Confronting the prostate cancer dilemma


By Henry L. Davis
News Medical Reporter

A man with early stage prostate cancer looks a blurring alternative of treatments. Yet little evidence ranks one treatment better than another at improving his odds of survival.

The problem begins with the PSA test to detect prostate cancer. It can't tell the difference between harmless tumors and those that will grow into dangerous cancers, leading many patients to get unnecessary therapies that drive up costs and risk complications.

Questions about the most diagnosed cancer in men go to the heart of health care reform. A new study indicates that the U.S. health care system wastes as much as $850 billion annually, and 40 percent is attributable to unneeded care.

Buffalo, where the PSA test was developed, is a microcosm of the national debate over some of the most vexing problems.

That includes the downside of competition.

Prostate cancer care here comes about amid a turf battle between two of the biggest providers of care; Roswell Park Cancer Institute and Western New York Urology Associates; an expensive marketing campaign that has raised tensions among doctors; and concern over the potential conflict of interest for urologists who refer patients to radiation equipment they own.

A patient can easily feel lost.

"You need to do your homework and educate yourself if you want to make a wise decision," said Lee Zengierski of North Tonawanda.

He chose radiation and brachytherapy for his cancer after carefully reading articles and surfing the Internet.

The prostate gland is about the size of a walnut and located below the bladder. It produces the liquid that carries sperm. Treatments for early stage cancer include surgery, radiation, and monitoring the tumor in a process called active surveillance.

Active surveillance is considered an option because prostate cancer is generally slow-growing, and experts estimate that 40 percent of patients 65 and older will die of other causes before their cancer requires treatment.

Within radiation, patients also have choices, such as external beam radiation and brachytherapy, in which doctors place radioactive "seeds" inside the cancerous tissue.

In external beam radiation, newer generations of machines are supplanting older versions. Some of the latest technology includes intensity modulated radiation therapy, or IMRT, and image guided radiation therapy, or IGRT.

These two therapies, using sophisticated computer programs and treatment plans, can deliver more radiation to a tumor with less damage to surrounding tissue.

Here's the dilemma for the estimated 192,800 men who will be diagnosed with prostate cancer this year: Each therapy has its advocates, and its pros and cons, but it's unclear which one is best.

The Agency for Healthcare Research and Quality, the federal agency in charge of research into health care quality, analyzed hundreds of studies and in 2008 concluded that not enough scientific evidence exists to identify a treatment as most effective at prolonging life or at limiting such common side effects as incontinence.

What is known is that the costs of the therapies differ.

Under Medicare, treatment expenses range from about $10,000 for brachytherapy and radical prostatectomy — not including postsurgical costs — to $30,000 for IMRT outside of a hospital, according to the Institute for Clinical and Economic Review.

Active surveillance costs far less. What's more, there is mounting evidence that many of the therapies are unneeded.

A major American study released last summer found no difference in prostate cancer deaths between men who got a PSA test and those who didn't. A similar study in Europe found that, on average, 1,408 men needed to be screened and 48 needed to be treated to prevent one prostate cancer death.

Patients aren't the only ones wondering what to do.

"It's a conundrum for primary-care doctors. We often don't have the expertise to judge which high-tech referral is best, and patients can get caught between conflicting recommendations," said Dr. Edward A. Stehlik, a Kenmore internist.

In this atmosphere of uncertainty, doctors at Roswell Park and in the community came together in 2001 to try to find common ground on treatment recommendations based on scientific knowledge, not on personal preferences.

But participation dwindled as physicians questioned the value of the guidelines and feared losing control of their patients.

Potential for conflict

In 2008, Western New York Urology Associates opened a new facility for its 19 doctors on Harlem Road in Cheektowaga and expanded into radiation cancer treatment by forming Cancer Care of Western New York. Cancer Care began with two IMRT machines with all the bells and whistles — the devices cost about $2.5 million each — and business is so good that it recently added a third.

The group saw an opportunity to bring urology and radiation treatment under one roof for the convenience of its patients and physicians, said Dr. K. Kent Chevli, a partner in the group.

"We knew IMRT was going to be the future because of its low side-effect profile. But we also wanted an integrated form of prostate cancer care," he said.

Cancer Care of Western New York also offers radiation treatment for other cancers, including those of the breast, head and neck.

In an IMRT treatment, which requires about 40 sessions over eight weeks, doctors aim very small beams of radiation at the tumor from many angles and can control the intensity of each beamlet.

"IMRT allows you to "paint' the radiation dose around the shape of the tumor," said Dr. Dhiren K. Shah, a radiation oncologist at Cancer Care.

Several other IMRT machines operate in the area, including a unit at Roswell Park, and results indicate that they improve upon older devices.

"There is no longer argument over whether a higher radiation dose is better. The question now is who is the appropriate patient," said Dr. James L. Mohler, chairman of urology at Roswell Park and chairman of the National Comprehensive Cancer Network's Prostate Treatment Guidelines Committee.

Mohler and others contend that treatment recommendations have changed in the Buffalo area since Western New York Urology Associates began referring patients to its Cancer Care radiation services instead of to outside radiation oncologists. "All of a sudden, it seems as though surgery has become obsolete, and radiation has taken precedence," he said.

Critics view self-referral as a conflict of interest, potentially influencing doctors to make treatment decisions based on profit. They also point to studies indicating that physicians who own radiation systems and diagnostic scanners order more treatments and scans than those who do not.

"The doctors [at Western New York Urology Associates] are superb and highly ethical. They sincerely believe radiation is the optimal treatment when they offer it. But I also think self-referral can create a perverse incentive," said Dr. Gerald Sufrin, chairman of urology at the University at Buffalo.

Urologists across the country have invested in IMRT. Some doctors see self-referral arrangements as an acceptable practice that boosts income, offsets Medicare cuts in other areas of care, and improves continuity of care to patients.

Advocates of IMRT acknowledge that treatment recommendations are changing, but for a good reason. They say the newer radiation systems are safer in many cases.

"We lay out the issues for patients, the risks and benefits of treatments, and let them decide," Chevli said. "But a lot of patients with prostate cancer are not going to die, and it's difficult to identify who those patients are. That makes it important to choose the least harmful treatment because it may turn out that it was not needed."

Controversy over ads
Like so much of the disagreement in prostate cancer therapy, others wonder whether IMRT's higher-dose radiation will lead to complications later in a patient's life.

The consortium's decline and the private urology group's venture into radiation oncology led Roswell Park to start a major marketing campaign. The state-supported cancer center would not release how much it has spent on TV, radio, billboards, a Web site and even ads in the urinals at HSBC Arena.

One of the billboards sat for months a few hundred feet from the offices of Western New York Urology Associates.

Chevli characterized the campaign as "disappointing" and a "sign of desperation."

Roswell Park also has drawn criticism for failing to offer on its "Prostate Club for Men" Web site adequate information about the uncertainty of screening or the importance of careful decisionmaking.

Officials at the cancer center counter that they started the club in response to patients who complained about being rushed into treatment. They describe the ads as an awareness campaign to encourage men to learn more and to talk about the appropriateness of PSA testing with their physicians.

No easy answers

The competition in urology and potential proliferation of costly IMRT devices have caught the attention of health insurers.

"There has been a shift in practice patterns, although I believe everyone has good intentions. Physicians choose treatments they are most comfortable with, have ready access to or have the most experience with," said Dr. Raghu Ram, senior medical director at BlueCross BlueShield of Western New York.

He and his counterpart at Independent Health, Dr. Thomas J. Foels, said the insurers are trying to understand the shift and determine whether it is leading to improved results for patients. "An overcapacity of machines creates its own demand and not necessarily better outcomes," he said.

Health care reform proposals in Congress call for research comparing the effectiveness of different treatments for the same illness as a way to reduce therapies of little benefit and to control the exploding cost of care.

The trouble is that high-tech treatments constantly evolve, likely making the results of long-term studies outdated. The proposals also don't offer much change in a reimbursement system that encourages more services and procedures, instead of one that rewards doctors for results.

In the meantime, the next big thing in radiation is around the corner. Proton beam therapy costs significantly more than $100 million for the facility alone, and communities are investing in it even though there isn't enough evidence to say the new therapy is better than IMRT.

With no easy solution to the treatment dilemma, consumer groups support greater efforts to give patients unbiased, science-based information before they make a decision.

"Patients need a clear idea of the evidence or lack of evidence, specially in prostate cancer," said Lyn Paget, spokeswoman for the Foundation for Informed Medical Decision Making.

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