostate cancer, relatively cost effective, and has a relatively low level of risk for side effects and complications.

The document also doesn’t mention high-intensity focused ultarsound (HIFU). This is not entirely surprising since this technique has only just been approved in the USA.

Finally, the section on “Questions for your doctor” appears to be far more focused on how soon the patient can get back to work (which may well be very important) than it is on how well a specific form of management might work for a specific patient!

We get the strong impression that the current document would have benefited from rather more expert opinion on the choices available to newly diagnosed men with low-risk prostate cancer. One also gets the impression that the document may have been heavily influenced by the opinion of a urologist who specializes in radical prostatectomy. (It would be interesting to learn how the breast cancer advocacy community feels about the comparable Proven Best Choices document on “Breast Cancer Screening Options for Women with Dense Breast Tissue“.)

3 Responses

  1. Makes one wonder the qualifications of those who assembled this paper, and apparently approved by Kaiser. And wonder as well why these conclusions were not vetted by physicians experienced in the treatment of our disease.

  2. Dear Chuck:

    Let me be very clear that (a) Kaiser Health News is just reporting what others had done and (b) Kaiser Health News is not affiliated in any way with the healthcare insurance/provider group Kaiser Permanente. It is a publication of the independent Kaiser Family Foundation.

  3. Please note that a corrected version of the ICER/Families USA document “Treatment options for low-risk prostate cancer” is now available on line, in which the reference to erectile dysfunction has been correctly moved to the section on side effects of radical prostatectomy.

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