Examining “value” in the management of prostate cancer

Three new articles in the Journal of Oncology Practice take close look at the issue of risk/benefit and “value” in the management of prostate cancer today — and the management of advanced disease in particular. In each case the full text of the article is accessible on line.

The first article is one by Gupta et al. and provides a very organized review of available data on issues related to the cardiovascular and metabolic effects of androgen deprivation therapy (ADT) in the management of prostate cancer. You can read this for yourself.

The second is a very practical commentary (by Khouri and Harrison) on how to think about the actual application of ADT and the mitigation of risk for cardiovascular and metabolic side effects in individual patients — a “how to” article that takes advantage of the key poonts in the revioew by Gupta et al.

However, the third, and perhaps the most interesting is a brief but fascinating assessment (by Ahmad and Raghavan) of the issue of “value” of a spectrum of factors related to the management of prostate cancer — ranging from who needs to be diagnosed through to the costs of treatment (and the financial toxicities) of newer forms of treatment for advanced disease. Again, this is an easily readable article for most support group leaders and other reasonably well-informed patients.

While the third article starts out as a second commentary on the paper by Gupta et al. it goes far beyond that to look at some (but by no means all) of the most challenging questions in the current management of prostate cancer (and advanced prostate cancer in particular). It also reminds us that for the thoughtful physician — and his or her patients — all healthcare is and should be “personalized” in oned way or another.

7 Responses

  1. I will try to read this, as two issues interest me now. First is “bundled care”, an American export of trivia that is being inflicted on the EU. Second is QALY. Some Europeans wonder why Americans accept this eugenic method so easily. Maybe the third article will help.

  2. Dear George:

    (1) I would respectfully suggest to you that you do indeed need to understand “bundled care”, which is by no means “an American export of trivia”. Rather, it is a way of thinking about assessing costs for healthcare management of differing types based on what the total costs (for example for a radical prostatectomy) ought to be as a reasonable average, as opposed to adding up all of the individual costs that get assigned to an individual patient (regardless of whether the patient needed all the services provided and/or whether some of those costs are associated with medical errors made by an institution and its staff).

    (2) With regard to the QALY as a unity of healthcare value, the problem is not the QALY per se. It is who decides how that QALY is being measured for a specific individual with specific health needs and how much a QALY is actually worth. Americans are far from the only society that uses the QALY. In fact NICE in the UK also uses QALYs on a regular basis, but they value a QALY at a much lower rate than Americans do (which may well be justifiable).

  3. Dear Sitemaster:

    In Holland the notion “reasonable average” is judged by private insurers. They compare something called “Routine Outcome Measure” (unsure about the last word) with care “benchmarks.” These are their reasonable outcome averages. Many Dutch physicians worry about this, I do because they do. They did not like the ROM instinctively; had an idea that it would fix maxima on treatments. Those insurers are doing that now, in mental health and physical therapy at least. But these medical people did not know what ROM was. I found out, by following a reference to the Harvard Business School. I did know a bit about that. These doctors and nurses and therapists are rightly worried. We do not know what will happen, but the signs are there: one insurance company is taking legal action, or threatening it, against qualified people who refuse contracts that limit treatments. Patients must pay for it themselves. I don’t know how this “reasonable” number is calculated, but do worry that ROM will be used, or is used. By “trivia” I mean the ideas behind bundled care. Many of us could write this stuff off the top of our heads.

  4. Dear George:

    It’s one thing to to be able to describe the “ideas behind bundled care”. You are correct. Many of us could do that. But the Devil is in the details.

    Could you, for example, even define all the individual components that would have to be “bundled” into the proper conduct of a single radical prostatectomy — and all the things that should not be “bundled” into that set of equations because they should not happen and so a hospital should not be allowed to include them in such a set of equations?

  5. Dear Sitemaster:

    Yes, I am almost certain I could do that … after a year or two spent studying. I’ve seen such a list for some kind of prostate cancer care. Of course that is the example I would use. I did not mean that many can fill in the details right now, but that after a brief look at treatments many of us could do that. Indeed, the bundled care and outcomes work has been criticised as being trivial. Business school profs have bragged about how they work out their ideas on the backs of envelopes. Today four Dutch hospitals announced that they might have to close. One article stated that a lump sum of cash given to that hospital by insurers, was poorly spent. There were too few patients yet the cost per patient went up too much. When I read that I tweeted the doctor who posted the article. I asked him if that has to do with the bundle idea. Stay tuned.

  6. Dear George:

    I am astounded. I don’t think for one second that I could compile an accurate set of data for the bundled cost of a radical prostatectomy. I know someone who can, and it took him quite a while to do it accurately, and he started out with the specialized knowledge of being a prostate cancer surgeon who knew exactly what it costs to put a surgical team into an operating room with relevant support staff and personnel to monitor the patient during recovery. What he then had to start to work out was the costs associated with insurance against all the things that might go wrong through no fault of the surgical team. That’s a very different but essential issue.

    I would also point out that when you say that “One article stated that a lump sum of cash given to that hospital by insurers, was poorly spent”, that doesn’t necessarily imply that any of it was spent to cover the costs it was supposed to cover. Diversion of funds for purposes they were never intended to cover is endemic across the business world, as you surely are aware. There may be a whole bunch of other reasons why the hospitals are going out of business.

    On the other hand, I would fully agree with you that calculations made by professors at business schools “on the backs of envelopes” is no recipe for accurately assessing the costs of health care.

  7. Dear Sitemaster:

    You are right, I wrote too quickly. Two points.

    1. In the case I mentioned it seems that the bundle was misused. Some patients got more spent on them than had been suspected, using up the cash. I know nothing more.

    2. Right. I should have been more specific. Those backs of envelopes referred to those fancy power point and other diagrams, with multi-colour arrows connecting boxes. They can be written on envelopes, meaning quick, simple diagrams to impress readers and listeners. But yes, filling in those boxes with data from a particular case takes knowledge of the example, and time. My real point is that cooking up a diagram is not hard and requires little knowledge. At university we called it one kind of obviousology. Business school specialists can consult with medical specialists to fill in a flow diagram.

    If I have time I will look into this more carefully. Right now I have looked at a few articles, to tell interested Dutch medical people what ROM is all about.

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