Defining value in the management of prostate cancer


Many years ago, among his other famous quotations on the subject of prostate cancer, Willet Whitmore, considered by many to be the “father” of urologic oncology, stated the following:

The current state of prostate cancer may not be good medicine but it sure is good business. There are more people making a living from prostate cancer than there are dying from it.

It is arguable that that statement is as true now as when Whitmore first said it (perhaps as early as the mid 1970s, because he said it many times over the years). And in a newly published article entitled “Value in prostate cancer treatment” in the Journal of Surgical Oncology, Bahnson makes highly appropriate reference to this statement by Whitmore.

Bahnson sets out to answer four questions set for him by the editors of the Journal of Surgical Oncology:

  1. Are there various interventions in [prostate cancer] with clinical equipoise, regardless of cost, that justify debate?
  2. Once the notion of cost is introduced, how does the value of each intervention change (if at all)?
  3. Are there any patient quality of life considerations that contribute to our understanding of value for a given intervention?
  4. Are there any population health or policy implications regarding value for [prostate cancer]?

In summary, he offers the following answers to these questions

  1. The interventions with curative intent produce similar outcomes. Therefore, value is improved by choosing the least expensive alternative.
  2. When cost considerations are paramount, observation with delayed endocrine therapy is clearly the least expensive.
  3. Urinary bother and sexual dysfunction are the major components of morbidity from a patient’s perspective. No treatment (observation) will eliminate all but age-related changes in these physiologic and psychosocial functions.
  4. As the US population ages and healthcare expenditures continue to predictably rise, value will be increasingly scrutinized. The challenge to all of us is to use healthcare expenditures as a valuable resource. We must define successful outcomes and then examine expense. Value will be clearer. For prostate cancer this riddle remains to be resolved.

As Bahnson is at pains to make clear, his are the opinions of a 62-year-old urologist. He makes no claims about the “rightness” of his answers to the questions, and he is writing for an audience of surgeons who treat a variety of solid tumors (from breast and prostate cancers to colon and pancreatic cancers).

Arguably, Bahnson’s answers are highly accurate … but they ignore a crucial aspect of the entire “value” equation, which is the impact of living with any or every form of prostate cancer (indolent, progressive, and metastatic; treated or not treated) on patients and their families, and what that can do to affect the lives of all concerned.

The truth today is that

  • We commonly still over-treat forms of low-risk prostate cancer that would be better not treated — but we don’t know well enough how to help patients make the decision to avoid such over-treatment (and many clinicians are motivated in differing ways to implement unnecessary treatment).
  • We often under-treat forms of high-risk prostate cancer, leading to the failure to cure at least some patients who could be cured (always assuming that we can identify such patients with accuracy).
  • All too often, we are less than 100 percent honest about the complications and side effects of almost all forms of available treatment for prostate cancer — which makes it impossible for patients to make the best decisions about what to do.
  • We over-promote the “benefits” of specific treatments in comparison to other, competitive treatment opportunities, even though we have no good data to support such promotion.
  • We are missing really critical data that might help to give us much better answers to important factors around the use of the term “value”.

Bahnson’s answers to the questions posed to him are “societal” and “cost-value” answers. From a societal perspective, they are accurate answers. From a purely economic point of view, the most cost-effective way to manage prostate cancer would be to do as little as possible for the vast majority of patients for as long as we could. However, from a “human” and “humane” point of view his answers are unacceptable.

We know that clinically significant prostate cancer is actually curable in appropriately selected patients. The problem is that we aren’t very good at selecting the right patients to try to cure, and even when we do pick the right patients, those patients may suffer serious adverse effects from the impact of treatment that are then, themselves poorly managed.

Your sitemaster has no good answers to this problem. What he does know is that the status quo continues to be a problem. We urgently need to become much better at ensuring that:

  • We appropriately identify patients in ways that allow us to categorize them into five basic groups.
    • Those who need immediate, ideally effective treatment with curative intent because their cancer needs to be treated and (ideally) cured
    • Those who may need treatment at some time in a future period that may be anywhere from a few months to years away, but can still be given treatment with curative intent when it is really needed
    • Those who will probably never need treatment with curative intent (because they are highly likely to die of something else long before their cancer becomes clinically significant)
    • Thos who will never be treatable with curative intent, but whose cancers may be arrested for a period of time, thus leading to a truly meaningful survival benefit
    • Those who will never be treatable with curative intent, or even with the intent to significantly extend survival, but who may need palliative care either immediately or at some point in the future.
  • We minimize the treatment of prostate cancer patients based largely on the personal beliefs of specific types of physician (by at least insisting that, whenever reasonably possible, prostate cancer patients get evaluated by a multi-specialty group of clinicians that includes someone whose job it is to act exclusively in the interests of the patient and help that patient come to the best possible decision for him).
  • We put in place well-defined protocols for the minimization of risk for the complications and side effects of treatment, and ensure that clinicians abide by these protocols.
  • We ensure that all patients have access to supportive care to address the common, debilitating side effects and complications of treatment — from short-term incontinence post-surgery to the well-recognized social and personal side effects of treatment that can often wreak havoc on family and interpersonal relationships (or simply on the patient’s personal attitudes to his own self-worth).

“Value” in the management of prostate cancer can not be measured exclusively in terms of outcomes related to the elimination of cancer. It can only be measured with real meaning when we put in place systems designed to optimize the overall outcomes for patients — from minimization of all the risks associated with specific interventions in the treatment of prostate cancer to the management of side effects and complications when they do, in fact, occur, regardless of every effort to avoid them.

 

2 Responses

  1. Good post and response.

    Thank you for your continued support for our community.

    Bill Manning

  2. “many clinicians are motivated in differing ways to implement unnecessary treatment”

    Indeed. The biggest single problem is conflict of interest by surgeons and other doctors. It is laughable that the person advising surgery is the private surgeon who is paid for doing the surgery or takes the risk of being sued by a patient for not advising surgery. This is simply unethical medicine. Until these conflicts of interest are removed, most of the flaws in the system will continue to exist. Conflicts of interest contribute to eventual medical reversals (see Prasad and Cifu), such as the reversal of PSA screening.

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